AKT1, CDH1, PIK3R1, CBL, LRP1, MALAT1, and XIST were proven to be associated with the pathogenesis of CRSwNP. AGR2, FAM3D, PIP, DSE, and TMC were identified to be related to the CRSwNP phenotype. Further exploration of these genes will reveal more important information about the mechanisms of CRSwNP.Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory disease with relatively easy recurrence. However, the precise molecular mechanisms of this disease are poorly known. Based on gene sequencing data obtained from the Gene Expression Omnibus (GEO) database, we constructed coexpression networks by weighted gene coexpression network analysis (WGCNA). Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed by the Database for Annotation, Visualization, and Integrated Discovery (DAVID). The core gene of pathogenesis, CRSwNP, was screened by protein-protein interaction data (PPI) from the HPRD database. Unsupervised clustering was applied to screen hub genes related to the phenotype of CRSwNP. Blue and turquoise modules were found to be most significantly related to the pathogenicity of CRSwNP. Functional enrichment analysis showed that cell proliferation in the blue modules, the apoptotic process in the turquoise module, and the cancer pathway in both modules were mostly significantly correlated with the development of CRSwNP. The noncoding RNAs (long noncoding RNA and microRNA) and the top 10 core genes in each module were found to be associated with the pathogenesis of CRSwNP. A total of nine hub genes were identified to be related to the CRSwNP phenotype. By qRT-PCR analysis,  SRC  Affymetrix Human Genome U133 Plus 2.0 Array. The normal control samples included uncinate tissues from 6 subjects with CRSsNP and 6 subjects with CRSwNP and NP tissues were collected from 6 subjects with CRSwNP. GSE107624 consists of 21 NP samples and 21 normal control samples, and its platform is the [HG-U219] Affymetrix Human Genome U219 Array. The samples were isolated from NPs or control nasal mucosa and cultured and differentiated at the air-liquid interface (ALI) cell culture system. The information in both datasets is summarized in The CRSwNP datasets GSE36830 and GSE107624 were obtained from the National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (GEO)  with the R package limma_3.40.2.Two sets of differentially expressed genes from the screened NP expression profile data were compared with the nasal polyp-related genes included in the public database (NCBI-gene and OMIM). Additionally, the union genes were set as the potential CRSwNP-related genes.The expression data of GSE107624 were selected to construct the expression profile of potentially related genes in CRSwNP. The WGCNA affy_1.62.0 package was used to mine the module and analyze the coexpression genes in the expression profile above . Database for Annotation, Visualization, and Integrated Discovery  was applied to annotate the functions and pathways of the excavated modules and to identify functional dysfunction modules with functions and pathways.http://starbase.sysu.edu.cn/starbase2/). Based on the 193388 pairs of human ncRNA-mRNA included in the StarBase database, the pivot nodes [ncRNA] of the regulatory dysfunction module were searched. To account for the 9396 pairs of human TF-mRNA recorded in the TRRUST v2 database (http://www.grnpedia.org/trrust/), the pivot nodes (TF) of the regulatory dysfunction module were searched.The mRNA-miRNA and miRNA-lncRNA interaction data were downloaded from the StarBase database (v2.0) (http://www.cytoscape.org/) was applied to construct the nasal polyp multifactor (ncRNA and TF) regulatory network.Using the information collected on the regulatory relationship between the pivot (ncRNA and TF) and the CRSwNP module using the method described above, Cytoscape (v3.4.0)  using the limma package. The ceRNA network of lncRNA-miRNA-mRNA was constructed according to the relationship between differentially expressed miRNA, differentially expressed genes, and lncRNA.http://www.hprd.org/), and each module above was input into the PPI. The protein interaction subnet was constructed, and the connectivity was analyzed. The genes with high connectivity were identified as exogenous core genes (drive factors).The protein-protein interaction data (PPI) were downloaded from the Human Protein Reference Database (HPRD)  dimension reduction was used to classify CRSwNP into different phenotypes. The expression patterns of these coexpressed key genes in different subclasses were examined, and the genes with significant differences in the expression of different subclasses were analyzed . These genes may be potential markers of CRSwNP subclass.The key coexpression genes were further used to classify CRSwNP. According to the method of finding the best sum of the squared error (SSE) inflection point to determine the optimal The few genes , and a total of 1063 potential genes  and turquoise modules  were more strongly correlated with CRSwNP, while the green module  was more strongly correlated with the normal control. In the control and disease columns, positive values indicated a correlation, and P < 0.05 indicated statistically significant.WGCNA analysis was performed using the expression profiles of 1,063 potentially relevant genes in the obtained nasal polyps. We analyzed the soft threshold power of the network topology with threshold weights from 1 to 20 and determined the scale independence and mean connectivity of WGCNA. An optimal threshold of 3 was selected to produce a hierarchical clustering tree of 1,063 genes . FinallyGene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed on the genes in the CRSwNP module using DAVID. As the results show, the blue module incorporated functions from GO, including the regulation of cell proliferation and responses to wounding, cell adhesion, and biological adhesion . The bluP < 0.05, connection > 2). The first 10 pivot node points with the most significant P value were selected for each module. The pivot (TF) node  for regulating the CRSwNP function module (blue and turquoise modules) was searched against the background of the regulatory relationship on 9396 pairs of human TF-mRNA in the TRRUST v2 database. The blue and turquoise modules and their regulatory factors were visualized, as shown in Figures Using the 193388 ncRNA-mRNA interaction relationship included in the StarBase database as the background of interaction, pivot nodes (ncRNA) regulating the CRSwNP module (blue and turquoise modules) were searched  were mapped to GSE107624 for unsupervised clustering, and the CRSwNP sample (N = 21) was selected. The K-means unsupervised clustering method was used to classify all CRSwNP samples. First, the optimal value of K was selected by finding the inflection point of the SSE. As can be seen in K = 4, so K = 4 was selected. The R package R-Tsne was used to reduce the dimensionality of the gene expression data. As shown in ST6GAL1, AGR2, FAM3D, PIP, COTL1, PHLDA1, MLPH, DSE, and TMC5 were differentially expressed in four clusters. Therefore, these nine genes may be related to the CRSwNP phenotype.Based on the analysis results of the WGCNA coexpression module, the coexpression network of the blue and turquoise modules was further analyzed. The screened SRC and SMAD3 are the first two core genes in the blue module, and they have been reported to be associated with the pathogenicity of CRSwNP in the previous literature, we decided not to include them in the experimental validation. In the turquoise module and ceRNA network, the genes with the most connectivity were selected for the experiment. In the blue and turquoise modules, the mRNA expression of AKT1 (0.35-fold), CDH1 (0.36-fold), PIK3R1 (0.44-fold), and CBL (0.52-fold) decreased, and that of LRP1  increased, all of which were significantly different between the CRSwNP and healthy control groups. Smad4 (0.69-fold) and CDK1 (0.65-fold) did not show any significant difference (MALAT1 (0.12-fold) and XIST (0.10-fold) decreased and showed significant differences between groups, while SCAMP1 (0.12-fold) was not significantly different between groups (AGR2 (0.39-fold), FAM3D (0.15-fold), PIP (0.46-fold), DSE (0.33-fold), and TMC (0.46-fold) decreased, and all of them were significantly different between groups, which were associated with the phenotype of CRSwNP, while ST6GAL1 (0.77-fold), COTL1 (1.19-fold), PHLDA1 (0.58-fold), and MLPH (0.96-fold) were not significantly different between groups.Based on the bioinformatics analysis results described above, we experimentally validated six genes in the blue module, three genes in the turquoise module, three lncRNAs in the ceRNA network, and all nine genes related to the CRSwNP phenotype. Although fference . In the n groups . The mRNST6GAL1, AGR2, FAM3D, PIP, COTL1, PHLDA1, MLPH, DSE, and TMC5) were determined to be related to the phenotype of CRSwNP. By experimental validation, AKT1, CDH1, PIK3R1, CBL, and LRP1 in the blue and turquoise modules and MALAT1 and XIST in the ceRNA network were shown to be associated with NPs. Five genes, AGR2, FAM3D, PIP, DSE, and TMC, were identified to be related as being related to the CRSwNP phenotype.CRSwNP, which leads to chronic inflammation of the nasal mucosa, nasal obstruction, and growth of NPs, causes a serious psychological burden and economic pressure on affected patients because of its refractory and relapse characteristics. Currently, little is known about the pathogenesis and phenotype of CRSwNP on a genetic level. In the current study, we used WGCNA to identify key modules and hub genes involved in the pathogenesis and phenotype of CRSwNP by R. The two most relevant modules of CRSwNP were identified, namely, the blue and turquoise modules, which were both positively shown to be correlated with the disease. By functional enrichment analysis, cell proliferation and apoptotic processes were found to be the most common biological processes in the blue and turquoise modules, respectively. The ceRNA network was constructed, and 10 hub genes were identified in each module as being involved in the pathogenesis of CRSwNP. Nine genes  were mined by WGCNA, and the blue and turquoise modules were shown to be most significantly correlated with CRSwNP. Using conventional experimental methods, previous studies have reported that cell proliferation plays an important role in the pathogenesis of CRSwNP , 13. Thrβ [Interestingly, in our study, both the blue and turquoise modules in the KECG pathway were remarkably enriched in the pathways associated with cancer. Previously, only one paper reported nasal polyposis is associated with malignancy. Specifically, Pourang et al found that patients with prevalent nasal polyposis are at an increased risk for malignancies of the head and neck, specifically squamous cell carcinoma, compared to individuals without nasal polyposis . Moreoveβ , Wnt [18β  pathwaysβ , 21. TheMALAT1 and XIST were most obviously related to CRSwNP in both modules. Although they have been reported to be correlated with cancer, they have not previously been associated with CRSwNP. By RT-PCR analysis of the top three lncRNA in the ceRNA network, MALAT1 and XIST are significantly downregulated in CRSwNP, and statistically significant differences between CRSwNP patients and healthy controls were shown. These two lncRNAs have been widely reported to be related to the occurrence of cancer. This study provides further evidence that CRSwNP shares certain pathways with cancer development [At present, only a few articles have reported the relationship between ncRNA and CRSwNP, mainly focusing on miRNA , 22, whielopment . AdditioSRC, Smad3, Smad4, AKT1, LRP1, IGF1R, FGFR3, CDH1, NCF1, and ARRB2 were most significantly related to CRSwNP. Except for SRC [Smad3 [CDH1 [PIK3R1, CDK1, CBL, INSR, VAV1, MDM2, HCK, SOS1, PRKCE, and ITGB2, no genes have been shown to be involved in the development of CRSwNP in the currently published literature studies. However, in this study, AKT1, CDH1, PIK3R1, CBL, and LRP1 exhibited statistically significant differences in CRSwNP patients, compared to the healthy controls in both modules. AKT1 plays an important role in cell survival and apoptosis. PI3K-Akt signaling pathway is a classical signal pathway, which involves a variety of cancers and inflammation. It has been reported that AKT1 was associated with inflammation of liver disease and acute pancreatitis [CDH1 is significantly downregulated in CRSwNP, which is consistent with previous research results [In both modules, we listed the top 10 core genes with the pathogenesis of CRSwNP. In the blue modules,  for SRC , Smad3 [C [Smad3 , and CDHd3 [CDH1 , no othereatitis , 27. The results . PIK3R1 ST6GAL1, AGR2, FAM3D, PIP, COTL1, PHLDA1, MLPH, DSE, and TMC5 were differentially expressed in the four clusters. However, none of them have been studied in relation to CRSwNP. In this study, by RT-PCR analysis, five genes  were identified as being related to the CRSwNP phenotype. Interestingly, AGR2 has been found to play an important role in prostate tumorigenesis and metastasis-related phenotypes [We determined nine genes related to the CRSwNP phenotype. In clinical practice, CRSwNP is commonly divided into eosinophilic and noneosinophilic NP according to the presence or absence of eosinophils. However, at a genetic level, the CRSwNP phenotype has not been described at all. In this study, CRSwNP was classified into four phenotypes, and a total of nine genes were found to be associated with its occurrence. This may be a new discovery. In other words, at a genetic level, CRSwNP could be further compartmentalized. enotypes . DSE wasenotypes . Future Our research shows that a large number of related genes can be mined through WGCNA, and through experimental verification, it was found that the predictions of WGCNA are mostly correct. This suggests that WGCNA is a good tool for the early exploration of disease genes. Although our method found some crucial genes and modules, there is one limitation and shortcoming in our study, which is that the datasets that we could obtain were very limited. CRSwNP datasets on GEO, especially large sample datasets, are very few in number. The results would be better if there was a larger dataset including nasal polyps and normal controls.AKT1, CDH1, PIK3R1, CBL, LRP1, MALAT1, and XIST were proven to be associated with the pathogenesis of CRSwNP. AGR2, FAM3D, PIP, DSE, and TMC were identified to be related to the CRSwNP phenotype. Further exploration of these genes will reveal more important information about the mechanisms of CRSwNP.In summary, we identified crucial modules, biological processes, pathways, ncRNA, and hub genes related to CRSwNP.


Patient- and caregiver-reported data are lacking on the burden of spasticity, and the impact of botulinum neurotoxin type A (BoNT-A) treatment for this condition, on patients' daily lives. As recommended in recent guidance from the US Food and Drug Administration, online patient communities can represent a platform from which to gather specific information outside of a clinical trial setting on the burden of conditions experienced by patients and caregivers and their views on treatment options in order to inform evidence-based medicine and drug development.The objective of our study is to characterize spasticity symptoms and their associated burdens on Western European and US patients and caregivers in the realms of work, daily activities, quality of life (QoL), as well as the positive and negative impacts of treatment with BoNT-A  using Carenity, an international online community for people with chronic health conditions.We performed a noninterventional, multinational survey. Eligible participants were 18 years old or older and had, or had cared for, someone with spasticity who had been treated with BoNT-A for at least 1 year. Patients and caregivers were asked to complete an internet-based survey via Carenity; caregivers reported their own answers and answered on behalf of their patients. Questions included the burden of spasticity on the ability to work, functioning, daily-living activities, and QoL, the impact of BoNT A therapy on patients' lives, and the potential benefits of fewer injections.There were 615 respondents (427 patients and 188 caregivers). The mean age of patients and caregivers was 41.7 years and 38.6 years, respectively, and the most commonly reported cause of spasticity was multiple sclerosis. Caregivers were most often the parents  or another family member  of their patients. Spasticity had a clear impact on patients' and caregivers' lives, including the ability to work and injection costs. For patients, spasticity caused difficulties with activities of daily living and reduced QoL indices. The median number of BoNT-A injections was 4 times per year, and 92% (393/427) of patients reported that treatment improved their overall satisfaction with life. Regarding the BoNT-A injection burden, the greatest patient-reported challenges were the cost and availability of timely appointments. Overall, 86% (368/427) of patients believed that a reduced injection frequency would be beneficial. Caregivers answering for their patients gave largely similar responses to those reported by patients.Spasticity has a negative impact on both patients' and caregivers' lives. All respondents reported that BoNT A treatment improved their lives, despite the associated challenges. Patients believed that reducing the frequency of BoNT-A injections could alleviate practical issues associated with treatment, implying that a longer-acting BoNT-A injection would be well received. Knowledge of patient and caregiver perspectives on a disease and related therapies help identify relevant patient-reported outcomes for assessment in clinical trials and inform clinical decision-making; therefore, it is critical for patient-focused drug development. Methodological guidance to support the collection of patient experience data has recently been published by the US Food and Drug Administration (FDA), which includes the utilization of online patient communities . An incrSpasticity is caused by an upper motor neuron lesion leading to intermittent or sustained involuntary activation of muscles  and is aTreatment of spasticity is indicated when it interferes with function or QoL. As spasticity can change over time, patients should undergo continuous re-evaluation . TreatmeBotulinum neurotoxin type A (BoNT-A) is integral to focal and multifocal spasticity management  and has The aim of this study is to characterize spasticity symptoms and understand their burden, as well as the impact of BoNT-A injections, from the patient and caregiver perspective. The ability to work, perform daily activities, and QoL were assessed, as well as the perceived benefits and challenges associated with BoNT-A treatment with a focus on injection frequency.The survey was conducted in France, Germany, Italy, Spain, the United Kingdom, and the United States between November 10, 2017, and February 28, 2018, using an established online approach -32. Patip set at 0.5 (maximum variability), the confidence level at 95%, and a maximum margin of error between 5% and 6% for each region.All questions were the same between countries except for those relating to BoNT-A formulation brand names, which were removed from the Spanish questionnaire to comply with Spanish regulations. The study had a prespecified target of 600 respondents: included 300 from the United States and 300 from Europe, determined using the Cochran formula, with The questionnaire comprised multiple-choice, sliding-scale, or free-text answers and consisted of 4 sections . For carThe second section collected information on the impact of spasticity on the ability to work, functioning, and QoL. The third section collected information on BoNT-A treatment behavior  and the impact of BoNT-A injections on patients' and caregivers' QoL. The final section collected information on the potential impact of reduced BoNT-A injection frequency on patients and caregivers (assuming efficacy was maintained). The sliding-scale questions in these sections are shown in The responses provided by the patients or caregivers regarding the patients' condition were self-reported and were not verified by an independent rater or reviewer. Free-text responses were categorized both automatically and manually (as appropriate) by Carenity personnel, who also developed a tool to program and code the questionnaire.Eligible participants were adult patients (≥18 years old) who self-reported as having spasticity and receiving treatment with BoNT-A for ≥1 year, and caregivers of patients meeting the survey criteria (caregivers were not those of the participating patients). Spasticity had to be due to MS, stroke, traumatic brain injury, spinal cord injury, cerebral palsy, brain tumor, or spastic paraplegia. Patients treated with oral antispasticity medications  or receiving concurrent physiotherapy  were permitted to participate.Descriptive analyses are presented: categorical variables are presented as frequency counts and percentages. Differences in reported burden, treatment behavior, and perceived benefits of fewer injections are compared between patients by limbs affected, level of difficulty experienced due to spasticity, symptoms experienced, and treatment received (number of injections).The study was conducted in accordance with Good Pharmacovigilance Practices Modules IV and VIII in compliance with relevant codes of conduct and data protection legislation, with no approval from the Clinical Research Ethics Committee or Independent Review Board required. All participants provided informed consent to participate and were made aware that the research was sponsored by a pharmaceutical company that manufactures a product approved for the treatment of spasticity.This study was sponsored by Ipsen. Where patient data can be anonymized, Ipsen will share all data that underlie the results reported in this paper with qualified researchers who provide a valid research question. Study documents, such as the study protocol and clinical study report, are not always available. Proposals should be submitted to DataSharing@Ipsen.com and will be assessed by a scientific review board. Data are available beginning 6 months and ending 5 years after publication; after this time, only raw data may be available.Carenity invited 16,494 members (who had agreed to receive invitations to participate in questionnaires) from their community of members affected by spasticity or one of the targeted diseases to complete the survey and, of these, 3548 members started the survey . ParticiIn total, 615 participants completed the survey (427 patients and 188 caregivers), and the survey was closed  years, and the mean time since diagnosis was 8.3 (95% CI 7.4-9.3) years. More patients had spasticity due to MS  than other conditions . The proThe current BoNT-A treatment was onaBoNT-A for most patients , with 18% (75/427) receiving aboBoNT-A and 11% (48/427) receiving incoBoNT-A . The meaThe mean age of caregivers was 38.6 (95% CI 36.9-40.2) years; 55% (104/188) were women and 45% (84/188) were men . The meaCaregiver profiles were similar in Europe and the United States, although the latter appeared to spend more time each week in their caregiving role .Overall, of the 427 patients, 412 patients (96%) were aged <65 years; 69% (284/412) were employed, 1% (6/412) were full-time students, and 30% (122/412) were unemployed . Among pMost caregivers  were also aged <65 years. Of these, 29% (53/184) reported that caring for their patient had an impact on their own professional status, including 21% (38/184) who reported having to take a part-time job and 8% (15/184) who did not work in order to take care of their patient .Compared with the participating European countries, more caregivers in the United States changed their working situation to care for the patient .Scores for the difficulties associated with daily living because of spasticity, as reported by patients, are shown in At least 85% (364/427) of patients experienced difficulties in ≥1 aspect of daily living; aspects most frequently affected were the ability to carry something , walking , performing daily tasks , and driving . Patients with >2 affected limbs experienced the most difficulties with daily living, with 91% (114/125) of patients experiencing 7 difficulties. Patients whose lower limbs only were affected experienced the fewest difficulties, with only 47% (39/83) of patients experiencing 7 difficulties.Scores for the impact of spasticity on patients' QoL are shown in Scores for impact on daily living and QoL reported by caregivers  are summarized in th percentile-75th percentile) number of patient-reported injections per year was 4.0  and was consistent across primary conditions, ranging from 4.0  to 5.0 , with the exception of brain tumors, which had very few respondents (13/427) and a median (25th percentile-75th percentile) number of reported injections per year of 3.0 (2.0-3.0). Patients receiving <3 injections per year reported fewer difficulties, and the number of injections per year was not related to the number of affected limbs (th percentile-75th percentile) number of injections per year was the same between formulations of BoNT-A .The median (25ed limbs . The mednot planned in 41% (32/79) of patients receiving <3 injections per year, compared with 11% (10/95) of patients receiving 3 injections per year, 5% (5/96) of patients receiving 4 injections per year, 11% (5/44) of patients receiving 5 injections per year, 6% (3/50) of patients receiving 6 injections per year, and 5% (3/63) of patients receiving >6 injections per year. In approximately one-third of cases (108/359), earlier retreatment sometimes had to be arranged due to spasticity symptoms, and in 9% (33/359) of cases, patients would have liked to have had earlier retreatment than scheduled, but this was not possible. Among those patients who received >6 injections per year, 38% (24/63) reported that they had to receive earlier retreatment due to spasticity symptoms, whereas for those patients who received <3 injections per year, only 9% (7/79) reported that they had to receive earlier retreatment due to spasticity symptoms  and caregivers  reported that treatment goals were discussed with doctors. The majority of patients  also indicated that retreatment was planned immediately after a treatment. This depended on the number of injections per year; retreatment was symptoms . CaregivThe majority of employed patients  and caregivers  had to take time off from employment (defined as any part of a working day) for BoNT-A treatment, and >50% of patients and caregivers took ≥5 days off per year .As expected, the number of days patients took off work to receive injections appeared to increase with the number of injections per year. Of the 32 patients who received <3 injections per year, 38% (12/32) required ≥3 days off work, compared with 73% (24/33) of patients who received 3 injections per year, 74% (32/43) of patients who received 4 injections per year, 90% (27/30) of patients who received 5 injections per year, 85% (29/34) of patients who received 6 injections per year, and 93% (41/44) of patients who received >6 injections per year.th percentile-75th percentile) scores of 7.0 (4.0-9.0), 7.0 (4.0-8.0), 6.0 (3.0-8.0), and 6.0 (4.0-8.0), respectively]. Among caregivers, at least 84% (157/188) reported issues with BoNT-A treatment, with the cost of injections and logistics representing the greatest burdens to them .At least 73% (312/427) of patients reported issues with BoNT-A treatment; cost, availability of timely appointments, fear of injections, and frequency of injections represented the greatest issues . Patients who reported experiencing difficulties in receiving BoNT-A treatment were more likely to expect benefits with less frequent injections: depending on the difficulties experienced, 74%-86% (273/427–318/427) answered “yes” to expecting benefits versus 59%-66% (35/427–39/427) who answered “no.”The number of BoNT-A injections per year that would be required to achieve perceived benefits was 2 or 3 for most patients and caregivers . Most patients and caregivers felt that 1 or 2 fewer injections per year would beneficially impact their lives . Patients receiving the highest number of injections reported the biggest reduction in the number of injections required to perceive benefits . CaregivEvidence-based medicine for the treatment of spasticity requires the patient perspective on the burdens of symptoms and receiving treatment, for which there is a knowledge gap. The present survey, which was self-reported by over 600 patients and caregivers in the international Carenity online community, is, to our knowledge, the largest of its kind for those affected by spasticity. The results presented here supplement efficacy and safety data from clinical trials of BoNT-A treatment for spasticity with information on treatment benefits to patients, the effects of symptoms on everyday life, and practical issues associated with treatment. Such insights can inform the development of new patient-reported outcome measures and help guide more effective management of spasticity in clinical practice, thus informing the development of new therapeutics.The use of online communities is becoming increasingly popular, as they can encourage patients to educate themselves about their condition, motivate patients to participate in clinical research, and are easily accessible; FDA guidance for collecting information from patients who are members of these communities is now available ,2. OnlinThe presented results confirm that spasticity, irrespective of etiology, has a clear and negative effect on patients' and caregivers' lives. Specifically, patients reported the impact of spasticity on the ability to conduct routine, everyday activities like walking and driving, and on various aspects of QoL. Many patients also reported that spasticity affected their ability to work; among those aged <65 years, 22% changed to part-time working and 22% gave up work completely. In caregivers of working age, the corresponding values were 21% and 8%, respectively. These results are consistent with data from several studies showing that spasticity has a substantial impact on patients' activities of daily living, QoL, and independent living ,33-35. TAll the surveyed patients had received treatment with BoNT-A for ≥1 year. Patients and caregivers reported that treatment improved the ability to conduct daily tasks and aspects of QoL that are affected by spasticity, increasing patients' overall satisfaction with life. Despite its well-established efficacy for spasticity, there was an average gap of 4.8 years between diagnosis and BoNT-A treatment initiation in the population surveyed. However, for conditions such as MS, spasticity may not be present at the initial diagnosis, appearing only later in the disease course. In a previous internet survey among patients with spasticity, almost 50% had to wait 1 year before BoNT was started, and 23% waited >3 years. The authors propose that this may reflect the cost of treatment to health care providers or patients, or a lack of experienced injectors . RegardiMany patients reported practical issues with BoNT-A treatment, including the availability of timely appointments and the frequency of injections. On average, patients received 4.4 injections per year, irrespective of BoNT-A formulation, and, although most planned their visits, some reported scheduling earlier appointments for emergent spasticity symptoms. It is important to note that this was an international study, and treatment intervals were largely dependent on each participating country's health care insurance authorization; therefore, the number of injections per year may be more reflective of this rather than the duration of efficacy or physician guidance. Additionally, these results are dependent on the participant being able to accurately remember how many injections they received per year, and therefore, may be affected by memory bias.When first asked whether reducing BoNT-A injection frequency (without reducing efficacy) would provide any benefits, 86% (368/427) of patients and 87% (163/188) of caregivers reported that it would, citing factors such as better QoL and fewer logistical constraints. Participants were later asked the same question alongside a prespecified list, from which they had to select the 3 most important benefits of less frequent injections. Only 3% (13/427) of patients and 3% (6/188) of caregivers responded that they would not experience benefits, which suggests that providing a list of potential benefits influenced responses, most likely by enabling participants to envisage benefits they had not been able to foresee previously. Importantly, the 3 most selected benefits  were related to prolonged symptom relief rather than a reduced number of injections.. These data appear to be corroborated by real-world evidence [These data collectively suggest that the option of a longer-acting BoNT-A formulation would be favorably received by patients and their caregivers, to provide sustained relief from spasticity symptoms and to overcome practical issues associated with more frequent treatment, as suggested in another patient survey . A recenevidence  and may evidence .The ability to reduce injection frequency depends on the duration of the effect of the BoNT-A injection. This, in turn, depends on several factors, including dose, muscle mass, and depth of injection . In a moThis study has several limitations. No formal prespecified statistical evaluation took place, and recruitment was conducted via the Carenity website, meaning results may not be representative of the general population of patients with spasticity and their caregivers. The proportion of patients with MS in this survey was higher than would be expected in the general population; in the United States, for example, the incidence of MS is surpassed by both stroke and traumatic brain injury . This suFrom the patient and caregiver's perspectives elucidated in this study, spasticity represents a great burden on many aspects of their lives, including the ability to work, QoL, and difficulties with daily living. Several challenges were identified with receiving BoNT-A treatment for spasticity, predominantly around scheduling and the associated costs of injections. Despite these challenges, it was established that patients and caregivers perceive that BoNT‑A improves patients' lives, with high levels of overall satisfaction reported. However, patients and caregivers reported that providing efficacy was maintained, BoNT-A injections of reduced frequency would alleviate practical issues associated with treatment and, more importantly, provide prolonged symptom relief. Using an online community enabled more rapid recruitment to the study and data collection regarding patient and caregiver perspectives than would have been possible in a clinical trial or a validation study of patient-reported outcomes.


This study aimed to compare the long-term weight loss results, remission of comorbidities and nutritional deficiencies of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and One-Anastomosis gastric bypass (OAGB) on type 2 diabetic (T2D) patients. Patients and Methods: A retrospective analysis of all the morbidly obese and diabetic patients undergoing SG, RYGB, and OAGB as primary bariatric procedures between February 2010 and June 2015 was performed. Anthropometric parameters, remission of comorbidities, nutritional deficiencies and supplementation requirements at 1, 2 and 5 years’ follow-up were monitored. Patients lost to follow-up 5 years after surgery were excluded from the analysis. Results: 358 patients were included. The follow-up rate was 84.8%. Finally, 83 SG, 152 RYGB, and 123 OAGB patients were included in the analysis. OAGB obtained significantly greater weight loss and remission of dyslipidemia than the other techniques. There was a trend towards greater T2D and hypertension remission rate after OAGB, while fasting glucose and glycated hemoglobin levels were significantly lower after OAGB. There were no significant differences in hemoglobin or protein levels between groups. SG obtained lower iron deficiencies than the other techniques, while there were no significant differences in other nutritional deficiencies between groups. Conclusion: OAGB obtained greater weight loss and remission of dyslipidemia than RYGB or SG. Excluding lower iron deficiency rates after SG, there were no significant differences in the development of nutritional deficiencies between groups. Obesity and its comorbidities are a global health problem, mainly in developed countries. In the last decades, morbid obesity has shown an exponential growth . BariatrRoux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most frequently performed bariatric procedures world-wide . HoweverDespite initial medical treatment of T2D patients consisting of a caloric restriction and including weight loss as a target for improving the glycemic control, after bariatric surgery, the improvement in glucose homeostasis typically begins within days of surgery before significant weight loss occurs. Thus, total body weight loss per se is unlikely to play a significant role in mediating early glycemic improvements. The physiological and molecular mechanisms underlying the beneficial glycemic effects of bariatric surgery remain incompletely understood. Diverse mechanism have been proposed to contribute to the glycemic control: proximal intestinal nutrient exclusion, rapid distal gut nutrient delivery, changes in bile acid metabolism, gastrointestinal tract nutrient sensing and glucose utilization, incretins, possible anti-incretin(s), or the intestinal microbiome. These changes, acting through peripheral and/or central pathways, lead to reduced hepatic glucose production, increased tissue glucose uptake, improved insulin sensitivity, and enhanced b-cell function .This study aimed to compare the long-term weight loss results, remission of comorbidities and nutritional deficiencies of these three bariatric techniques on a selected population of T2D patients.A retrospective analysis of all the morbidly obese and diabetic patients undergoing SG, RYGB, and OAGB as primary bariatric procedures between February 2010 and June 2015 was performed. 2 or BMI > 35 Kg/m2 with the presence of comorbidities associated with obesity and age older than 18 years. Exclusion criteria were patients undergoing bariatric techniques other than SG, RYGB and OAGB, and patients undergoing any other surgical procedure added to the bariatric surgery.Inclusion criteria were body mass index (BMI) >40 Kg/mA multidisciplinary team, including surgeons, endocrinologists, dieticians, and psychologists, performed a work-up to evaluate potential surgical candidates. A dietician established a diet consisting of total daily energy intake of 1200 Kcal. Given the prolonged waiting list for bariatric surgery at our institutions, a weight loss of at least 10% of the patient’s weight was considered an indispensable condition to undergo the surgery. In this way, the patients who could benefit most from surgery were selected according to the results of previous studies of our group ,14.Psychologists assessed additional interviews to evaluate the implication of the patient with the consequences of the surgery in order to guarantee an adequate follow-up scheme and determine if the selected patients would have total adherence to the recommended diet and supplementation. In our preoperative evaluation protocol, this thorough selection was applied to all the candidates for bariatric surgery.Patients received information from the bariatric surgeon, the endocrinologist and the dietician about possible perioperative complications, eventual postoperative deficiencies and necessary nutritional supplementation.All procedures were performed laparoscopically, described in the literature previously ,8. Acces®, Bayer®, Leverkusen, Germany) was prescribed in all three groups (2 tablets/day).In the 3 techniques described, after surgery, the recommendations at hospital discharge were as follows: advice from the medical team, nutritional support and specific exercise adapted to each patient. In addition, mineral and multivitamin supplementation : plasma glucose <100 mg/dL and glycated hemoglobin (HbA1c) below 6% in the absence of hypoglycemic treatment. The variables to determine the remission of arterial hypertension (HT) were <135 mmHg in systolic blood pressure and <85 mmHg in diastolic pressure in the absence of antihypertensive treatment. Among the lipid profile variables, a remission of dyslipidemia (DL) was considered if total cholesterol <200 mg/dL, triglycerides <200 mg/dL, and high-density lipoprotein cholesterol>40 mg/dL in the absence of pharmacological therapy.Anthropometric variables were analyzed: weight, BMI and excess BMI loss (EBMIL). The assessment of the remission of the studied comorbidities , the specific needs for vitamin and mineral supplementation, hemoglobin, albumin, total proteins, lipid and glycemic profile were determined before surgery (baseline), 1, 2 and 5 years after surgery. A retrospective database was performed including all these variables.p-value. Significance was set at p-value < 0.05.Data were analyzed using IBM SPSS v. 22.0 software . Quantitative variables that followed a normal distribution were summarized as means ± standard deviations (SD). Medians and ranges were recorded for non-Gaussian variables. Qualitative variables were summarized by number and as percentage of cases. A comparison of quantitative variables between the 3 groups was conducted using analysis of variance (ANOVA). A comparison of qualitative variables was performed with the chi-square test; in cases with fewer than 5 observations in the cell, the Fisher exact probability method was used. Pairwise comparisons of groups used a Bonferroni corrected This study was approved by the University of Valladolid Institutional Review Board and the Ethics Committee of the Faculty of Nursing (Identification code: 2020/JMJP01). Informed written consent was obtained from all subjects before undergoing the bariatric procedure and includes their acceptance of using their personal data anonymously with research purposes. The study adhered to the Declaration of Helsinki (2013). 2. All the patients were under oral antidiabetic treatment and 23.2% under insulin therapy. Baseline features and distribution of patients by the procedure are summarized in A total of 358 T2D patients were included for analysis in the present study, 273 women and 85 males, with a mean age of 43.3 ± 10.9 years and a mean BMI of 44 ± 9.1 Kg/mPostoperative complications included two staple line leaks after SG, one gastro-jejunal anastomotic leak and one hemoperitoneum after RYGB, and one anastomotic leak and two cases of intraperitoneal bleedings after OAGB.The patients lost to follow-up at 5 years postoperatively were excluded from the analysis of weight loss, remission of comorbidities, laboratory data, and needs for supplements, even if there were data available at 1 and 2 years’ follow-up. From all the patients operated, the follow-up rate at 5 years postoperatively was 87.2% in the SG group, 83.2% in RYGB and 85.7% in OAGB. Finally, 83 patients were analyzed in group SG, 152 in RYGB and 123 in OAGB.p < 0.001, in all the determinations), while there were no significant differences between RYGB and SG at any of the time points. Similarly, EBMIL after OAGB was significantly higher than after RYGB and SG at all the determinations , but without reaching statistical significance between RYGB and SG. There were no cases of BMI below 19 Kg/m2 in any of the groups.Postoperative BMI and EBMIL are summarized in p = 0.010). At 5 years postoperatively, the complete remission rate was observed in 16.7% after SG, 30.8% after RYGB and 66.7% after OAGB (p = 0.0005).The remissions of comorbidities are shown in When stratifying the sample, according to the preoperative treatment for T2D, with or without insulin, significantly lower remission rates were determined for patients under preoperative insulin therapy and undergoing RYGB or OAGB. For patients undergoing SG, there was a trend towards lower remission rates. Thus, it can be observed that preoperative insulin needs are a risk factor for lower remission rates .Analyzing exclusively the patients under insulin treatment, significant differences in complete remission rates of T2D could not be determined between the different techniques .The duration of T2D was not associated with the complete remission rates of T2D in any group.Referring to the glycemic and lipid profile, OAGB obtained significantly lower fasting glucose, HbA1c, total cholesterol, and triglycerides levels than the other two techniques at 1, 2 and 5 years after surgery, while HDL-cholesterol values were significantly lower after RYGB when compared with SG and OAGB. Pairwise analyses, comparing OAGB with RYGB, revealed significantly lower levels of glucose, glycated hemoglobin, total cholesterol and triglycerides after OAGB at the three time points .There were no significant differences in hemoglobin, albumin and total protein levels between groups . ReferriIn the present study, we compare 358 T2D patients undergoing OAGB, RYGB, and SG, aiming to evaluate long-term weight loss, remission of comorbidities and nutritional deficiencies. The two main strengths of the present paper are the long-term results and the high follow-up rate at our institutions. We describe a follow-up of over 80% of the patients in the three groups. The recently published YOMEGA trial , compari2, whereas in the RYGB and SG groups, the mean BMI was in the range of obesity, and the weight curve shows a clear weight regain 5 years after surgery. At a 2 years’ follow-up, the weight loss that we obtained in the OAGB group is higher than that reported in the YOMEGA trial [In the present study, a significantly greater weight loss in the OAGB group could be observed at 1, 2 and 5 years. Five years after surgery, the mean BMI in the OAGB group was 25.9 Kg/mGA trial  also conGA trial . Thus, tIn the present study, we include only patients with T2D, and obviously these subjects present more increased rates of metabolic comorbidities (hypertension and dyslipidemia) than the general morbidly obese population. Consequently, it could be expected that weight loss could be reduced in this selected population. Comparing the weight loss results obtained in the present study with data obtained in a previous study of our group , we obseFive years after surgery, all the groups presented a good complete remission rate of T2D, globally overcoming 75%. However, significantly greater T2D remission rates could be observed after OAGB. In addition, when analyzing laboratory data, fasting glucose and HbA1c levels were significantly lower in the OAGB group in comparison with the other two groups. The pairwise analysis revealed that after OAGB lower levels of both glycemic parameters were observed, the RYGB group also showed inferior levels to SG. These results confirm the data reported in the YOMEGA trial , presentOAGB obtained a complete remission of DL at all the time points: 5 years after RYGB the remission rate was 69.8%, while after SG it did not reach 30%. Moreover, significantly lower levels of triglycerides and total cholesterol were obtained after OAGB when compared with the other two techniques. In the YOMEGA trial, the aim was to analyze the biological lipid profile and report no significant differences between OAGB and RYGB. However, the criteria of dyslipidemia remission and the number of patients under statin treatment were not described. Thus, the results should be interpreted with caution [In our opinion, the most life-threatening nutritional complication after bariatric surgery is hypoproteinemia, as it is the most difficult deficiency to be supplemented once oral absorption is impaired. We have already reported that after OAGB with measurement of the total bowel length and customizing the limb lengths according to a percentage rather than to a fixed measure, the risk of hypoproteinemia can be reduced . The YOMExcluding iron deficiency, there were no other significant differences in mineral and vitamin deficiencies between groups. In our previous study comparing the three techniques, significantly lower folic acid deficiencies were also observed after SG, but there were no significant differences in deficiencies or specific supplementation needs in any of the other vitamins or minerals (8). This contrasts with the results of the YOMEGA study. They describe the confusing term “nutritional complications”, defined as at least one vitamin deficiency, malnutrition, anemia, or iron deficiency, or a combination of these, and report 21% of nutritional complications after OAGB and none after RYGB . The absThe main limitation of this study is the retrospective evaluation. Further studies focused on the T2D population, mostly well-designed randomized clinical trials, are still necessary to confirm our results. In conclusion, OAGB obtained greater weight loss and remission of T2D and dyslipidemia than RYGB or SG. Excluding lower iron deficiencies after SG, there were no significant differences in nutritional deficiencies between groups. In our opinion, OAGB, customizing the limb lengths according to a percentage rather than to a fixed measure, is a superior technique to SG and RYGB in terms of greater weight loss and remission of comorbidities, but with similar nutritional deficiencies. For T2D patients, most of them with metabolic syndrome associated, OAGB is not only a safe alternative, but it may be considered the gold-standard approach.This study describes the results of weight loss, remission of comorbidities and nutritional deficiencies of SG, RYGB and OAGB in patients with type 2 diabetes (DM2). Long-term results with greater weight loss were obtained in OAGB, as was remission of dyslipidemia with respect to the RYGB and SG techniques. A greater trend was observed in the control of DM2, with lower glucose and glycosylated hemoglobin after OAGB. Except for iron deficiencies that were lower after SG, there were no significant differences in nutritional deficiencies between the different surgical techniques analyzed.


Different additive manufacturing technologies have proven effective and useful in remote medicine and emergency or disaster situations. The coronavirus disease 2019 (COVID-19) disease, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, has had a huge impact on our society, including in relation to the continuous supply of personal protective equipment (PPE). The aim of the study is to give a detailed overview of 3D-printed PPE devices and provide practical information regarding the manufacturing and further design process, as well as describing the potential risks of using them. Open-source models of a half-face mask, safety goggles, and a face-protecting shield are evaluated, considering production time, material usage, and cost. Estimations have been performed with fused filament fabrication (FFF) and selective laser sintering (SLS) technology, highlighting the material characteristics of polylactic acid (PLA), polyamide, and a two-compound silicone. Spectrophotometry measurements of transparent PMMA samples were performed to determine their functionality as goggles or face mask parts. All the tests were carried out before and after the tetra-acetyl-ethylene-diamine (TAED)-based disinfection process. The results show that the disinfection has no significant effect on the mechanical and structural stability of the used polymers; therefore, 3D-printed PPE is reusable. For each device, recommendations and possible means of development are explained. The files of the modified models are provided. SLS and FFF additive manufacturing technology can be useful tools in PPE development and small-series production, but open-source models must be used with special care. Additive manufacturing (AM) technologies have reshaped medical diagnostics, preventive and preoperative measures, treatment and rehabilitation, as have tissue engineering processes in recent years ,13,14,15In the last month of 2019, a new disease battered the people of Wuhan City, Hubei, China ,28. The COVID-19 is transmitted primarily by respiratory droplets, close physical contact, and airborne transmission to a smaller extent. Consequently, frequent disinfection is essential to prevent transmission ,35,37,38Compared to conventional technologies, the use of additive manufacturing in the medical field has several benefits, such as inner specific design, personalized layout, sustainability, and time reduction, in addition to minimalized transportation costs. It also has disadvantages, such as essential post-processing, limited available materials, skilled operator, and low production volume ,15,16. Bm/m% solution was applied ) sheets  were applied. In order to assess the mechanical properties of the objects, based on international standards, all the material tests were performed on test specimens without disinfection, after 5 and 10 disinfection cycles, respectively. As a disinfection agent, the commonly used solution of tetra-acetyl-ethylene-diamine (TAED) and sodium-perborate solution  2  applied ,46,52,53As a dynamic mechanical test, Charpy impact test (ISO 179-1) was used on the un-notched specimens with a size of 80 × 10 × 4 mm. For the static mechanical analysis, a 3-point bending test (ISO-178) and tensile strength test (ISO-527-2) were performed. The 3-point bending test was carried out on the specimens with a size of 80 × 10 × 4 mm, and tensile strength tests are specified as B1. A flex resistance test of the ZA-22 silicone materials was carried out according to the ISO 32,100 standard using a Zwick/Roell  e/m actuator. The size of the test specimen was 70 × 45 × 1 mm and the number of cycles was 1000, 2000, 3000, 4000, and 5000 in case of all disinfected and non-disinfected samples. Shore A hardness measurements were performed in the case of the silicone test specimens. All of the test bars were laid on the printing bed with the largest surface facing downwards. All of the test specimens were measured in the “X” printing orientation. The room temperature was set to 22.6 °C, while the relative humidity was 49.5%. According to international standards, 5 pieces of test bars were printed for each test. The broken surfaces of the test specimens were examined using scanning electron microscopy  at 10× and 60× magnification. Gold sheeting was applied to the test bars. After a flex resistance test, the surface of the silicone samples was examined with a König digital microscope with 55× magnification. For the statistical analysis, OriginPro 2018 software was used.To determine the effect of disinfection procedure on the transparency of PMMA sheets, spectrophotometry measurements were performed on test samples of 0.3 mm thick and 50 × 30 mm size samples using Secoman Anthelie Advanced 2 spectrophotometry device . The change of intensity was measured, between 300 and 900 nm wavelength, on non-disinfected and disinfected test specimens. All measurements were repeated 5 times. According to publicly available materials and sources, three different types of PPE have been manufactured by 3D printing communities to date, mainly using FFF technology. Since biological agents transferred by droplets can easily enter the human body through mucous membranes, safety goggles can be used to specifically protect viral penetration via the eye. To protect the face from aerosol-based biological threats such as SARS-CoV-2, face masks can be used. This equipment is especially useful for all healthcare professionals who might come into contact with the virus. Protective half masks are important in filtering the air, which can reduce the risk of exposure to airborne diseases and aerosol-based microorganisms; therefore, they can be useful at all levels of the healthcare system. The effectiveness of half masks mainly relies on the type of incorporated filter and the fitting parameters to the face. Further protection can be achieved by applying face shields, either in combination with other PPEs or solely for non-medical purposes. Three main models of the aforementioned PPEs were examined, considering the production time, costs, and practical aspects. The following open-source (OS) models were examined: a half mask  degree of change in all cases, before and after the disinfection procedure as well . There wAlthough there are many research papers describing the layer-based structural characteristics of FFF 3D printing technology, the examination of PA structures created with SLS technology focuses on the granule itself and the in-production states of melting ,55,56,57In the case of face shields and goggles, visibility is a key factor; therefore, the light intensity passing through the PMMA sheets is essential to the proper use of these PPE. Medical personal and other healthcare staff must clearly see through them, so disinfection methods should not affect their vision. The spectrophotometry measurements revealed that five or even 10 disinfection cycles did not decrease the light intensity significantly; interestingly, a small amount of increase (1–2%) can be observed .OS Shield: The initial design has three main disadvantages: it does not protect the top of the head, it has a relatively high printing time (100 min with FFF and 51 min with SLS/piece) and high material usage, and the shield part is not long enough to protect the whole face.OS Half Mask: The available open-source model has severe fitting problems if it is printed using PLA or other relatively rigid thermopolymers. A specific size filter with an unknown origin can be fitted inside, which reduces the compatibility with other products. In this form, the design has several air leakage possibilities around the filter holder. With certain design modifications, a more compact configuration could provide better safety features. Furthermore, using SLS technology would make it possible to reduce the material’s overall weight (one piece) to 59.09% and the cost to 78.73% of the original values.OS Safety Goggles: The initial model is promising, but the application with a half mask is fairly difficult. Safety goggles reduce the peripheral viewing angle, which could be dangerous in a clinical environment. Furthermore, adding a poly (methyl methacrylate) (PMMA) or polyethylene terephthalate glycol (PETG) sheet is not practical, which reduces the possibility of applying disinfection measures.In general, FFF technology has some disadvantages and thus poses potential hazards in PPE production. First, the layers of thermoplastic polymers can be easily separated from each other. It could be extremely dangerous if, for example, a half mask is produced, and the resultant small holes cause air leakage, thereby increasing the risk of infection. If the post-processing techniques involve removing support materials and if the parameters are not carefully maintained, the remaining small fins and barbs could hurt and irritate the skin, which could provide an avenue for several infections and cause avoidable discomfort. The majority of these problems can be solved using SLS 3D printing technology, where the integrity of the models is considerably higher than the models printed by FFF technology. The details of the findings and potential hazards regarding the OS models , Table 1In this study, the OS models were modified using different CAD software solutions ; Fusion 360™, Autodesk, San Rafael, USA). Based on the findings and practical aspects, the research team created models that are cost-effective, easy to print and assemble, and adaptable for special or unique needs, and they can potentially increase the effectiveness and protection level of each device. The novel models are referred to as V.2.0.Shield V.2.0: The part of the model where the transparent polymer (PMMA) shield can be fitted is elongated to cover and protect a larger area of the face. The overall size of the model is decreased compared with the earlier model, which reduces the printing time in the case of FFF technology from 100 to 38 min for one piece. With SLS technology, the productivity is highly increased with the new model, as 41 pieces can be printed out in a full chamber. It was also important to design a cover to prevent contamination of the top of the head. This cover is fabricated from the same material used for the shield part . The matFace Mask V.2.0: In general, half-face masks are extremely important in the prevention of COVID-19. The available OS models generally seek certifications to provide information about the level of protection . To receive a certification, one of the major criteria is fitting to the face and nose, since a good fit ensures that virus particles cannot enter the airway system. To improve the face fitting in the V.2.0 model, a silicone layer was designed to reduce air leakage, which could be easily molded by an FFF 3D-printed mold tool. As the flex resistance test revealed, the used silicone is a durable and long-lasting solution, which can be disinfected without affecting the mechanical stability. Since a proper and easily changeable filter holder is a crucial safety feature of the mask, a solution for this part was also established. To further prevent air leakage and increase safety, an O-ring can be inserted into the connector part. The material weight for one piece is reduced from 120 to 70 g with FFF printing technology, and the price is reduced from 0.73 to 0.43 Euros. In the case of SLS models, a silicone layer can also be used .Safety Goggles V2.0: Two main modifications have been applied for the new model. To provide a wider angle for peripheral view, two side openings were designed in the goggles, which can be covered with transparent polymer sheets. The changing of the transparent sheets is easy and fast, which helps in the disinfection process. The nose fitting was also redesigned to enable parallel use with a face mask. In terms of productivity, the use of SLS 3D printing technology is recommended . The speAM technologies have had a serious impact on the development and production of PPE worldwide. Both FFF and SLS printers play a role in this field based on their characteristics and available printable materials. PLA is a suitable option for face shield production due to the cost-effectiveness and wide availability of the devices. In the case of supply shortages, as occurs in the COVID-19 pandemic, FFF technology can provide a temporary solution for PPE production, especially with previously described methods for strengthening functional 3D-printed parts . FFF priIn light of the enormous demand for PPE, companies and individuals have started to make 3D-printed masks, shields, and goggles. It is especially important to mention that the majority of these devices have not been approved by the Food and Drug Administration (FDA) or the European Community (CE); therefore, potential users must be aware of this fact and potential hazards. Some 3D-printed half masks have already gained preliminary approval from the FDA or obtained FFP3 equal validation (EN 140:1999 norm. CIIRC R95-3D), and they are meant for public use ,71,72,73In conclusion, during the COVID-19 pandemic, 3D printing technologies can help in preventive measures as an effective tool for PPE development and small-series production. Compared to other production methods such as injection molding, the lead time can be decreased, since there is no need for molding tool design. This fact also decreases the upfront cost. However, it is important to emphasize that after reaching the break-even point of production, 3D printing technologies are not sufficient from an economic perspective. According to previous studies, this break-even point can be estimated at around 200–300 product pieces, but the values strongly depend on the complexity and mass of the model ,75. FFF


BackgroundContrast-induced nephropathy (CIN) after primary percutaneous coronary intervention (PCI) is associated with increased mortality and morbidity. The aim of this study is to determine the frequency of CIN after primary PCI and its association with risk factors in patients with ST-segment elevation myocardial infarction (STEMI) at a tertiary care cardiac center in Pakistan.MethodologyIn this observational study, we included 282 patients who presented with STEMI and underwent primary PCI at the National Institute of Cardiovascular Disease, Karachi, Pakistan, from October 2017 to April 2018. The serum creatinine (mg/dL) levels were obtained at baseline and 48 to 72 hours after the primary PCI procedure, and patients with a 25% increase or ≥ 0.5 mg/dL rise in post-procedure creatinine level (after 48 to 72 hour) were categorized for CIN.ResultsOut of a total sample of 282 patients, 68.4% (193) were males, and the mean age was 56.4 ± 9.1 years. A majority of the patients, 78.7% (222), were hypertensive and 34% (96) were diabetic. The CIN was observed in 13.1% (37) of the patients, and increased risk of CIN was found to be associated with the presence of diabetes mellitus and increased (>200 mL) use of contrast during the procedure, with odds ratios of 2.3 (1.14-4.63) and 3.12 (1.36-7.17), respectively.ConclusionsThe CIN after PCI is a common complication associated with the presence of diabetes mellitus and the use of an increased amount of contrast during the procedure. Primary percutaneous coronary intervention (PCI) is the recommended and preferred reperfusion strategy for the patients with ST-segment elevation myocardial infarction (STEMI). When performed within the 12-hour window of symptom onset, it is an effective treatment strategy associated with a significant reduction in mortality and morbidity as compared to thrombolysis . In receDespite widespread use of contrast agents in intervention and radiographic studies, the pathophysiology of CIN is complex and not fully understood and involves various mechanisms, such as oxidative stress, vasoconstriction, medullary ischemia, and allergic reactions to contrast media ,10. VariPotential preemptive strategies to minimize the CIN are risk stratification of high-risk individuals, optimization of volume status, monitoring of adequate hydrations and infusion of normal saline before and after the procedure, and use of minimum contrast amount during the procedure. Guidelines on various preventive nonpharmacological and pharmacologic agents are not clear, and there is poor concordance in the literature, and despite the varying degree of agreement, iso-osmolar contrast or nonionic low-osmolar contrast is the preferred media among the interventional cardiology ,14.CIN after primary PCI and its associated risk factors widely vary from study to study, and very limited data on our population are available regarding this important clinical condition; therefore, in this study our aim is to determine the frequency of CIN after primary PCI and its association with risk factors in patients with STEMI at a tertiary care cardiac center in Pakistan.In this observational study, we included patients who presented to the emergency department with STEMI within 12 hours of the onset of symptoms and received primary PCI for revascularization at the National Institute of Cardiovascular Disease, Karachi, Pakistan, during October 2017 to April 2018.The consented patients who fulfilled the inclusion criteria of the study were included consecutively. The Inclusion criteria were either gender, between 30 and 70 years of age, and normal serum creatinine level (<1.2 mg/dL) at baseline. Hemodynamically unstable patients, such as patients in shock or Killip class IV or those with pre-existing CKD or end-stage renal disease were excluded from the study.Baseline demographic characteristics, such as gender and age (years), and clinical characteristics, such as history of diabetes, hypertension, and smoking, were recorded for all the patients. Diagnosis of STEMI was made based on history and electrocardiographic (ECG) changes at presentation, such as history of typical chest pain lasting for more than half an hour and supported by the baseline ECG findings of ST-segment elevation. Patients with a history of taking anti-hypertensive and anti-diabetic medication for at least six months were categorized as hypertensive and diabetic, respectively. Patients currently smoking or with a history of smoking a pack per day for at least one year were categorized as smokers.The serum creatinine (mg/dL) levels were obtained at baseline and 48 to 72 hours after the primary PCI procedure, and patients with a 25% increase or ≥0.5 mg/dL rise in post-procedure creatinine level (after 48 to 72 hours) were categorized for CIN. The primary PCI procedures were performed by the consultant cardiologists, and the amount of contrast (mL) used during the procedure was also recorded.Appropriate, frequency (percentages) or quantitative summary measures, such as mean ± standard deviation and minimum and maximum, were reported for the qualitative and quantitative characteristics of the patients. Stratifications were made by demographic characteristics (such as gender and age), co-morbidities , and procedural characteristics (such as among of contrast used during the procedure), and odds ratios (ORs) along with 95% confidence interval (CI) were computed and the chi-square test was applied. Data analysis was performed with the help of IBM SPSS Version 19 , and the level of significance was set at 5%.In the study sample of 282 patients, 68.4% 193) were male patients, and the mean age of the study sample was 56.4 ± 9.1 years. Hypertension was the most common co-morbid condition, which was observed in 78.7% (222) patients. The mean serum creatinine level increased from 0.77 ± 0.16 mg/dL at baseline to 1.06 ± 0.19 mg/dL, p < 0.001, after 48 to 72 hours of the procedure. The CIN was observed in 13.1% (37) patients. The demographic and clinical characteristics of the patients included in this study are reported in Table 93 were mIn this study, we observed no statistically significant association between the CIN, and gender, age, presence of hypertension, and smoking status of the patients. However, increased risk of CIN was found to be associated with the presence of diabetes mellitus and increased >200 mL) use of contrast during the procedure with ORs of 2.3 (1.14-4.63) and 3.12 (1.36-7.17), respectively. Rate of CIN by various patient demographic and clinical characteristics and associated ORs are presented in Table 00 mL useCIN after primary PCI is an important complication reported to be associated with increased risk of in-hospital mortality, prolonged hospitalization, and post-procedure complications such as need of ventilator and major bleeding events . In our In our study, we observed that increased risk of CIN is associated with patients and procedure-related characteristics such as diabetes and increased amount of contrast used during procedure. A positive relationship between increased incidence of CIN and increased amount of contrast agent during procedure has been documented by various past studies ,18. BatrConsidering the implications of this complication in the current era of intervention, it is important to adopt preemptive preventive strategies, pharmacological or nonpharmacological, in these patients. In a multicenter clinical trial, Chong et al.  reportedIn clinical setting, early recognition of patients at increased risk of development of CIN is crucial, and various risk stratification modalities have been proposed in various studies. Mehran et al.  developeIn conclusion, CIN after primary PCI is a common complication, and patients with diabetes mellitus are at an increased risk of development of CIN. Use of an increased amount of contrast during primary PCI procedure significantly increases the risk of post-procedure CIN. Early risk stratification and preemptive preventive measures are needed in clinical practice to minimize the clinical burden of CIN after primacy PCI.


Dermatomyositis is often presented as paraneoplastic syndrome. The diagnosis of dermatomyositis can prompt clinicians to further investigate the underlying cause, in particular malignancy. This case report illustrates the association of lung adenocarcinoma and dermatomyositis with antecedent presentation of cutaneous and musculoskeletal manifestations, one year prior to the diagnosis of carcinoma. Dermatomyositis is an inflammatory myopathy with typical cutaneous presentations including heliotrope rash of the periorbital skin, erythematous scaly plaques on dorsal hands along with periungual telangiectasia, and photosensitive poikilodermatous eruptions. Proximal myopathy is generally symmetrical and progresses within a period of weeks to months . It is aA 61-year-old gentleman, ex-smoker with no past medical illness, presented with breathlessness and cough for one month. He also reported having skin lesions over his eyebrows and progressive weakness of upper and lower limbs for the past one year. Examination revealed heliotrope rashes over both of his eyebrows, Gottron’s papules at the knuckles of hands Figure , 1B, perChest radiograph on admission revealed right upper lobe collapse. Computed tomography (CT) thorax also showed similar findings with lung mass at the right upper lobe measuring 6.5 cm × 7.1 cm × 5.3 cm Figure , 3B, 3C.Serial chest radiographs after a course of antibiotics showed expansion of collapsed right upper lobe with evidence of speculated mass at right middle zone. Bronchoscopy showed nodular lesions at right bronchiole of the right upper lobe. Biopsy of the nodules revealed the presence of lung malignant cells Figure . Also, iDermatomyositis is an idiopathic autoimmune disease characterized by skin and muscle lesions, with an incidence rate and female to male ratio of 0.6-1.0 per 100,000 individuals and 2:1, respectively ,6. There are many classification systems for dermatomyositis, of which the earliest was described by Peter and Bohan ,8. The dIn our study, the patient was diagnosed with dermatomyositis as he fulfilled three of the above-mentioned criteria, i.e., symmetric proximal muscle weakness, elevation of serum skeletal muscle enzymes, and typical skin rash of dermatomyositis.The onset of dermatomyositis has been frequently observed shortly before or after the detection of a malignant disease -11. Our Dermatomyositis is more commonly associated with small cell carcinoma than non-small cell carcinoma. Among the different histological types of lung cancer, dermatomyositis is found to have the highest incidence in small cell lung cancer, followed by squamous cell, and lastly adenocarcinoma .Treatment of dermatomyositis is mainly by glucocorticoids, immunosuppressants, and removal of the underlying cause. Common immunosuppressants used in dermatomyositis are methotrexate, azathioprine, and mycophenolate mofetil. The main aim of treatment for dermatomyositis is to relieve the symptoms and prevent worsening of the disease. Several case studies demonstrated that complete resolution of dermatomyositis without steroid treatment after the underlying malignancy is treated. As for this patient, he was given oral prednisolone 0.5 mg/kg/day, and his musculocutaneous symptoms were markedly controlled. However, he will need further treatment pertaining to his lung adenocarcinoma, namely chemotherapy and possibly tyrosine kinase inhibitor if driver mutations are present.Cutaneous and musculoskeletal manifestations of dermatomyositis with the presence of respiratory symptoms can be the antecedent findings for the diagnosis of lung cancer. Hence, it warrants careful compilation of patient history, further investigations, and follow-ups.


Background: Aspirin use has been associated with improved survival rates in various cancers. However, it remains unclear if aspirin confers a survival benefit on patients with nasopharyngeal carcinoma (NPC). The aim of this study was to assess the associations between aspirin use and survival in different stages of NPC. Methods: This is a 10-year retrospective cohort study of NPC patients. A total of 565 NPC patients were recruited after we performed a 1:4 propensity score match between aspirin users and non–users. Cox regression models with adjusted covariates were employed to evaluate factors that influence the survival rate of NPC patients. Results: The Kaplan-Meier analysis revealed that the overall survival (p < 0.0001) and disease-specific survival (p < 0.0001) rates of 180-day aspirin users increased. Increased survival rates were also observed in 180-day aspirin users with Stages III and IV, T, N1 and 2, and N3 categories. Cox regression models indicated that factors, including aspirin use , were independent prognostic factors for survival. Conclusions: Aspirin use for more than 180 days is associated with an increased survival rate and is a positive independent prognostic factor in NPC. Nasopharyngeal carcinoma (NPC) is a malignant tumor in the head and neck areas. Unlike other head and neck cancers, NPC is characterized by increased invasiveness and metastasis ,2,3,4. CAlthough NPC is rare in most parts of the world, it has a higher regional incidence in Asia than in Western countries ,8,9. TheDespite the fact that the five-year survival rate for people diagnosed with early-stage NPC is 72%, the survival rate is dramatically lower in patients with late-stage NPC due to its anatomical position as it relates to detection and management . FurtherAspirin is widely used as a drug to prevent cardiovascular diseases and has been shown to possess anti-inflammatory properties . The antOur interest in evaluating the potential of aspirin to improve the clinical outcomes of NPC patients increased owing to the fact that it improves the survival and cancer management in patients with other cancers ,25,26,27The cohort was comprised of a total of 2666 patients who were diagnosed with NPC in Chang Gung Memorial Hospital, Taiwan, between January 2007 and December 2017. Demographics and clinical characteristics from these 565 NPC patients, such as age, sex, AJCC stages of cancer, treatments, lifestyle risk factors, and comorbidities, are summarized in ≤60 vs. >60 =2.05, 95% CI = 1.43–2.95, p < 0.001), AJCC stages of cancer , CT , and aspirin use  were significantly associated with the survival rate, while patient sex  and RT  were not significantly related to survival. The multivariate Cox regression analysis, the results of which were similar to those of the univariate analysis, indicated that the factors of age , AJCC stages of cancer , CT  and aspirin use  were still significantly associated with survival. In contrast, patient sex  and RT  were not independent prognostic factors for survival  in 565 patients. Regarding aspirin use, there were 17 (15%) deaths in the 113 patients who were aspirin users and 184 (32.6%) deaths in the 448 patients who were non-users . We perfp < 0.001), while no statistical significance was observed in patients with Stages I and II NPC (p = 0.302)  . We also= 0.302)  or N (N1= 0.302)  in termsAspirin is relatively safe and affordable and can help ease the burden of long-term medical care of diseases. It has shown promising beneficial effects for treatments across a broad range of diseases ,27,29,30Due to detection and management limitations, late-stage NPC is considered to be a serious health problem in Taiwan and is the leading cause of cancer-related death ,11,12,13In this study, we attempted to minimize the bias between aspirin users and non-users by using a propensity score match at a 1:4 ratio. As one of the results from this matching, the baseline patient characteristics revealed that the patients who had aspirin prescribed were more likely to have comorbidities related to cardiovascular diseases, such as CVA, DM, hypertension, and hyperlipidemia, compared to non-users . This reWe observed that aspirin use for at least 180 days after diagnosis of NPC positively affected 10-year OS and DSS rates ; this efIt has been suggested that age plays a role in cancer survival ,33,34,35PIK3CA and BRAF, may also have an impact on the benefits of aspirin use for several types of cancer. [Several studies have shown that aspirin use improves survival rates in the late-stage of various types of cancers ,24,26,27 cancer. ,39. Inte cancer. . Collectn = 290), aspirin use less than 180 days (n = 114), nasopharyngeal malignancies with morphology codes other than 8010, 8020, 8070, 8071, 8072, and 8082 (n = 38), and less than 20 years of age (n = 21). In total, 2203 patients were analyzed in our study.This cohort study was approved by the Institutional Review Board (IRB) of the Kaohsiung and Chiayi branches of Chang Gung Memorial Hospital with reference numbers 202000714B0 and 201700253B0C602. The requirement for informed consent was waived, according to the nature of the study design and IRB regulations. During the time period of 01/01/2007–12/31/2017, 2666 patients diagnosed with nasopharyngeal malignancy  in the Chang Gung Research Database were identified. Exclusion criteria were AJCC Stage IVc or missing data on stage of cancer  was created using the Greedy method with a 0.25 caliper-width using NCSS 10 software   41,42,4,46,47. TIn summary, we conducted 10-year cohort study using a database from Chang Gung Memorial Hospital, which was an accurate reflection of diverse patient subgroups and representative of the nation’s NPC cancer cases in Taiwan. Our findings indicated that OS and DSS rates exhibited significant improvement in patients with NPC after aspirin use for more than 180 days. According to the univariate and multivariate Cox regression analyses, which confirmed previous findings that factors, such as patient age and AJCC stages of cancer, are significantly associated with survival rates in patients with NPC. Moreover, these analyses contribute additional evidence that suggests aspirin use is an independent prognostic factor for improving survival rates. Taken together, these new understandings will provide the opportunity to improve the management of cancer care and survivorship for patients with late-stage NPC in Taiwan, as well as in the areas where NPC is endemic.


The COVID-19 has spread to more than 200 countries and territories. But less is known about the knowledge, protection behavior and anxiety regarding the outbreak among the general population.A cross-sectional, population-based online survey was conducted in China and abroad from January 28 to February 1, 2020. Socio-demographic information was collected and knowledge scores, practice scores, anxiety scores and perceived risk were calculated. General linear model and binary logistic regression were used to identify possible associations.We included 9,764 individuals in this study, and 156 (1.6%) were from Hubei Province. The average knowledge score was 4.7  ; 96.1% maintained hand hygiene, and 90.3% of participants had varying levels of anxiety. People in Hubei Province were the most anxious, followed by those in Beijing and Shanghai. People who had experienced risk behaviors did not pay more attention to wearing masks and hand hygiene.The public had high awareness on knowledge of COVID-19 outbreak, and a high proportion of people practiced good hand hygiene behavior. Many people claimed anxiety, especially in heavily affected areas during pandemic, suggesting the importance of closing the gap between risk awareness and good practice and conduct psychological counseling to public and patients. On January 8, 2020, a novel coronavirus (named SARS-CoV-2 a month later4) was laboratory confirmed as the cause of the outbreak, similar to the severe acute respiratory syndrome coronavirus (SARS-CoV)5 that caused severe acute respiratory syndrome outbreaks in China in 2003 and the Middle East respiratory syndrome coronavirus (MERS-CoV)6 that caused severe respiratory disease outbreaks in the Middle East in 2012. Since January 3, China began to report the outbreak information to the World Health Organization (WHO) regularly.7 The test kit was initially developed on January 10. As of January 28 (when this study started), COVID-19 infection caused 5,974 cases in Mainland China and the number was growing dramatically.8 As of February 1 (when this study ended), 14,380 cases were reported.9 Currently COVID-19 has caused a global pandemic, with more than 6 million cases and more than 370,000 deaths reported in 216 countries and territories by the end of May 202010  was estimated approximately as 2.68.13 The outbreak coincided with the Chinese Lunar New Year, and the mobility of people visiting relatives and friends increased, which also increased the difficulty of prevention and control. To improve the awareness of self-protection among the general population, the National Health Commission had released six versions of the new coronavirus pneumonia prevention and control protocol14 and published guidelines for public prevention, recommending minimizing outings, wearing a mask, and keeping hands clean.15 These suggestions, as well as daily outbreak information, are transmitted to the public through television, mobile phones, the internet, and other means. People have discussed the outbreak and expressed their views in “we media” era during the spread of the outbreak. Due to the rapid spread of the outbreak and the control activities, some people developed anxiety and fear. Guidance on emergency psychological crisis intervention was published for patients, medical professionals, and the general public to prevent the psychological damage caused by the outbreak and promote social stability.16 Psychological assistance hotlines have been set up in all cities and counties, providing free 24-hour service.17The dissemination of epidemic information and personal protection knowledge plays an important role in preventing and controlling the outbreak. The evidence suggested that human-to-human transmission had occurred among close contacts,18 Therefore, at the beginning of the COVID-19 outbreak in China, we designed an online questionnaire to measure the knowledge and practice, providing references for reassuring citizens and outbreak control.To our knowledge, there has been no article reporting the current public awareness and psychological status of Chinese people focused on virus and epidemiology of outbreak. Understanding the public knowledge, practice of prevention, and psychological status can improve effectiveness of health risk communications, and analyzing their demographic differences can help avoid unequal protection across society.A cross-sectional, population-based online survey was conducted from January 28 to February 1, 2020. It was an open online questionnaire for all the population aged 18 years or above residing in China and abroad. Those willing to respond could complete the questionnaire by mobile phone or by computer.We designed a structured Chinese questionnaire and collected data on Wenjuanxing, an online platform providing functions equivalent to Amazon Mechanical Turk. In the questionnaire, we collected the following information: (1) the socio-demographic information of the respondents; (2) knowledge of COVID-19, including the transmission routes, susceptible population, incubation period and response principle ; (3) practices of preventive measures against COVID-19, including wearing masks, personal hygiene practices, avoidance of contact with high risk group ; (4) anxiety towards COVID-19, using the five-question short form of the State-Trait Anxiety Inventory (STAI) to measure anxiety; (5) risky behavior, defined as coming in contact with someone with a confirmed or suspected case; and (6) perceived risks, including five categorical options . The questionnaire consisted of 33 questions and can be completed in 3–5 minutes see .We used SPSS  and STATA  for data cleaning and statistical analysis. Categorical variables were expressed as absolute and relative frequencies in different groups. According to the following principle, we calculated scores: (1) Knowledge of COVID-19, measured using “knowledge scores”: questions were scored “1 point” (correct answer) or “0 point” (wrong answer or incomplete answer in multiple choices); (2) Practices of preventive measures against COVID-19, measured using “practices scores”: questions were scored “1 point” (correct practice) or “0 point” (wrong practice); (3) Anxiety towards COVID-19, measured using a five-point Likert-type scale to ascertain the degree of anxiety for five questions ; (4) risk behavior, categorized as a binary variable ; and (5) perceived risks, which were divided into five order categories according to severity .Direct standardized questionnaire was used to measure knowledge scores, practices scores, and anxiety scores on different ages and educations of population to improve comparability among provinces. General linear modeling (GLM) was used to identify associations of sociodemographic factors  with knowledge scores, practices scores, and anxiety scores. We used trend linear regression to test the change trend of scores in people with different age and education. Binary logistic regression was used to explore the relationship between risk behaviors and wearing masks and hand hygiene, and odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated. The component ratio was used to describe the channel through which people obtained information.P values were less than 0.05.The spatial data analyses were conducted using ArcGIS . The significance level was considered when We monitored the progress of the survey every day. After the deadline, we checked the accuracy of data, and excluded the questionnaire if (1) the age range was below 18 or above 100 years, (2) the answering time was less than 150 seconds, or (3) there were logical contradictions between the answers to the questionnaire.This study was approved as ethical exemption by the Peking University Health Science Center Ethics Committee (IRB00001052). All subjects participated in the survey voluntarily, and the information in the database was completely de-identified.In total, 10,966 individuals participated in this online survey. Among these, 1,202 were excluded due to out of age range or incomplete questionnaire, and the rate of completeness was 89.0%  See .The participants of this study covered all 31 provincial administrative regions in Mainland China. Among the 9,764 eligible participants, 156 (1.6%) were from Hubei Province, 9,408 (96.4%) were from other provinces in China , and 200 (2.0%) were from abroad; 3,278 (33.6%) was male; average age was 38.0  years; 9,281 (95.1%) were with senior high school education or above; 7,841 (80.3%) were urban people; and 6,681 (67.8%) were married . 77.3% of respondents  accurately knew the transmission route of COVID-19, and 95.4%  knew the incubation period of the disease.P < 0.05). People over 50 years had lower knowledge scores . With the increase of education, people obtained higher knowledge scores (P < 0.01). Knowledge scores of medical personnel were higher than those in people with other occupations. There was no significant difference of knowledge scores in people with different marriage status  but not statistically different with those in people abroad  . 66.9% of respondents  were able to wear appropriate masks to prevent COVID-19 infection, and 81.5%  were able to change their masks regularly. 96.1% of people  maintained hand hygiene and washed their hands in time.P < 0.01). People over 40 years old had lower practice scores (P < 0.01). People with senior high school education and above and medical professionals obtained higher practice scores (both P < 0.01). We did not find significant difference in people with different marriage status   Table .25 = 8; P75 = 15). The proportion of women (30.6%) in high anxiety state was higher than that of men (21.0%). With the increase of age, the anxiety of the population gradually decreased . With the increase of education, the proportion of people with high anxiety level rose gradually ;  of participants had experienced varying levels of anxiety. Thirty-six percent  people reported that they were frequently angry, and 33.8%  people often had pessimism. Only 5.0%  of people were not nervous about the outbreak. Among all participants, the median anxiety score was 11 (PP < 0.01) and abroad  , followed by those living in Beijing (30.5% with high anxiety) and Shanghai (30.2% with high anxiety) Figure D. The reP = 0.76, P = 0.66, and P = 0.32, respectively). After adjusting for gender, age, education, and province, people with risk behaviors could clearly know that they were at high risk . However, people who had experienced risk behaviors were less likely to wear masks and practice good hand hygiene than those without risk behaviors   or clean their hands frequently . People over 30 years were more likely to wear masks than those under 30 years . The perceived risk and the possibility of wearing masks and hand hygiene of the people in Hubei Province were not significantly different from those in other provinces  of the respondents paid attention to the epidemic information every day; 79.0%  believed the outbreak would be fully controlled within 3 months; and 93.9%  of the respondents obtained epidemic information through official announcement, followed by social media (61.4%) and traditional media (54.1%)  surveillance, contact tracing, quarantine, and self-protection, just like SARS-cov and MERS-cov.24,25 However, based on Chinese guidelines, we could conclude that more than 30% of respondents were not able to wear appropriate masks to prevent COVID-19 infection, and nearly 20% did not change their masks regularly. The proportion of people taking preventive measures is similar to that among the population in Reunion Island during the influenza A (H1N1) pandemic,26 but still low. Previous literature showed that the relationship between age and preventive behavior may change with different diseases and different population.26–28 Reducing the misunderstanding of personal protection is the focus of public awareness and health education in the next step.We found that 66.9% of respondents were able to wear appropriate masks to prevent COVID-19 infection, 81.5% were able to change their masks regularly, and 96.1% of people maintained hand hygiene and washed their hands frequently. WHO and United States Centers for Disease Control and Prevention does not recommend wearing masks to prevent infection and suggests hand-washing as a protective measure for general population as of the completion of this investigation.29 In addition to Hubei Province, people in multiple provinces, like Shanghai and Beijing, also had experienced much anxiety. Cities that experienced previous outbreaks might be more sensitive to the epidemic of infectious diseases.30,31 Younger people living in urban areas or with higher education were more anxious about the outbreak, which showed similar trends observed for anxiety and panic during the H5N1 avian influenza pandemic in Hong Kong32 and during the SARS outbreak in Qatar.33 While COVID-19 is still spreading across the country, the public generally experiences high levels of panic, fear, anxiety, and irritability. These negative emotions can progress into behavioral changes, such as being afraid to leave the house, blindly disinfecting, and scrambling for medicines. Baidu, one of the most common search engines in China, has released an information index, for which “psychological counseling” in Hubei Province increased by 3,275% from January 20th to January 26th, and the search index increased by 51% in the 7 days.34 In this study, 86.5% of people in Hubei Province reported that they had contacted high-risk population or environment, compared with only 6.5% of people in other provinces. Besides, many areas have cut off traffic with Hubei. This would increase their psychological stress. These results suggested we should not only support Hubei Province in medical treatment, but also need to strengthen health education and psychological counseling. It is recognized that extensively implementing mental health monitoring in the community is a worthwhile strategy. Community workers should regularly assess the psychological status of community families and report to their superiors. Meanwhile, the government should strengthen media efforts to ensure the validity and accuracy of output information. We strongly recommend that the government develop health education strategies to address mental health issues, promote healthy behaviors, and reduce psychological stress.Our study confirmed that anxiety related to COVID-19 outbreak was common in the general population. Anxiety and fear has a negative impact not only on health, but also has economic effects and social consequences, as was seen during the SARS outbreak in 2003.In this study, people with risk behaviors clearly know that they were at high risk, but they did not pay enough attention to wearing a mask when going out and maintaining good hand hygiene. According to local regulations, people must wear masks when going out. What’s more, maintaining hand hygiene is an effective protection for themselves. We consider that appropriate risk perception of the outbreak can lead to beneficial changes in health behaviors, such as wearing masks and washing hands frequently. And strong publicity and punishment may increase the possibility of wearing masks and other protective behaviors. However, due to the sudden outbreak, the supply of masks in China is insufficient to meet the needs of some people.There are some limitations to our study. First, online questionnaires led to a biased selection. The respondents are mainly those living in urban area and with high school education or above, which may overestimate the knowledge of the outbreak and protection. Second, although we have carried out quality control, there may be errors in the information because the online questionnaire cannot be modified after filling in. Third, this study is a cross-sectional survey and cannot show trends. In order to dynamically assess knowledge, practice, and psychological pressure of Chinese people on the outbreak, we have conducted a follow-up survey while the epidemic was under control.In summary, the public was very concerned about the COVID-19 outbreak, with high knowledge of the transmission route and incubation period of the disease, and a high proportion of people practiced good hand hygiene behavior; however, quite a number of people experienced anxiety caused by quarantine or mobility control, especially in Hubei Province. The findings suggest the importance of closing the gap between knowledge and good practice, and the need to reduce anxiety caused by the pandemic. Conducting psychological counseling and health education to public and patients is an important and key measures to address the public anxiety issue.