The COVID-19 pandemic severely disrupted European universities’ educational process. With the vaccination rollout, in-class instruction broadly resumed beginning in September 2021. In order to mitigate the risks of SARS-CoV-2 transmission, European universities apply COVID-19 containment protocols. The aim of this paper is to evaluate the COVID-19 containment protocol that Greek universities implemented in order to fully reopen in the fall of 2021 and for the entire academic year 2021–2022. A case study was conducted at the Department of Industrial Management and Technology, University of Piraeus (Athens’ port), Greece. Data were collected from November 2021 to July 2022 and a quantitative statistical analysis  was performed. A total of 330 unique (and 43 reinfections) COVID-19 cases were confirmed, including 241 undergraduate students, 73 postgraduate, and 2 doctoral students, 10 faculty, and 4 administrative personnel. Contact tracing reported four confirmed and eight potential cases of in-classroom transmission. The person in charge of implementing the COVID-19 containment protocol in the department ordered more than 6000 rapid tests during this period. The Department of Industrial Management and Technology at the University of Piraeus used a rigorously monitored and coordinated strategy of vaccine promotion, screening/testing, contact tracing, isolation, and quarantine in order to control COVID-19 transmission. The results show, on one hand, that the protocol’s implementation is effective and leads to in-classroom transmission minimization and, on the other hand, verify the hypothesis that the department’s confirmed COVID-19 cases are less (with a mean percentage difference of 50%) than the community’s respective 18–39 age group. More than two and a half years after its emergence in Wuhan, China, the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the highly contagious causative agent of COVID-19, continues to strain healthcare systems. By 19 July 2022, 563,608,165 confirmed cases of COVID-19, including 6,371,423 deaths, were reported globally [Focusing on universities, SARS-CoV-2 posed significant challenges to their daily activities. Universities represent a unique environment with a dense population of primarily young students . With thIn order to assess the protocol’s effectiveness, a case study from the Department of Industrial Management and Technology at the University of Piraeus, a medium-sized urban university in Athens, is presented. The hypothesis that the confirmed COVID-19 cases in the department were systematically less than the community’s, due to the protocol’s rigorous implementation, is tested.The remainder of this paper is organized as follows: Tertiary education students come from a variety of backgrounds, moving and intermixing at the university and at a wider community level. The features of a university, such as the students’ age distribution and extracurricular activities, influence the COVID-19 pandemic dynamics. COVID-19 containment and surveillance protocol’s success is of paramount importance for universities’ viability, since it was proven in the academic years 2019–2020 and 2020–2021 that e-learning cannot fully substitute students’ physical presence in a tertiary education system. However, although from the first days of 2020 COVID-19-related epidemiological literature thrived, research work focusing on evaluating the pandemic’s containment protocols used in universities is scarce and restricted mostly to the U.S.A. This research work can be divided in two categories: pre- and post-vaccines advent.In the first category, efforts were made to assess the control plans used for reopening universities  in all places where an educational process was carried out with physical presence, (b) in all internal spaces of the university and internal common areas of the student residences, and (c) in all external areas of the university where overcrowding was observed. Mask use was enforced for all students, staff members, and visitors. Faculty and staff members asked those who were unmasked or improperly wearing a mask to comply. Non-compliant students received sanctions, including being unable to attend classes in-person. www.edupass.gov.gr, accessed on 20 July 2022). Whenever a positive laboratory test was carried out, the system was updated and the case was recorded, provided that the case was registered in the platform.The monitoring of compliance by all individuals who participated in the educational process of universities with a physical presence took place through an electronic platform , Greece, with ten departments and approximately 17,500 undergraduate students, drafted its COVID-19 surveillance/containment protocol at the end of September 2021 and updated it at the end of April 2022. The protocol was posted on the University’s main website .According to this protocol, a person in charge of implementing the COVID-19 surveillance/containment protocol in each department was assigned. Confirmed cases with COVID-19 stayed in quarantine for 10 days until 1 January 2022 and 5 days since then, based on evolving data from European Centre for Disease Prevention and Control(ECDC). Their isolation ended after this period, and if there were no symptoms with complete subsidence of fever for a 24 hour period without the use of antipyretics. In order to return to the educational process, a laboratory confirmed negative test should be carried out and after 1 January 2022, the use of a high respiratory protection mask or a double mask for at least another five days from the end of isolation was mandatory. For every confirmed case, a risk assessment for her/his possible contacts was carried out by the person in charge for the protocol’s implementation. A contact of a case of COVID-19 infection was defined as a person who had a history of contact within a period of time ranging from 48 h before the onset of symptoms of the case to 10 days (5 days since 1 January 2022) after the onset of symptoms. Depending on the level of exposure, the contacts of the case were categorized into: (a) close contacts (high-risk exposure), i.e., individuals who had face-to-face contact with a COVID-19 confirmed case at a distance less than 1.5 m for at least 15 min and without mask use by both; (b) contacts (low-risk exposure), i.e., individuals who had face-to-face contact with a COVID-19 confirmed case within 1.5 m for less than 15 min. Additional measures, such as enhanced hand/respiratory hygiene, social distancing recommendations, disinfection of classrooms/laboratories/equipment and common areas , minimization of elevators’ utilization, and enhancement of all building ventilation systems, were implemented. Finally, the educational activity was carried out without taking a break, in order to reduce crowding when leaving and entering the lectures’ halls.The Department of Industrial Management and Technology is one of the ten departments of the University of Piraeus. For the academic year 2021–2022, it enrolled 1266 undergraduate students in a four year curriculum, 197 M.Sc. students in a three semesters program, 29 Ph.D. students, 25 faculty members/adjunct faculty, and 5 administrative staff. Out of the 1266 Department’s undergraduate enrolled students, 447 were registered more than eight years ago, therefore, they are actually inactive and they do not attend courses. The same holds for the M.Sc. program, where from the 197 students, only 135 are actually active, being enrolled no more than three years ago.screening the non-vaccinated students, staff, and faculty (regardless of the presence of symptoms) twice per week; or testing, where students, staff, and faculty were either symptomatic and tested or they were tested after an announcement from the person in charge for the COVID-19 protocol’s implementation. His information channels were the electronic platform or a direct notification by the confirmed case with an e-mail or a phone call. The confirmed cases were interviewed via phone calls, the relevant data from the confirmed cases were recorded after their informed consent and the quarantine procedure was established. Data included sex, affiliate status (undergraduate/graduate students and their enrollment year vs. faculty and administration staff), date of their positive laboratory test, symptoms’ (if any) onset date and description, contact tracing information (classes they attended the last 48 h before their symptoms’ onset and close contacts identification), and vaccination status. These data were then de-personalized. According to a Department’s General Assembly Decision, at the end of September 2021, the author was assigned as the person in charge for implementing the University’s COVID-19 surveillance/containment protocol. Confirmed cases were identified by a rapid or PCR test through either Statistical analysis was performed using the MS Excel. The data in this study were analyzed using simple descriptive statistics and inferential statistics hypotheses’ testing, where a significance level of 5% was used.In-class instruction resumed in the Department of Industrial Management and Technology on 11 October 2021 for the graduate programs courses and 18 October 2021 for the undergraduate program courses. At that time, the department’s non-vaccinated students, undergraduate and graduate, were less than 25%, whereas faculty and staff were all fully vaccinated. From the pandemic’s start until the end of September 2021, the confirmed cases with SARS-CoV-2 infection in the department were approximately 9%.Although it was not mandatory, students’ registration in the COVID-19 monitoring electronic platform was strongly suggested and encouraged. In total, 594 undergraduate , 114 M.Sc. , 15 Ph.D. , and all faculty and administrative staff were registered.The first confirmed case after in-class instruction resumed was recorded on 4 November 2021. Since then, and until 20 July 2022, 330 unique (and 43 reinfections) COVID-19 cases were confirmed, including 241 undergraduate students, 73 postgraduate, and 2 doctoral students, 10 faculty, and 4 administrative personnel. Out of the 330 unique COVID-19 confirmed cases, 201 were males and 129 were females. Considering that females in the department account for approximately 38.7%, they had a slightly higher infection rate (44.3%) than males (43.6%).When comparing infections by their year of studies in undergraduate students enrolled after 2018  the percentages of those who tested positive for SARS-CoV-2 are similar, ranging from 40.9% to 45.6%. An impressive 72.7% of the first-year M.Sc. students were infected . The percentage of confirmed cases among faculty was 40% and among administrative staff, 80%.From the 330 unique cases with positive test results, complete data became available for 259 . A total of 20.7% of the cases were non-vaccinated, 1.4% were partially vaccinated, 35.9% were fully vaccinated, and 42% were vaccinated with a booster dose. The total number of reinfections was 43 . A total of 23.3% were non-vaccinated, 4.7% partially vaccinated, 37.1% fully vaccinated, and 34.9% vaccinated with a booster dose.The “information delay” between the date of positive laboratory test and the person in charge’s notification had a mean of 1.3 days . The time interval between symptoms onset and the positive test result had a mean of 1.7 days . Their reported symptoms included fatigue, fever, headache and body ache, sore throat, cough, and runny nose. The time interval between symptoms onset and the person in charge’s notification had a mean of 2.9 days . For all 259 confirmed cases with available data, a class roster analysis was initially performed in order to identify potential close contacts and sources of transmission for 48 h before their symptoms’ onset. This practice was quickly abandoned, since it was not possible to identify every single encounter where the case was within a distance of 1.5m of each other for at least 15 min. Moreover, there was no obligatory attendance in courses’ lectures; therefore, it was impossible to verify which students attended each course. Finally, it was systematically observed that students used their masks properly only in classrooms and not in the remaining internal spaces and common areas. Therefore, it was decided that all students and faculty attending a class with a confirmed case within 48 h from symptoms’ onset were considered as close contacts. They were required to carry out a rapid or PCR test, at days 1 and 5 after the person in charge was notified until 1 May 2022 and day 5 since 1 May 2022. In total, 152 classes were mandated to carry out a test until 20 July 2022, summing up to more than 6000 tests. In December 2021, COVID-19 case counts rose rapidly in Greece, with viral genomic sequencing confirming the Omicron variant as the cause. Although the University of Piraeus and the urban environment in which it is located experienced high Delta transmission at the time of Omicron introduction, Omicron rapidly became the dominant variant. Omicron’s spread through the department is documented during the Christmas holidays (23 December 2021–5 January 2022), leading to unprecedented increases in the confirmed case counts. In general, confirmed cases numbers increased after every holiday , concentrated mostly among undergraduate/graduate students. All of these outbreaks were quickly controlled when students returned to classes. This is the first evidence that the containment protocol applied in the department was efficient and effective.p-value = 0.203), a two-sample t-test was performed comparing the means values of weekly students’ confirmed cases in the department vs. the community’s weekly confirmed cases in the age group 18–39. The yielded results  support the argument that the hypothesis the department’s confirmed COVID-19 cases were less than the community’s respective 18–39 age group cannot be rejected at a 5% significance level.A second argument regarding the protocol’s efficacy stems from the fact that the confirmed cases in the department were systematically less than the community’s. In general, there is a lack of empirical data in a university environment about the efficacy of the individual NPIs involved, but it is beyond doubt that they reduced COVID-19 transmission. Focusing on mask usage, some first results indicate a reduction between 2.7 and 3.6 times in new infections through classroom interactions . The extFinally, vaccine effectiveness against symptomatic Omicron infection was reduced, even in the highly vaccinated department’s population. Current vaccines are protecting against severe illness, hospitalization, and death , but OmiSummarizing, the case illustrates that an Omicron peak took place during a time when classes were not in session, and the return to class in 2022 was marked by rapidly falling disease incidences in the department, despite in-person classes, confirming evidence from the respective studies in U.S. universities ,15,16. MAlthough the major limitation of the present analysis is the inherent subjectivity of the confirmed cases remembering all relevant information during the phone interviews, the Department of Industrial Management and Technology of the University of Piraeus case is important. The short information time of the person in charge for the protocol’s implementation regarding confirmed cases, followed by rapid contact tracing and isolation, led to limited transmission in the department. No major outbreaks were observed when classes were in session and the resulting number of confirmed cases was manageable under the applied NPIs framework. It has to be stated here that students were adherent and positive to the implemented protocol, which is in agreement with previous research findings .Data support the hypothesis that developing a communication channel to students, staff, and faculty; vaccination promotion; frequent and adaptive testing; and vigorous face masking prevents widespread outbreaks of COVID-19 in universities, despite the worsening epidemiological conditions. The department’s confirmed COVID-19 cases were less (with a mean percentage difference of 50%) than the community’s respective 18–39 age group. The presented evaluation can be helpful in terms of forming a standardized protocol for tertiary education institutes in case of future epidemics.


For 84 cases of no metastasis, monochromatic spectral and iodine maps were obtained to compare differences under various breast densities using the K-means algorithm. The optimal T/B, T/M, and CNRb (related to mammary glands) were achieved for the 40-keV image. Conversely, CNRm (related to lungs) was better for higher energy. The optimal balance was achieved at 80 keV. T/B, T/M, and CNR were excellent for iodine maps, particularly for density > 25%. In conclusion, energy of 80 keV is the parameter most suitable for observing the breast and lungs simultaneously by using monochromatic spectral images. Adding iodine mapping can be appropriate when a patient’s breast density is greater than 25%.Differentiating tumor tissue from dense breast tissue can be difficult. Dual-energy CT (DECT) could be suitable for making diagnoses at breast cancer follow-ups. This study investigated the contrast in DECT images and iodine maps for patients with breast cancer being followed-up. Chest CT images captured in 2019 were collected. Five cases of metastatic breast cancer in the lungs were analyzed; the contrast-to-noise ratio (for breast tissue and muscle: CNR According to data from the International Agency for Research on Cancer, there were 19.3 million new cancer cases and almost 10 million cancer-related deaths in 2020. Breast cancer had the highest morbidity and mortality rates for female patients. In Taiwan, breast cancer is the most common cancer in women. In 2017, the median age of cancer development was 63 years, but the median age for breast cancer development was 55 years. Therefore, the average age of patients with breast cancer is becoming lower [Mammography and breast ultrasound are methods commonly used to detect breast cancer. The accuracy of breast ultrasound is strongly affected by the equipment used and the operator performing the procedure; by contrast, mammography is a more standardized method. Therefore, for early-stage breast cancer that cannot be detected through palpation, mammography can be used to easily detect breast calcification. Mammography enables assessment of breast lumps detected through palpation, as well as asymptomatic breast lumps that cannot be detected through palpation. Mammography detection produces optimal results on individuals with breast atrophy and hence has excellent detection results when applied to postmenopausal women because it can detect microcalcifications and stage 0 breast cancer in which there are no symptoms, thereby reducing the breast cancer mortality rate among women aged 40–74 years. The sensitivity of mammography is affected by the stage of the patient’s menstrual cycle. Therefore, women should undergo mammography during the week after the end of their period because the sensitivity of mammography is highest and the density of breast tissues is lowest at that time ,6,7.The sensitivity of mammography ranges from 83% to 98% for fatty breasts but 48% to 64% for dense breasts [The advantages of CT include its ability to provide excellent diagnostic information and extremely clear images within short scanning times. CT has recently been upgraded to dual-energy CT (DECT). Taking advantage of the fact that different tissues attenuate X-rays to differing degrees, DECT uses dual energy spectra to obtain images with tissue characteristics or an iodinated contrast media distribution; it enables exclusion of the location difference between tissues and organs or the time difference of contrast media between tissues and organs ,11,12. DTherefore, this study used DECT and iodine mapping to investigate contrast differences in recurrent breast cancer for breasts of various densities and thus determine whether DECT can be used to detect lesions and improve the sensitivity of postoperative follow-ups. This study had two expected outcomes. The first outcome was the optimal monochromatic spectrum, in which the contrast between mammary glands, muscles, and tumors could be identified; tumors include breast cancer and metastatic cancer in the lungs. The second outcome was the use of the K-means algorithm to calculate the breast density and investigate the contrast in the optimal monochromatic spectral images and iodine maps when different breast densities were used.This study was reviewed by the Institutional Review Board (IRB) of Yuan’s General Hospital and was exempt from a full IRB review. Chest CT images obtained between January and December 2019 were collected from the Picture Archiving and Communication System of Yuan’s General Hospital; the images were captured using nonionic contrast media. The total number of cases was 2010; 1815 cases were not breast surgery cases, 80 cases were of patients who had undergone breast surgery, and 26 cases were of patients who had undergone breast implantation; hence, these cases were excluded from the current study. Of the remaining 89 cases, 5 cases were patients with metastatic breast cancer in the lungs; the 5 corresponding images were used for energy optimization. The other 84 cases were patients with breast cancer, and 80-keV monochromatic spectral images and iodine maps for each of these cases were reorganized and the data exported.For all cases, scanning was performed using a GE Discovery CT750 HD scanner  in the single-source, dual-energy gemstone spectral imaging (GSI) mode. It is in one rotation by completing 80 kVp and 140 kVp instantaneous switching to collect data. Compared with the conventional multi-detector CT, it provides not only virtual monochromatic spectral images at 40–140 keV but also material decomposition images. Precontrast CT images were obtained first. A nonionic iodinated contrast agent of concentration 300 mgI/mL was administered through the antecubital vein by using a 20-gauge intravenous catheter with a power injector . All patients received 90 mL of contrast agent at a rate of 1 mL/s. Image processing and analysis were performed using GSI Viewer software 4.6 . The virtual monochromatic images and iodine-based material decomposition images were reviewed.b was the CNR of breast tumor in the monochromatic spectral image and iodine map and expressed as m was the CNR of metastasized tumor in the monochromatic spectral image and iodine map, expressed as tumor/HUgland, to observe the difference between the tumor and normal mammary glands. T/M was the tumor-to-muscle ratio and is defined as the HU ratio of marked breast tumor to normal muscle tissues, HUtumor/HUmuscle, to observe the difference between the tumor and normal muscle tissues. This study used analysis of variance to analyze the images obtained at energy of 40–140 keV and identify differences. ANOVA and Fisher’s least significant difference (LSD) method were employed for multiple comparisons.In experiment 1, the images of the five cases of metastatic breast cancer were reorganized to obtain monochromatic spectral images with the optimal outcome. Next, the reorganized CT images were exported to a computer for analysis, and the DICOM viewer was used to mark the region of interest. The virtual monochromatic spectral images for the energies 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, and 140 keV were generated, and four items were marked, namely breast tumor, metastasized tumor, mammary gland, and muscle. For each item, three sections were taken and used to calculate the contrast-to-noise ratio (CNR) of the monochromatic spectral image for each patient. CNRb, T/B, and T/M were analyzed, and the t test was used for comparison.The optimal monochromatic spectral image was the image obtained at 80 keV. In experiment 2, the 80-keV images of the 84 cases were reorganized. Next, the iodine map was opened to mark the areas that were exactly the same in two images. The median CNRBreast density is defined as the percentage of mammary glands in a breast. The Breast Imaging Reporting and Data System was referenced to divide breast density into four classes, namely 0–24%, 25–49%, 50–74%, and 75–100%.The craniocaudal view was used for mammography imaging, and the K-means algorithm  was emplb, and CNRm determined. The median T/B, T/M, and CNRb for the 40-keV image were 5.04, 2.30, and 7.39, respectively; this was the best result (p < 0.05). Therefore, obtaining images at 40 keV can maximize the difference between tumor and tissues. However, CNRm was highest for the image obtained at 140 keV; its median value was 164.58 (p < 0.001). This study thus discovered that a balance must be made between the greatest contrast for breast cancer and that for metastatic breast cancer in lungs.p = 0.03, 0.02, 0.009, 0.006, 0.004, 0.003, and 0.002, respectively). The second-best T/B value, found when the image was obtained at 50 keV, was superior to the result when the image was obtained at 110, 120, 130, or 140 keV . The optimal T/M was achieved when the image was obtained at 40 keV; this result was superior to the results when the image was obtained at 60, 70, 80, 90, 100, 110, 120, 130, or 140 keV . The T/M achieved when the image was obtained at 50 keV was superior to the result when the image was obtained at 70, 80, 90, 100, 110, 120, 130, or 140 keV , and that for the 60-keV image was superior to the result when the image was obtained at 80, 90, 100, 110, 120, 130, or 140 keV . Similarly, the T/M values for the 70-keV image was superior to those for the images obtained at 100, 110, 120, 130, and 140 keV . A superior T/M was found for the image obtained at 80 keV than at 130 or 140 keV . The optimal CNRb, achieved for the image obtained at 40 keV, was superior to those achieved for the images obtained at 80, 90, 100, 110, 120, 130, and 140 keV . The CNRb achieved for the image obtained at 50 keV was superior to that for the images obtained at 110, 120, 130, and 140 keV . The optimal CNRm was discovered for the image obtained at 140 keV; the differences between this CNRm and the results for the images obtained at 40, 50, 60, 70, and 80 keV were significant . The CNRm value achieved for the image obtained at 130 keV was superior to the result when the image was obtained at 40, 50, 60, 70, or 80 keV . The CNRm value for the image obtained at 110 keV was superior to the result for the images obtained at 40, 50, 60, and 70 keV . The CNRm value achieved when the image was obtained at 100 keV was superior to that when the image was obtained at 40, 50, or 60 keV . The CNRm value achieved for the image obtained at 90 keV was superior to the result for the images obtained at 40, 50, and 60 keV . The CNRm value determined for the image obtained at 80 keV was superior to that for the images obtained at 40 and 50 keV . Finally, the CNRm value achieved for the image obtained at 70 keV was superior to the result for the image obtained at 40 keV (p = 0.02).The results of Fisher’s LSD method indicate that the optimal value of T/B was achieved for the image obtained at 40 keV; this result was significantly superior to the results when the image was obtained at 80, 90, 100, 110, 120, 130, or 140 keV .In this part of the study, the images of the 84 cases were analyzed in b obtained from the iodine maps were significantly higher than those obtained from the monochromatic spectral images, and as the density increased, the average and maximum values of T/B, T/M, and CNRb from the iodine maps and monochromatic spectral images also increased. Therefore, contrast may become sharper when breast density is higher.Next, the K-means algorithm was used to classify the images on the basis of the four classes of breast density. The results revealed that 13 images corresponded to density in the first class 0–24%; , 59 to tb were achieved for the images obtained at 40 keV. Khan et al. observed the lungs using conventional CT and DECT and reorganized monochromatic spectral images to investigate tuberculosis. Their results indicated that the monochromatic spectral images obtained at 140 keV were superior to those obtained at 80 keV and that the combination of the two types of images achieved superior results to conventional CT images [m results were attained for these images. In conclusion, this study focused on the follow-up of breast cancer—that is, the detection of recurrent breast cancer—and assessed the quality of images. The mammary glands and lungs, where cancer cells can metastasize, were investigated. Breast CT and lung CT are usually performed together clinically; hence, this study aimed to identify the parameter with which the optimal identification can be made. The analysis results were standardized, and 80-keV energy was discovered to be the parameter most suitable for observing the breast and lungs simultaneously , and This study used the K-means algorithm to classify breast density. Numerous studies have employed the K-means algorithm in CT or magnetic resonance image analysis , as wellAnother study has also indicated that the breast density of women decreases as they age  because b in the monochromatic spectral image and iodine map increased as the breast density increased, as revealed in This study compared the age of the patients with their monochromatic spectral image or iodine map and discovered that the average and maximum T/B, T/M, and CNRvol is 7.6 ± 0.9 mGy vs. 9.9 ± 1.4 mGy (for patients with BMI ≤ 25 kg/m2); 7.7 ± 0.9 mGy vs. 10.8 ± 1.6 mGy (for patients with BMI >25 to <30 kg/m2); 9.3 ± 1.6 mGy vs. 13.3 ± 3.7 mGy (for patients with BMI ≥ 30 kg/m2). There were significant differences in objective assessments for DECT were 26.8% lower than SECT, but no significant differences in subjective assessments for the image quality [2. DECT is a promising approach that provides quantitative visualization as well as the ability to suppress material such as iodine while maintaining radiation dose. Dual-energy techniques acquire spectral CT datasets by scanning the same area twice with different kilovolt peaks. This can be achieved either by dual-source CT or through rapid tube potential switching (our study). However, these approaches may require patients to be prospectively selected for DECT. In the latest generation, multiple energy spectral photon counting DECT systems use a dual-layer detector [According to a comparion of chest CT using DECT and SECT revealed that the mean CTDI quality . The mea quality , but is detector ,23 to caIn DECT, monochromatic spectral images are mainly used by physicians for diagnoses, and tissues, such as mammary glands, tumors, fat, and lymph nodes in the images must be clearly distinguished by physicians after comprehensive detection. This study proposed that monochromatic spectral images obtained at 80 keV are the most suitable images for such use. In addition, this study proved that excellent T/B, T/M, and CNR values are achieved for iodine maps when distinguishing normal mammary glands from malignant breast cancer, particularly for breasts of density > 25%. Therefore, using monochromatic spectral images and iodine maps can make the identification of small tumors and distinguishing of tumor edges more straightforward.


Acetobacter, norank-c-Cyanobacteria, and Weissella played key roles during fermentation process. Norank-f-Actinopolyporaceae, norank-c-Cyanobacteria, Pediococcus, and Microbacterium had significant correlations with the physicochemical characteristics. The most common bacterial species were associated with a citric acid content, whereas the least number of bacterial species correlated with malic acid content. Findings could be helpful for the bioreactor optimization, and thus reaching the level of pilot scale and industrialization.The bioreactor based on solid-state fermentation technology has been developed for vinegar production, standardization of fermentation process and stabilization of vinegar quality. The microbial community diversity, and volatile compounds of six cultivars of vinegar samples fermented in a self-designed solid-state fermentation bioreactors were investigated using Illumina MiSeq platform and gas chromatography mass spectrometry (GC-MS) technology. The correlations between the richness and diversity of microbiota and volatile profiles, organic acids, as well as physicochemical indicators were explored by R software with the coplot package. The findings indicated that  TraditiLactobacillus, Acetobacter, Trichoderma, and Candida were considered as the dominant genera. These studies help us to better understand the mechanism of traditional vinegar fermentation process, as well as the dynamic changes of volatilization, physicochemical properties, and microbial community structure during fermentation.In the last decade, the studies on Chinese vinegar research have mainly focused on the dynamics and diversity of microbial communities, and mainly adopted culture-dependent or culture-independent methods , 7. MeanCurrently, Chinese vinegar is generally produced under open and non-sterile environmental conditions . These fThe rapid development of bioreactors based on SSF technology opens a new way for vinegar production, standardizing fermentation process and stabilizing vinegar quality . It has Combining the principle of multilateral co-fermentation of traditional vinegar SSF with mechanized equipment, the rotary drum type vinegar SSF bioreactor was designed to suit the vinegar fermentation process in our preliminary study. The bioreactor is composed of a power system, baffle, ventilation, and vinegar drenching device, which can complete the steps of inoculation, fermentation, vinegar drenching, and vinegar fumigation in the bioreactor. The baffle device combines the functions of cooling and stirring into one, which reduces the minimum speed of the reactor and reduces energy consumption. The intermittent vinegar drenching process and vinegar fumigation methods were also proposed for the characteristics of the bioreactor. The intermittent rotation strengthens heat and mass transfer, which is beneficial for the growth of microorganisms. In addition, the convective transport is enhanced by increasing the surface contact of the base with wet air and cooling water due to the mixing process. Unfortunately, despite these advantages, the utilization of bioreactors to produce vinegar on an industrial scale has not yet been fully realized. Thus, in order to further improve the design of the bioreactor to meet the needs of industrial scale production, it is essential to deeply understand the fermentation performance of the bioreactor and explore the changes of metabolites during fermentation. In addition, since the coexistence of various microorganisms has a significant influence on the unique flavor and taste of vinegar, a deep understanding of the microbial composition is also required.Therefore, the aim of this study is to deeper insight into the changes in vinegar quality indexes and microbial dynamics during AAF in this self-designed rotary drum bioreactor. The objectives of this study were to monitor the changes of physicochemical properties, organic acid content and volatile flavor components. The diversity and succession of microbial communities were explored using high-throughput sequencing technology. Furthermore, the potential correlation between dominant bacteria and vinegar quality indexes was determined through multivariate data analysis. The findings in this study could be helpful for the bioreactor optimization, and thus reaching the level of pilot scale and industrialization.2.2.1.5 U/ml) and glucoamylase (1 × 105 U/ml) were purchased from Shanghai Yuanye Biotechnology Co., Ltd. . Lactic acid, acetic acid, oxalic acid, citric acid, malic acid, succinic acid, and tartaric acid were chromatographic grade and purchased from Shanghai Yuanye Biotechnology Co., Ltd. The DNA extraction kit was obtained from United States Omega Bio-Tek . Other standard compounds were of analytical purity and purchased from Tianjin Tianli Chemical Reagent Co., Ltd. .The fermentation raw materials including flour, bran, rice chaff, and Daqu were collected from the local farmers market of Baoding city in Hebei Province, China. The high-activity yeast culture was purchased from Angel Yeast Co., Ltd. Amylase  were added into the reactor through the inlet pipe, and were stirred entirely by rotating the bioreactor for 20 min, which promoted vinegar fermentation. At the stage of saccharification and alcohol fermentation, the fermentation culture temperature was maintained at 28–32°C. The oxygen content at the outlet pipe and the internal material temperature were kept at 18–20% and 32–35°C, respectively. On the 19th day of the fermentation, the total acid contents in the vinegar declined, which suggested the end of the AAF stage. Consequently, the fermentation proceeded into the maturation stage, lasting for 5–7 days. After the fermentation, the acetic acid in the fermented grains of solid vinegar was soaked into the water through the water inlet pipe. After the immersion, the vinegar permeated into the juice tank through the solid–liquid isolation sieve plate, and then flowed into the storage tank via the bottom vinegar pouring pipe. Afterwards, one side of the tank was opened, the reactor was rotated, and the fermented grains were released immediately. When fumigating vinegar, high-temperature steam was injected into the baffle to heat the vinegar grains.During fermentation, 100–150 ml of vinegar samples from three vinegar drenching valves were collected on the 1st, 4th, 7th, 11th, 15th, and 19th day of the solid-state acetic acid fermentation process, and then mixed thoroughly to ensure the uniformity and representativeness of the samples. All samples were stored at −80°C until used for further analysis.2.3.The changes of physicochemical properties, including ethanol, total acid, involatile acid compounds, and reducing sugar content of the collected vinegar samples were determined according to GB 5009.225-2016 , GB/T 12456-2008 , GB 5009.235-2016 , and GB 5009.7-2016 , respectively.2.4.g for 5 min, and then the supernatant was filtered through a 0.22-μm filter prior to HPLC analysis. The instrument used was equipped with an automatic injector and a photodiode array detector UV at 210 nm. Separation was realized using a Sep-Pak C18 column  at 30°C. The mobile phase was 0.02 mol/L NaH2PO4, with a flow rate of 0.9 ml/min, and the injection volume of samples was 10 μl. Finally, each organic acid was quantified by calculating the peak area.Organic acids were measured by high-performance liquid Chromatography  referring to a previous method . The sta2.5.Volatile compounds of the vinegar samples were analyzed by utilizing head space solid phase microextraction coupled with gas chromatography mass spectrometry (HS-SPME-GC/MS) analysis  . BrieflyGC/MS analyses were performed on an Agilent 7890A GC and an Agilent 5953C MS equipped with a capillary column  . The GC The volatile compounds were then identified by matching the MS with the NIST05 mass spectral database and quantitatively calculated using the peak-area normalization method. All samples were analyzed in triplicate.2.6.2.6.1.To monitor the dynamic changes in a microbial community, samples were collected periodically on the surface of fermentation materials in the bioreactor on the day 1, 4, 7, 11, 15, and 19 during the AAF process. For each day, each 150 g of sample was collected at three different locations and mixed thoroughly to ensure the uniformity and representativeness of samples. All samples were put into sterile sealed bags and stored in a freezer at −80°C. Then DNA extraction was performed using the Soil DNA Kit . The concentration of extracted DNA was measured by a NanoDrop 2000 UV-vis spectrophotometer  and checked by 1% agarose gel electrophoresis. Bacterial primers 338F (5′-ACTCCTACGGGAGGCAGCAG-3′) and 806R (5′-GGA CTACHVGGGTWTCTAAT-3′) with specific barcode were employed to amplify the V3-V4 region of bacterial 16S rRNA genes by thermocycler PCR system . The PCR reaction was run as the method from our lab, which has been published by Ma et al. . The results were visualized with heatmap by using R software with the “corrplot” package.All the determinations were conducted in triplicate unless otherwise stated. Statistical analysis was performed using SPSS 22.0  and Origin9.1. Principal component analysis (PCA) was performed using the i-sanger tools to cluster samples according to the relative abundance of microbes. The correlation between bacterial community and physicochemical indicators, organic acids and volatile compounds were investigated by Spearman’s correlation coefficient at |3.3.1.2A), total acid (2B), amino nitrogen (2C), and reducing sugar contents (2D) are shown in th day (7.18 g/100 ml) of AAF. This observation was in agreement with previous studies . The succinic acid content showed a gradual upward trend, while the malic acid content decreased during AAF.The ratio of lactic acid to acetic acid gradually decreasing, and this ratio was less than 1 on the 11th day of fermentation, indicating that the acetic acid content exceeded lactic acid content. During the alcoholic fermentation of the early stage of AAF, the anaerobic condition is favorable for the metabolisms of lactic acid bacteria to produce lactic acid. On the 3rd day of fermentation, the acetic acid bacteria were introduced from the outside and began to proliferate in the reactor, leading to the rapid production of the acetic acid. Consequently, the content of acetic acid exceeded the lactic acid content, accounting for the largest proportion of total organic acids. However, the high lactic acid content can soothe the pungent taste of acetic acid . Additio3.2.Volatile compounds give vinegar a special flavor. Most volatile compounds are derived from microbial metabolic reactions, while others can be derived from degradation or Maillard reactions . In thisEsters are the most common aroma category in vinegar and contributed to the fruity and baking flavors of the product . Herein,Alcohols mainly originated from the alcohol fermentation stage that provided the precursors for the synthesis of organic acids . In thisAcidic compounds have a crucial influence on the sensory characteristics of vinegar . A total3.3.via 97 percent sequence identity cutoff, were obtained for bacterial dynamics and diversity. At the genus level, taxonomic affiliations of 97 percent sequence similarity clusters revealed a substantial taxonomic shift during the AAF process.After filtering low-quality reads, removing adapters, barcodes, and primers, and detecting chimera, roughly 39,705 to 59,287 effective tags, with various phylogenetic OTUs ranging from 16 to 48 Lactobacillus, Acetobacter, Cyanobacteria, Pediococcus, Weissella, and Mitochondria , Pediococcus (1.22–0%), and Weissella (0.09–0.01%) groups were also noted. These findings revealed that Lactobacillus and Acetobacter were competing spontaneously. Acetobacter was a fierce competitor in the bacterial community’s succession. Alpha diversity indexes representing the number of OTUs, Sobs, Chao, Shannon, Simpson, Ace, and Coverage index were determined to further confirm whether our sequencing results were sufficient to analyze the food fermentation ecosystem, and these indexes demonstrated that the richness of diversity varied during AAF , which could be due to the insufficient oxygen flow in the bioreactor.However, the relative content of tetramethylpyrazine detected in this study was low. Bacillus is a high-yield bacterial strain for tetramethylpyrazine biosynthesis and is closely related to the formation of ligustrazine and its precursors, 2,3-butanedione and 3-hydroxybutanone. The relative content of 4.Lactobacillus and Acetobacter are the most common bacteria associated in AAF. Bacterial diversity increased early in the AAF process and subsequently declined afterwards. The bacterial growth during the AAF process was related to pH, titratable acidity, and alcoholic degree. During the entire AAF process, the abundance of lactic acid and acetic acid bacteria was greater than 60%, implying that lactic acid and acetic acid bacteria had a significant impact on vinegar flavor. Furthermore, after AAF, the structure of the bacterial population may be altered to reflects the properties of acidophilic and aerobic communities. The interaction between metabolic processes, bacterial patterns, and fermentation settings are being explored in greater depth, providing new insights into the role of bacterial communities in fermentation. Changes in metabolites during the AAF process were also caused by the dynamics and diversity of microbial population succession. These preliminary findings represent a paradigm shift in our understanding of AAF systems, in which acidophilic and aerobic bacterial communities play critical roles in enhancing alcohol availability and vinegar acetic acid yield. This work established the relationship between bacterial dynamics and metabolite changes in AAF of vinegar production, which might be used as a guide for future AAF fermentation experiments to improve the quality of vinegar.The bacterial composition and dynamic succession in the entire solid-state AAF vinegar was studied. The original contributions presented in the study are publicly available. This data can be found here: NCBI, accession number PRJNA934156.WW: conceptualization, data curation, formal analysis, investigation, and writing original draft. FZ: methodology, formal analysis, writing—review and editing, and visualization. XD: writing—review and editing and visualization. YL and JM: investigation, resources, and writing—review and editing. JW: supervision and writing—review and editing. QM and JS: funding acquisition, project administration, supervision, validation, and writing—review and editing. All authors contributed to the article and approved the submitted version.The authors are grateful to the Young Scholar Scientific Research Foundation of Hebei Agricultural University (YJ201850), the Program of the Hebei Youth Top-notch Talent Supporting Plan (0316027), Hebei Province “Three Three Three” Talent Project (A202005002).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.


As-prepared porous composite with adjustable interior structure and enhanced thermal property could be a promising candidate in the tobacco field.Porous composites have been widely used in the adsorption and catalysis field due to their special structure, abundant sites, and light weight. In this work, an environmentally friendly porous composite was successfully prepared via a facile freeze-drying method, in which cotton cellulose nanofiber (CCNF) was adopted as the main framework to construct the connected flue structure, and aramid nanofiber (ANF) was used as a reinforcer to enhance its thermal property. As-prepared porous materials retained a regulated inter-connected hole structure and controllable porosity after ice template evolution and possessed improved resistance to thermal collapse with the introduction of a small amount of aramid nanofiber, as evaluated and verified by FTIR, SEM, and TGA measurements. With the increased addition of cotton cellulose nanofiber and aramid nanofiber, the porous composites exhibited decreased porosity and increased pressure drop performance. For the CCNF/ANF-5 sample, the pressure drop was 1867 Pa with a porosity of 7.46 cm Porous materials possess a huge amount of voids among solids with different shapes, dimensions, or diameters, and the micro-channels formed by the inner-connected holes all endow porous materials with special physical properties such as penetrability, pressure drop, and low density. With an appropriate choice of raw materials and preparation technology, the specific geometric parameters of porous materials can be tuned to an ideal value, finally obtaining the desired density and specific surface area, etc. ,2,3. DueOne typical application of porous materials is the flow of smoke in the cigarette filter rod. The large-scale commercial use of cigarette filters began in 1952, using cellulose diacetate (CA), and nearly 95% of the world’s sold cigarettes are sold with a CA filter today ,11. Thus2, TiO2) [Cellulose, as a rising star, has been widely studied because of its wide abundance and attractive properties, in which cotton cellulose fiber accounts for approximately 40% of global fiber production . Researc2, TiO2) ,22 has rAramid nanofiber (ANF), a 1D nanofiber, also has a similar structure to CA and CCNF but with a higher modulus, high-temperature resistance, and impressive chemical and thermal stabilities. Based on these advantages, it has been applied in composite reinforcement, battery separators, adsorption filtration, electrical insulation, and supercapacitor electrodes ,24,25. YTo the best of our knowledge, several new materials such as polylactic acid, cellulose nanofibers, and polypropylene have been evaluated for commercial cigarette filter rods. However, they are difficult to apply to large-scale production due to the limitation of material properties or the molding process. In this paper, a simplified binary porous system consisting of the CCNF main framework and ANF reinforcement is proposed via the freeze-drying method. By adjusting the ratio and concentration of raw materials, different porous structures and controllable pressure drop performances can be obtained to meet the performance requirements of the cigarette filter rod.Cotton cellulose nanofiber with a diameter of 4~10 nm and a length of 1~3 μm was purchased from Guilin Qihong Technology Co., Ltd . Aramid nanofiber  was obtained from Shandong Jufang New Material Co., Ltd . Deionized water was homemade in the lab and used throughout the whole experiment.Cotton cellulose nanofibers with abundant polar hydroxyl groups can form a stable hydrogel with water due to a great deal of hydrogen bonding. Furthermore, the amide groups and carboxyl groups of aramid nanofiber provide convenience when combining them with cotton cellulose nanofibers. In order to guarantee good dispersion, the blending order should strictly follow the following steps. Firstly, 0.89 g of ANF was dispersed in 30 g of deionized water with a hand-held homogenizer for 5 min. Subsequently, 2.5 g of CCNF was slowly dropped into the above mixture and stirred for 15 min. The obtained hydrogel samples were sealed and stored at a low temperature.innerΦ = 7 mm, length l = 88 mm), and then transferred into a fridge at zero degrees centigrade for 12 h. Finally, paper tube samples were placed in a freezer dryer for 24 h to remove the ice template. According to the ratio and amount of CCNF and ANF, the obtained samples were labeled as CCNF/ANF-x, where the x value could be 1, 2, 3, 4, 5, or 6. The detailed composition proportion of the experimental sample and the control group sample were displayed in The above-prepared hydrogel sample was injected into a hollow round paper tube  and EDS  to obtain their microstructure and element distribution. FT-TR  and TGA  were used to test the chemical composition and thermal properties. The pressure drop performance of porous CCNF/ANF filter rods was recorded by the cigarette/filter rod integrated test bench  with an inlet pressure of 3 bar and a gas flow of 17.5 ± 0.1 mL/s. To eliminate the possible errors, each group tested 10 samples, and finally, exported an averaged value.Referring to the pressure drop test standard of the CA cigarette filter rod with a standard length of 120 mm , the acceptable pressure drop value is 2550 ± 290 Pa. After conversion, the acceptable pressure drop value of the 88 mm long filter rod used in this test should be 1870 ± 213 Pa.−1 and 1062 cm−1 correspond to the stretching vibration of -OH and C-O ether groups [−1 represents -CH2 groups, and other peaks at 1419 cm−1 and 1325 cm−1 belong to the -CH2 scissoring and wagging motion in cellulose. Moreover, the absorption bands at approximately 1053 cm−1 and 900 cm−1 are in accordance with cellulosic β-glycosidic linkages, indicating the existence of amorphous cellulose [−1 and 1650 cm−1 correspond to N-H stretching vibrations and C = O stretching vibrations from ANF [r groups , and it ellulose ,30. It ifrom ANF ,32. The SEM images of the pure CCNF porous sample and the CCNF/ANF porous sample are displayed in As ANF is introduced into the porous composites, tremendous changes in the micro-structure take place, as shown in An EDS test of CCNF/ANF porous samples was conducted, as shown in Subsequently, the thermal stability of as-prepared porous composites was characterized by TGA under an air atmosphere. As aforementioned, aramid nanofibers have better heat resistance than cotton cellulose nanofibers, and three typical samples were chosen to make an intuitive comparison, as displayed in The pressure drop performance of porous samples is listed in P), which can be calculated as follows [ρ1 and ρ2 represent the density of the CCNF/ANF porous composite and solid framework , M1, V, r, and l respectively represent the weight of the porous composite and the volume, radius, and length of the filter rod . In addition, the weight of each single hollow round paper tube is approximately 0.47 g. To further investigate the pressure drop performance transformation law, the inner structure and porosity should be explored in comparison with the pressure drop. The quantitative data that can be evaluated include the porosity ( follows :(1)P=1ρ13/g, and the minimum porosity is exhibited by the CCNF/ANF-6 sample with a value of approximately 7.34 cm3/g. It is apparent that the pressure drop performance shows a negative correlation with porosity in All the porous composites show porosity of approximately 7~13 cmTherefore, the pressure drop values of CCNF/ANF-4, CCNF/ANF-5, and CCNF/ANF-6 meet the requirements of the cigarette filter rod, and CCNF/ANF-5 is the best choice. By adjusting the addition ratio of CCNF and ANF, controllable pressure drop performance with enhanced thermal stability can be obtained.3/g. The finite element analysis of the flow field on the basis of the inner structure and porosity can be conducted in future work to deeply reveal the flow mechanism of gas in micropores. These porous nanofiber-based composites with adjustable pressure drop performances will shine brilliantly in future cigarette applications.With a facile freeze-drying method, porous composites were synthesized and exhibited controllable pressure drop performance and enhanced thermal stability. Using ice as a soft template afforded long continuous channels for excellent gas flow, while CCNF and ANF constructed the main framework and reinforcement parts. With the increased addition of CCNF, the pressure drop value increased. ANF could break down the neighboring walls formed by CCNF, enhancing internal connectivity and providing more active sites for adsorption. With an appropriate ratio of CCNF and ANF, an ideal pressure drop could be realized. CCNF/ANF-5 showed the best pressure drop value of 1967 Pa with a porosity of 7.46 cm


To explore the risk factors of recurrence after second endovascular embolization of recurrent aneurysms and the characteristics of recurrent refractory aneurysms to help clinical decision-making.Forty-nine patients with recurrent aneurysms who underwent repeated embolization were retrospectively enrolled and divided into the recurrent and non-recurrent group. The risk factors of recurrence, complications and follow-up results of repeated embolization, and characteristics of recurrent refractory aneurysms were analyzed.P = 0.022), aneurysm classification (P = 0.014), and Raymond-Roy grade after the second embolization (P = 0.001) were statistically different between the two groups. Multivariate analysis demonstrated the Raymond-Roy grade as an independent risk factor for the recurrence of aneurysms after the second embolization (P = 0.042). The complication rate after the second embolization was 4%. There were five recurrent refractory aneurysms with an average aneurysm size of 23.17 ± 10.45 mm, including three giant aneurysms and two large aneurysms. To achieve complete or near-complete embolization of the recurrent refractory aneurysms, multiple treatment approaches were needed with multiple stents or flow diverting devices.Among the 49 patients with the second embolization, 5 were lost to follow-up, 9 recurred, and 35 did not. Univariate analysis showed that aneurysm size (Aneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices. Ever since the short-, medium-, and long-term results of the International Subarachnoid Hemorrhage Trial (ISAT) were published –3, the pThis retrospective study was conducted between January 2012 and June 2017 with approval from the ethics committee of our hospital. All patients had given their signed informed consent to participate. The inclusion criteria were imaging-confirmed saccular cerebral aneurysms which were recurrent after endovascular embolization, the initial treatment and retreatment approaches being endovascular embolization and complete follow-up data in digital subtraction angiography (DSA). The exclusion criteria were dissection, fusiform, and blister-like aneurysms, pseudoaneurysms, aneurysms concurrent with a dural arteriovenous fistula, cerebral arteriovenous malformation, Moyamoya disease and malignant tumors, aneurysms which were treated with flow diverting devices at the first time, and aneurysms which were treated with parent artery occlusion at retreatment. The enrolled patients were divided into two groups: the recurrent group including aneurysms that were recanalized after the second endovascular embolization and the non-recurrent group with aneurysms that remained completely occluded after the second endovascular embolization.The clinical data were collected, including age, sex, smoking history, alcohol abuse, hypertension, hyperlipidemia, and diabetes mellitus. The aneurysm data were also recorded, including the aneurysm size , wide or narrowed necks (wide: >4 mm or neck to dome ratio >1/2), lateral/bifurcation aneurysms, anterior or posterior circulation, and ruptured or un-ruptured aneurysms based on computed tomography (CT) findings of subarachnoid hemorrhage.Aneurysm recurrence after the second endovascular embolization was defined as angiographically increased aneurysm volume at follow-up compared with angiography at the end of the second endovascular embolization. Non-recurrence was defined as no change in the aneurysm volume at follow-up angiography compared with that at the end of the second embolization. Aneurysm recurrence was confirmed by two experts in endovascular embolization. Mild recurrence indicated mild compression of coils with the display of the aneurysm neck, whereas major recurrence was caused by obvious loosening and compression of coils or herniation of coils with the display of the aneurysm dome. The Raymond-Roy classification system was used to describe aneurysm occlusion degree immediately after aneurysm embolization, with grade I indicating complete occlusion, II near complete occlusion with a residual neck, and III incomplete occlusion with a residual aneurysm sac. Recurrent refractory aneurysms refer to aneurysms that recur after the third endovascular embolization.The re-embolization criteria were aneurysms with re-rupture, major recurrence or recurrence >20% of the original aneurysm volume, progressive enlargement of the remnant neck or growth of a small sac, and aneurysms that were suitable for both surgical clipping and endovascular embolization. For recurrent aneurysms after embolization, interventional embolization was preferred, especially for posterior circulation aneurysms. In order to prevent the recurrence after the second embolization, stent-assisted embolization should be performed as far as possible. If there was a high possibility of recurrence after stent-assisted embolization, multiple stents should be adopted to assist embolization, or flow diverting devices should be used. For recurrent aneurysms that were difficult to be treated by the second endovascular embolization or might not be embolized with complete or near-complete occlusion, surgical clipping should be considered.Endovascular embolization was performed with the patient under general anesthesia. Systemic heparinization was applied during the procedure, with the first dose of heparin being 3,000 IU followed by 1,000 IU / h. The catheters and microcatheters were continuously infused with heparin sodium saline under pressure. After the right femoral artery was punctured using the Seldinger technique, a 6F or 8F femoral artery sheath was implanted. The guiding catheter was navigated to the level of the petrous bone segment of the internal carotid artery or the second cervical vertebra of the vertebral artery, and three-dimensional rotational angiography was performed with three-dimensional reconstruction for the measurement of recurrent aneurysm size and the proximal and distal diameters of the parent artery. Then, a microcatheter was navigated to the aneurysm cavity for coil embolization. Stent-assisted coiling was conducted for wide-necked aneurysms until no filling of contrast agent in the aneurysm. If the Pipeline Embolization Device (PED) was used to treat recurrent aneurysms, an 8F Envoy guiding catheter  and 6F Navien  and Masksman  microcatheters formed a triaxial system to support the release of PED.For un-ruptured recurrent aneurysms requiring stent-assisted embolization, oral antiplatelet drugs (100 mg aspirin and 75 mg clopidogrel) were started at least 3 days before the operation. For recurrent aneurysms with acute rupture, aspirin (300 mg) and clopidogrel (300 mg) were administered orally or intranasally 2 h before the operation. For emergent treatment of ruptured aneurysms requiring stent-assisted embolization, tirofiban (8.0 μg / kg in a bolus within 3 min) was given after stent implantation, and tirofiban 0.1 μg / kg / min was continually pumped in after operation until the patient was able to take oral drugs. After the embolization, the patients were treated with dual antiplatelet medications (100 mg aspirin and 75 mg clopidogrel) for 6 weeks and then aspirin 100 mg for 6 months. For recurrent aneurysms that needed to be treated with PED, antiplatelet drugs (100 mg aspirin and 75 mg clopidogrel) were administered orally at least 5 days before the operation. Thromboelastogram was tested at the same time, and the drugs were adjusted according to the platelet activity inhibition rate. After the operation, the drugs were administered orally continuously for 6 months and then changed to aspirin 100 mg for life.Six months after the second embolization of intracranial aneurysms, whole-brain DSA was routinely performed for all patients, and then magnetic resonance angiography (MRA) or DSA was performed every 1 year according to the last angiographic follow-up results. The patients were followed up for at least 5 years. If follow-up DSA showed that the aneurysms had dense embolization with no obvious signs of recurrence, follow-up angiography would be performed with MRA. If follow-up DSA demonstrated recurrence signs in the embolized aneurysms, the follow-up would be performed with DSA.All patients were evaluated with the modified Rankin scale (mRS) scores before discharge and 6 months after operation: 0, no symptoms or discomfort; (1) with symptoms but no neurological defect; (2) mild disability but being able to live on themselves; (3) moderate disability requiring other people's care; (4) moderate and severe disability, unable to take care of themselves; (5) severe disability and being bedridden; (6) death. The prognosis was good if the score was lower or stable between 0 and 2, but poor if the score was increased to 3–5.t-test. Counting data were expressed as numbers and percentages and tested with the Chi-square test or Fisher's exact probability method. Univariate and multivariate logistic regression analyses were analyzed. P < 0.05 was considered to be statistically significant.The statistical analysis was performed with the SPSS22.0 software . Measurement data were expressed as mean ± standard deviation and tested with the independent sample Among 867 patients with saccular cerebral aneurysms who were treated between January 2012 and June 2017, 123 patients experienced aneurysm recurrence (a recurrence rate of 14.2%), including 56 aneurysms with mild recurrence and 67 with major recurrence. Among 67 aneurysms with major recurrence, six patients were transferred to surgical clipping, and 12 refused retreatment because of a higher risk of treatment and poor prognosis. The remaining 49 patients with 49 recurrent aneurysms underwent the second endovascular embolization and were enrolled in this study, including 16 male and 33 female patients with an age range of 27–69 years (mean 47.71 ± 10.22). There were 18 patients with hypertension, 6 with hyperlipidemia, 5 with diabetes mellitus, 10 with alcohol abuse, and 7 with a smoking habit .The mean size of the 49 aneurysms was 13.07 ± 8.57 mm (range 3.37–38 mm), including 7 small, 16 medium, 21 large, and 5 giant aneurysms, with the large and giant aneurysms accounting for 53.1% (26/49). The mean size of the aneurysm neck was 4.76 ± 1.79 mm (range 1.3–9.37 mm), with 29 wide-necked and 20 narrow-necked aneurysms. Twenty-four aneurysms were ruptured, 29 lateral and 44 in the anterior circulation. There were 18 aneurysms in the ophthalmic artery segment: 14 in the posterior communicating artery segment, 5 at the anterior communicating artery, 4 in the cavernous segment, 2 at the basilar artery, 1 at the middle cerebral artery, and 5 in other locations .n = 9, n = 35, After the second endovascular embolization of recurrent aneurysms, 5 patients were lost to follow-up, and the remaining 44 patients had angiographic follow-up and were divided into the recurrent n = 9,  and non-P < 0.05) difference between the two groups in aneurysm size (P = 0.022), aneurysm classification based on aneurysm size (P = 0.014), and aneurysm occlusion degree  after the second embolization (P > 0.05) difference was detected between the two groups in age, sex, hypertension, hyperlipidemia, diabetes mellitus, aneurysm neck size, aneurysm type and location, rupture status, mode of second embolization, aneurysm occlusion degree after the first embolization, and follow-up time.The clinical data , aneurysm data , re-embolization approaches, follow-up time, and aneurysm occlusion status were analyzed. Univariate analysis demonstrated a significant  (After the risk factors with = 0.042) . CompareTwo patients (4%) had a thrombotic event during the second embolization procedure of recurrent aneurysms, without causing any symptoms. In one case of internal carotid artery ophthalmic artery aneurysm treated with stent-assisted embolization, stent thrombosis occurred, and 10 ml of tirofiban (0.1 mg / ml) was given intravenously rapidly and later was pumped in continuously for 24 h . After the blood vessel was recanalized, neither new cerebral infarction nor neurological deficit was found in the postoperative examination. In the other case harboring an A1 aneurysm at the anterior cerebral artery which was embolized with coils alone, the coil herniated into the parent artery, resulting in ipsilateral A1 occlusion but no symptoms because of collateral circulation through the opened anterior communicating artery. There were no bleeding events during and 1 month after the second embolization.Among the 49 patients with recurrent aneurysms treated with the second embolization, five cases were lost to follow-up, and the remaining 44 cases were followed up for an average of 12.45 ± 11.14 months, with recurrence in nine cases, including three cases of mild recurrence and six cases of major recurrence. Five patients with major recurrence received the third endovascular embolization . Among 4Among 49 patients with recurrent aneurysms who received repeated embolization, five aneurysms in five patients received embolization≥3 and were defined as recurrent refractory aneurysms (two ruptured and three un-ruptured), with the aneurysm size ranging from 14.8 mm to 38 mm (mean 23.17 ± 10.45), including three giant aneurysms and two large aneurysms. There were four women and one man with an age range of 36–60 years (mean 49.4 ± 9.42). The location of the recurrent refractory aneurysms was the ophthalmic artery segment in three cases, a posterior communicating artery in one, and the A1-A2 junction in one. Four patients received embolization three times, and one received embolization four times. Eleven Enterprise stents and two PEDs were used in treating these five recurrent refractory aneurysms , 6.P = 0.022) and aneurysm occlusion degree (P = 0.001) as the risk factors affecting recurrence after the second embolization, whereas multivariate analysis demonstrated the Raymond-Roy aneurysm occlusion grade as an independent risk factor affecting the recurrence of intracranial aneurysms after the second embolization (P = 0.042). Complete occlusion significantly reduces the risk of recurrence after second embolization compared with near-complete occlusion. Multiple stents or PEDs are needed to completely occlude the recurrent refractory aneurysms.With continuous progress in endovascular treatment technology and concept, as well as rapid development in new materials and equipment, endovascular treatment technology has been widely used in the treatment of intracranial aneurysms. Compared with surgical clipping, interventional embolization of aneurysms has the advantages of less trauma, faster recovery, and lower surgical risk, and has been accepted by the majority of patients as one of the first choices for the treatment of intracranial aneurysms , 27–31. At present, there is no consensus on the principle of retreatment for recurrent aneurysms after embolization. Raymond et al.  suggesteAt present, there is no unified view on the method of retreatment. Dorfer et al.  believedIn our study, we usually give priority to interventional therapy for recurrent aneurysms after embolization, especially for posterior circulation aneurysms. For recurrent refractory aneurysms, we even adopted multiple stents to assist embolization or used the flow diverting device for treatment. For recurrent aneurysms that are very difficult to be re-treated by endovascular intervention or may not be completely or nearly completely embolized, surgical clipping is recommended. Large or giant aneurysms with a wide neck or a perforator are prone to recurrence after repeated endovascular embolization. For large or giant wide-necked aneurysms, stent-assisted coiling may not be able to obtain an endurable complete occlusion status, and flow diverters with adjunctive coiling are preferred. For large or giant aneurysms with a perforator, aneurysm recurrence is easy because dense packing cannot be achieved for fear of occluding the perforator, and in these cases, surgical clipping is recommended. Nonetheless, the morphology and position of the aneurysm should be considered in repeated treatment. For recurrent aneurysms, especially those in the posterior circulation, we tended to use endovascular embolization in the repeated treatment. This is because the risk and difficulty of surgical clipping are greatly increased for recurrent aneurysms which had been treated with coil embolization, especially for those at the posterior circulation. For one thing, coils within the aneurysm sac may cause the surgical clip to shift, resulting in stenosis or occlusion of the parent artery. Clip shift may increase the difficulty to free the aneurysm, which increases the difficulty of surgical clipping. For another, due to the space-occupying effect of the coils inside the aneurysm sac, the operation space for clipping is limited. Even in some cases, the coils are closely related to the aneurysm neck so that the aneurysm neck cannot be directly clamped. At this time, it is necessary to remove part or all of the coils, which are closely adhered to the aneurysm wall. Particularly, when the aneurysm neck is involved, forcibly removing the coils may lead to tearing of the aneurysm neck, resulting in serious consequences.P = 0.022) and aneurysm occlusion degree (P = 0.001) were the risk factors affecting recurrence after the second embolization. Generally, large aneurysms have relatively wide necks. After recurrence, the neck is relatively shallow and difficult to embolize, and incomplete occlusion may result after embolization, which is a possible reason for repeated recurrence  giant aneurysms (> 2.5 cm), accompanied by peripheral nerve and vascular compression symptoms; (2) fusiform and serpentine aneurysms, with wide necks or undefined necks; and (3) atherosclerotic plaques in the aneurysm . ComplexP = 0.005).Chalouhi et al.  reportedHemodynamic studies also showed that the flow velocity into intracranial aneurysms and the shear stress of aneurysm wall both decreased with the number of stents deployed within the parent artery , 48, indThe blood flow diverting device has a higher metal coverage rate, can better divert the blood flow away, and more easily promote the vascular endothelium to cover the damaged area of the parent artery, so as to achieve the purpose of curing the aneurysm. It transfers the idea of treating aneurysms from the filling of aneurysms to the reconstruction of the parent artery, which makes many complex aneurysms, such as serpentine and fusiform aneurysms, cured. Some good results have been achieved in using the PED for treating recurrent aneurysms with a complete occlusion rate between 76.7 and 86.7% at follow-up –51. The Some limitations existed in this study. First, the compliance of the patients was poor, and regular angiographic follow-up could not be completed on time. Second, the sample size of this study was relatively small. Third, this study was a single-center, retrospective study. All these issues may affect the publication bias, and the results of this study need to be further verified by multiple centers with prospective randomized controlled studies.In conclusion, the Raymond-Roy grade of aneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence of aneurysms after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of Beijing Tiantan Hospital. The patients/participants provided their written informed consent to participate in this study.Y-FH and PJ: study design. Y-FH, Z-BT, X-HC, JL, and Z-XW: data collection. Y-FH and B-LG: data analysis. Y-FH: writing of the original work and supervision. B-LG: review and revision. All authors contributed to the article and approved the submitted version.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.


Background: The intermittent abdominal pressure ventilation (IAPV) is a non-invasive ventilation (NIV) technique that avoids facial interfaces and is a diurnal ventilatory support alternative for neuromuscular patients during stable chronic phases of the disease. Coronavirus disease 2019 (COVID-19) is a novel infection possibly causing acute respiratory distress syndrome (ARDS). Neuromuscular diseases (NMD) and preexisting respiratory failure can be exacerbated by respiratory infection and progress to severe disease and ICU admission with a poor prognosis. Aim: To report on the versatility and feasibility of IAPV in acute restrictive respiratory failure exacerbated by COVID-19. Patient: We describe the case of a 33-year-old man with spastic tetraparesis, kyphoscoliosis, and impaired cough, eventually leading to a restrictive ventilation pattern. COVID-19 exacerbated respiratory failure and seizures. An NIV trial failed because of inadequate interface adhesion and intolerance. During NIV, dyspnea and seizures worsened. He underwent a high flow nasal cannula (HFNC) with a fluctuating benefit on gas exchange. IAPV was initiated and although there was a lack of cooperation and inability to sit; the compliance was good and a progressive improvement of gas exchange, respiratory rate, and dyspnea was observed.Conclusions: IAPV is a versatile type of NIV that can be adopted in complicated restrictive respiratory failure. COVID-19 exacerbates preexisting conditions and is destined to be a disease of frailty. COVID-19 is not a contraindication to IAPV and this kind of ventilation can be employed in selected cases in a specialistic setting. Moreover, this report suggests that IAPV is safe when used in combination with HFNC. This hybrid approach provides the opportunity to benefit from both therapies, and, in this particular case, prevented the intubation with all connected risks. Non-invasive ventilation (NIV) is widely indicated for ventilatory pump failure. It improves dyspnea, hypoventilation, and quality of life ,2. NIV rIntermittent abdominal pressure ventilation (IAPV) is an NIV technique that avoids facial interfaces and has been successfully used as diurnal ventilatory support for neuromuscular patients during stable chronic phases of the disease . The intCoronavirus disease 2019 (COVID-19) is a novel infection possibly causing acute respiratory distress syndrome (ARDS) and early intensive care unit (ICU) admission. The disease has a very variable presentation and progression. According to data from Wuhan in China, an estimated 14% of cases experience a severe illness, and 5% of cases progress to a critical disease requiring treatment in the ICU . The casWe describe the case of a 33-year-old man affected by acute respiratory failure and COVID-19. The patient is affected by spastic tetraparesis and a severe neuro-psychomotor developmental delay consequent to perinatal asphyxia. Our patient shows kyphoscoliosis, spasticity, hypotonia, impaired cough, and retained tracheobronchial secretions, eventually leading to a restrictive ventilation pattern. In addition, epilepsy contributes to the global complexity and limits cooperation. The patient’s weight is 47 kg.2 79 mmHg, pO2 56 mmHg, lactate 0.8 mmol/L, HCO3− 38.3 mmol/L). The high-resolution computed tomography (HRCT) of the chest showed ground-glass opacities and consolidations bilaterally , vitamin C, potassium, magnesium, antiepileptics, and supportive therapy. Since the frailty, an extended panel of microbiological surveillance was performed at baseline. Cultures from blood, urine, and intestinal tract were negative. On the third day of hospitalization, Pseudomonas A. and Staphylococcus A. were isolated with a significant bacterial load on tracheobronchial secretions. Intravenous Ceftobiprole was added.2 of 28%. The patient tolerated well the HFNC up to 12 h daily. The heated and humidified high flow was set to facilitate mucociliary clearance and provide an adequate airflow based on the body size. In addition, we promptly started a physiotherapy and rehabilitation targeted program. This included a daily cough assist device used in between the HFNC sessions. Simultaneously we administered a high-flow nasal cannula (HFNC). The device was set with a temperature of 37 °C, a flow of 45 L/min, and an FiO2O, PS 8 cmH2O, rise time 80%, and expiratory trigger 50% (I:E ratio 1:2.4). The patient reached good synchrony with the ventilator, thus reaching a satisfactory tidal volume and respiratory frequency. Unfortunately, it was impossible to guarantee the fit of the interface in the long term. Several types and sizes of masks were tried without success. The blood gas revealed a further worsening, along with seizures, feeding difficulties, and oral secretions.After 5 days from hospital admission, we observed a stable improvement of oxygenation but a worsening of pH (7.33) and hypercapnia (97 mmHg). Blood tests, including inflammatory markers, improved. On the contrary, dyspnea and seizures were difficult to manage. At this point, we performed an NIV trial. We set a pressure support ventilation (PSV) mode with the following settings: EPAP 4 cmHAt this point, we considered the possibility of intubation with a multidisciplinary team. The risk of difficult intubation and periprocedural complication was very high due to a reduced mouth opening and a small range of motion of the neck and mandible, not considering a distorted tracheal anatomy. Overall, the prognosis was poor with invasive mechanical ventilation.2O, respiratory time 1.5 s, frequency 14 pm, and rise time 1. The belt was applied in sessions of 3 to 5 h, twice daily. IAPV consented to enteral nutrition, and it was applied after gastric digestion. At the time the patient was bedridden and the IAPV was well tolerated with bed inclination up to 20°. We did not observe overdistention of the enteric tract or regurgitation. Noteworthy is that the subject received at the time a 4-drug regimen for epilepsy and totally lacked cooperation. During the application of IAPV, he continued the HFNC therapy, thus taking advantage of a hybrid approach.The IAPV trial was performed on the 10th day. The settings were: belt pressure 20 cmH2 was higher during IAPV plus HFNC compared to HFNC alone. pH and pCO2 constantly improved after the IAPV sessions  recently renovated. The technological advancement guarantees reliability and ease of use by healthcare personnel and caregivers. Despite this, IAPV is still considered a niche product. A specialist’s knowledge is required to apply it in clinical practice and to target the patients adequately. In fact, IAPV aims at a specific group of restrictive respiratory failure. Neuromuscular diseases, chest wall abnormalities, kyphoscoliosis, paresis, diaphragm weakness, or respiratory muscle paralysis are suggested indications ,10, espeThis report suggests that IAPV is a versatile type of NIV that can be adopted in multifactorial respiratory failure. Restrictive patterns and anatomical abnormalities of the chest trachea and face can substantially limit NIV with the most common interfaces. COVID-19 exacerbates preexisting conditions and is destined to be a disease of frailty. COVID-19 is not a contraindication to IAPV and this kind of ventilation can be employed in selected cases in a specialistic setting. Further studies and reports are needed to clarify the role of IAPV in COVID-19.


To assess the levels of stress, burnout, and job satisfaction among mental healthcare professionals in Jeddah City, Saudi Arabia.A cross-sectional study was conducted on mental healthcare professionals in Jeddah between January 2017 and October 2018. Sociodemographic characteristics and levels of stress, burnout, and job satisfaction were assessed using the Perceived Stress Scale-14 (PSS-14), Maslach Burnout Inventory (MBI), and Job Satisfaction Scale (JSS). Descriptive statistics were used. Independent sample t-test, one-way ANOVA, Mann-Whitney, and Kruskal-Wallis tests were conducted to assess for effects of demographic variables on the perceived stress score, emotional exhaustion (EE) score, depersonalization (DP) score, professional accomplishment (PA) score, and the job satisfaction score (JSS).A total of 107 participants were included  with response rate of 79.2%. Prevalence of stress was 56.1%. High levels of emotional exhaustion and depersonalization were present among 41 (38.3%) and 26 (24.3%) of the respondents, respectively, while high score of low personal accomplishment were present among 61 (57%) respondents. In terms of job satisfaction, 25 (23.4%) were satisfied and 74 (69.2%) were indecisive. Male participants’ emotional exhaustion score (27±12) was significantly higher than females (22 ±10), (t(105) = 1.99, p-value = 0.049). Also, participants with a monthly income above SR 20,000 had significantly higher total job satisfaction .Our findings suggest rates of stress and burnout among mental health professionals that warrant attention, with less than one-quarter of the participants being satisfied with their jobs. Further studies are needed to expand the findings and to explore the contributing factors. Additionally, interventions should be established by authorities to address the increasing rates of stress and burnout. Increased awareness about the prevalence of mental distress in the healthcare setting has revealed considerable levels of occupational stress among healthcare professionals. When the stress persists for a prolonged duration, it eventually leads to burnout that evolves gradually and is described as a combination of emotional exhaustion, depersonalization, and low personal accomplishment .The consequences of burnout are detrimental to healthcare services. It contributes to lower job satisfaction, decreased productivity, increased errors, poor patient care and a higher turnover , 3. The There are numerous studies that have examined stress and burnout among different specialties. The prevalence of burnout among the US physicians was found to be 54%, which was almost twice the prevalence among the general working staff . In SaudAdding to all previous literature on burnout among healthcare workers, the COVID-19 pandemic has imposed a greater deal of stress on them. A systematic review on all studies assessing burnout during the first year of the pandemic showed general trend of worsening in burnout rates compared to pre-pandemic rates . A natioTo our knowledge, no study in Saudi Arabia has examined mental wellbeing of all professionals at psychiatry departments and hospitals. Therefore, this study aimed to measure the prevalence of stress, burnout, and to assess job satisfaction among different mental healthcare professionals in Jeddah city, Saudi Arabia.This cross-sectional study was conducted between January 2017 and October 2018 in Jeddah, Saudi Arabia. In Jeddah, there are five psychiatry departments in general hospitals, one hospital for addiction, and one mental health hospital. The study population consisted of all psychiatrists, psychiatric residents, psychologists, social workers, and psychiatric nurses, men and women, across all age spectrum, who were working in these centers during the duration of the study. Professionals who did not speak English were excluded. A self-administered printed questionnaire was distributed to all 135 mental healthcare professionals who met the inclusion criteria. Ethical approval was obtained from the institutional review board at King Abdullah International Medical Research Centre. Informed consents were obtained from all participants.The questionnaire consisted of a section addressing sociodemographic variables  followed by three widely used scales to measure perceived stress, burnout and job satisfaction. These scales were the Perceived Stress Scale (PSS), Maslach Burnout Inventory–Human Services Survey (MBI-HSS), and Job Satisfaction Scale (JSS) –15.The PSS is a 14-item scale used to determine the level of stress that professionals experience. Items are rated on a 5-point scale, ranging from 0 (never) to 4 (very often). An item example includes: “in the last month, how often had you felt that you were not able to control the important things in your life?” The mean score was calculated and participants with higher score than average were labelled to be stressed.The MBI-HSS is a 22-item scale to measure emotional exhaustion, depersonalization, and professional accomplishment. It was used to assess the level of burnout of participants. Items are rated on a 7-point scale, ranging from 0 (never) to 6 (everyday). An item example includes: “How often: working with people all day is really a strain for me”. For emotional exhaustion, A score of ≤ 16 and signified low levels of burnout, between 17 and 26 were considered as moderate burnout, and scores over 27 were of high-level burnout. Regarding depersonalization, the score of ≤ 6 or less indicated low levels of burnout, scores between of 7 and 12 were considered as moderate burnout and a score over 13 was of a high-level burnout. Lastly, personal accomplishment scores of ≤ 31 were a marker of high burnout, 38 to 32 indicated moderate burnout, and over 39 indicated low levels of burnout.The JSS is a 36-item scale with nine subscales that are pay, promotion, supervision, fringe benefits, contingent rewards, operating conditions, coworkers, nature of work and communication. Items are rated on a 6-point scale, ranging from 1 (disagree very much) to 6 (agree very much). An Item example includes: “I feel a sense of pride in doing my job”. The absolute approach was used to compute and interpret the overall JSS score . The ranAll data were entered into an excel file and then were managed through Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistical analyses were used. Values were reported as proportions and percentages for categorical variables and as means and standard deviations or modes with ranges for continuous variables. Since the PSS-14 has no cut-off value, the scores were stratified into four groups based on the quartiles, where the upper two combined were labelled as stressed and the lower two as not stressed. Independent sample t-test, one-way ANOVA, Mann-Whitney, and Kruskal-Wallis tests were conducted to assess for effects of demographic variables on the perceived stress score, emotional exhaustion score, depersonalization score, professional accomplishment, and the total job satisfaction score. Statistical significance was considered at p-value < 0.05.A total 135 professionals were invited to participate, while 107 agreed to take part (response rate = 79.3%). Out of them, 54 (50.5%) participants were men. Majority of the sample were in the age group 20–35 years  and married . Professionals from other nationalities than Saudis represented only 18.7%. Physicians and physicians in-training were the main group of participants . Rest of the sociodemographic variables are shown in The overall mean PSS score was 25.9 (± 5.5). A total of 60 participants (56.1%) had high scores and were labelled stressed, accordingly . Nurses In terms of burnout , most ofOf the 107 participants, 25 (23.4%) were overall satisfied about their job, while the majority were indecisive . Most of the sample were satisfied about the supervision  and nature of work . In contrast, more than half of the respondents  were dissatisfied about the operating conditions .As shown in To our knowledge, our study is the first in Saudi Arabia to examine stress, burnout, and job satisfaction among mental healthcare professionals. Majority of the participants had a higher level of stress than the average, moderate to high prevalence of burnout symptoms and ambivalent job satisfaction.Nurses were the main subgroup to suffer from stress. This goes in line with much research that showed mental health nurses to experience a great deal of stress , 18. A lA systematic review and meta-analysis on burnout among mental health staff was conducted in 2018 and included 33 studies (n = 9409) . The pooRegarding the job satisfaction, our results indicated that 69.2% of the mental healthcare professionals were neither satisfied or dissatisfied, 23.4% were satisfied, and only 7.5% were not satisfied. Moreover, the healthcare professionals satisfaction had significant association with their income. This is similar to a study in a tertiary hospital in Saudi Arabia where satisfaction with income among physicians predicted total satisfaction about their jobs . Also, lOur findings shed the light on the increasing prevalence of the mental distress among mental healthcare workers in Jeddah city, Saudi Arabia. Interventions should be designed to identify the mental healthcare workers needs and to address them accordingly. A few interventional studies on mental healthcare workers have tried with some success to reduce the burden of burnout , 31. ForThis study has some limitations to be acknowledged. First, we excluded non-English speakers because the JSS had no validated Arabic version. Second, the study was conducted in one city and in cross-sectional design which limit its generalizability to all settings in Saudi Arabia. Third, some professions were underrepresented in our sample, such as social workers, which may also limit the generalizability of the results to this sub-group.Our findings suggest high rates of stress and burnout with less than one-quarter of the participants being satisfied about their jobs. Future large-scale research should be conducted on mental healthcare workers in other regions of Saudi Arabia for comparison and expansion of our findings. Interventions, such as educational sessions on stress and burnout, should be established by authorities to increasing rates of stress among mental health providers, explore the contributing factors, and to promote a better working environment for them. Also, further studies are needed explore other contributing factors that we did not look at.