Blunt chest trauma (BCT) accounts for up to 65% of polytrauma patients. In patients with 0 to 2 rib fractures, treatment interventions are typically limited to oral analgesics and breathing exercises. Patients suffering from BCT experience symptoms of severe pain, poor sleep, and inability to perform simple daily life activities for an extended period of time thereafter. In this trial, we aim to investigate the efficacy of acupuncture as a functional and reliable treatment option for blunt chest trauma patients.The study is designed as a double-blind randomized control trial. We will include 72 patients divided into 2 groups; the acupuncture group (Acu) and placebo group (Con). The acupuncture group will receive true acupuncture using a uniquely designed press tack needle. The control group will receive placebo acupuncture treatment through the use of a similarly designed press tack needle without the needle element. The acupoints selected for both groups are GB 34, GB 36, LI 4, LU 7, ST 36, and TH 5. Both groups will receive 1 treatment only following the initial visit to the medical facility and upon diagnosis of BCT. Patient outcome measurements include: Numerical Rating Scale, Face Rating Scale, respiratory function flowmeter, Verran Snyder-Halpern sleep scale, and the total amount of allopathic medication used. Follow-up time will be scheduled at 4 days, 2 weeks, and lastly 3 months.The results of this study can potentially provide a simple and cost-effective analgesic solution to blunt chest trauma patients. This novel study design can serve as supporting evidence for future double-blind studies within the field of acupuncture.The study will be conducted in the thoracic surgical department and acupuncture department in China Medical University Hospital, Taichung, Taiwan. The study will be conducted on blunt chest trauma patients and is anticipated to have minimum risk of adverse events. Enrollment of the patients and data collection will start from March 2020. Study completion time is expected in March 2022.(CMUH109-REC1-002), (NCT04318496). In the case of preserved organ function, it is the bony structures and soft tissues which are most commonly affected by BCT injury. According to previous literature, BCT patients can be divided into 3 levels based on the severity of injury as identified by chest plain film findings. Level 1 includes patients without rib fractures; level 2 includes patients with 1 or 2 rib fractures; and level 3 includes patients with more than 2 rib fractures. Based on retrospective studies, level 3 patients experience increased frequency of hospitalization, thoracotomies, and a higher mortality rate. Levels 1 and 2 patients are commonly treated as out-patients, but still suffer greatly from chest pain and tend to experience breathing difficulties.,3 The pain associated with the BCT injury may in turn lead to the inability have sufficient sleep, with the resultant lack of rest impeding the recovery process. The most commonly used conventional treatments are analgesics.,5 Moreover, while nerve block surgical intervention is also practiced as a treatment intervention, it is commonly reserved for level 3 patients experiencing severe pain and/or thoracic deformity.,5 While analgesic medication can relieve pain temporarily, most patients still suffer prolonged nociceptive hypersensitivity and usually have difficulties in performing daily life activities for sometime after. Furthermore, elderly and renal insufficiency patients are at a higher risk of experiencing harmful effects from long term use of analgesics and muscle relaxants.The rib cage and associated anatomical structures are responsible for protecting the vital organs located within the chest cavity.–9 Accordingly, in order to maintain an unbiased approach, the acupuncture intervention of this particular study will be compared to a placebo intervention. Our study implements a novel design that maintains clinical efficacy, through the use of press tack needles and similar placebos that look identical, hereby ensuring blindness of both the patient and the acupuncturist.For thousands of years, acupuncture has been used in the treatment of all kinds of traumatic injuries. Moreover, in recent decades, stimulation of acupuncture points for the treatment of visceral pain, post-operative pain, cancer pain, and chronic pain is well established and has been widely investigated in a number of clinical trials.With a goal to improve the analgesic effect and life quality in patients suffering from BCT, we designed a double-blind study comparing press tack acupuncture to press tack placebo interventions. In the trial, we aim to investigate the efficacy of press tack acupuncture based on traditional acupuncture concepts and point locations. Furthermore, we hypothesize that press tack acupuncture will have a superior analgesic effect when compared to press tack placebos.22.1The study is designed as a single-center randomized control, parallel-arm, double-blinded trial. It will take place in the out-patient clinic of China Medical University Hospital. The study will be conducted from March 2020 to March 2022. The study was approved by the institutional review board of China Medical University Hospital (CMUH109-REC1-002), and was registered on clinicaltirl.gov (NCT04318496).The main goal of the study is to reduce pain and improve the respiratory function and sleep quality of patients after BCT. The participants will be divided to 2 groups; acupuncture group (Acu) who will receive the true press tack needles, and a placebo group (Con) who will receive press tack placebos on the same acupoints without the needle element. Patient outcome measurements include: Numerical Rating Scale (NRS), Face Rating Scale (FRS), respiratory function flowmeter Verran Snyder-Halpern sleep scale (VSH), and the total amount of allopathic medication used.2.2We will include a total of 72 patients who are suffering from BCT. After the patient's accident, such as falls, kicks, fights, or traffic accidents, they will be sent to the emergency room and visit a chest surgical out-patient clinic for treatment and follow-up. Those who meet the inclusion criteria will be informed about the study and can freely choose to participate. They will sign the informed consent and will be randomized accordingly, with commencement of the study occurring immediately. The patients are allowed to drop out from the study at any time point of the study.2.3Age 20 to 80 years old.Patients who have chest trauma as described by themselves or based on medical chart records within 1 week of injury.Injury Severity Score (ISS) is less than 18 points.Body mass index < 30.2.4Sternal fracture.ISS is equal to or more than 18 points.History of intercostal nerve injury.History of cardiovascular disease.History of chronic lung disease.Significant lung mass or chest deformity noted in the chest plain film.2.5From the informed consent discussion and form, the intervention, risks, benefits, and patient's rights in the study will be explained in a simple language that patients can clearly understand . The informed consent will be signed by the patient or by a legal guardian. In the circumstance that they wish to withdraw from the study, our strategy is to use the available data for the final analyses and accommodate the patients’ wishes accordingly.2.6The participants will be randomized into 2 groups with a 1:1 ratio produced by the SPSS program software, version 22. A computer-based simple random sampling with a 1:1 ratio without stratification will be used. A number (1–72) will be affiliated to each patient at the time of their first visit to the out-patient clinic and after completing the informed consent. The number, patient name, and date of birth will be written down on a non-transparent envelope by a study nurse 1 (researcher EB-A). Inside the envelopes, there will be 14 separate sterile press tack needles or identical looking press tack placebos. The envelopes in both groups will appear identical. Study nurse 1 will write down the number, patient name, and intervention in an electronic chart and create a file for each patient.2.7Study nurse 1 will be responsible for randomization and prepare the needles in the envelopes. Outside the envelopes, there will be a number belonging to 1 patient, and inside the envelopes, there will 14 separate sterile needles which can be either true press tack needles or press tack placebos. The envelopes and the pouch of needles will look the same. The acupuncturist will be asked not to check the needles when they insert them. At the time of acupuncture, a nurse will accompany the acupuncturist and will verify that he/she is not examining the needles closely. Study nurse 2 will perform the outcome measurement tests. The acupuncturist, patients, and study nurse 2 will be blinded to patient allocation.2.8The participants will be divided into 2 groups. One group will receive press tack needle acupuncture (Acu); the other group will receive press tack needle placebos without the needle element (Con). Both groups will receive 2 individual treatments on the same set of acupoints. The needle retention time will be 4 days. Needle withdrawal will be done by the acupuncturist or acupuncture nurses who have trained in needle withdrawal techniques in the out-patient clinic Fig. .2.9Φ0.20 mm × 0.6 mm made by Seirin Corporation) have a diameter of 0.2 mm and a length of 0.6 mm. Each needle is packed separately in a sterilized pouch. As for the placebo, the individual press tack and pack are identical to the press needles, except the needle element has been removed. Both interventions will be performed by a qualified acupuncturist and a medical doctor with at least 1 year of experience in acupuncture practice.In the protocol, the press tack needles , GB 34 (YangLingQuan), ST 36 (Zusanli), LI 4 (HeGu), LU 7 (LieQue), TH 5 (Waiguan) were chosen for both groups. Each patient will receive 12 press tack needles in total. The needle's depth of insertion will be 0.6 mm. The acupuncturist will manually press the press tack needles over the above-mentioned acupoints without any needle manipulation or “De Qi” sensation. The participants will lay on the treatment bed for the duration of 30 minutes. After the aforementioned process, the vital signs, pain levels, and flowmeter will be recorded again to represent the immediate effect after acupuncture. Finally, the acupuncturist will educate the patients about the total number of press needles and the allotted time of retention. The press tack needle retention time will total 4 consecutive days.2.11The participants in the placebo group will experience the same treatment course including the selection of acupoints and associated outcome measurement recording. However, the placebo group participants will receive press tack placebos . The press tack stickers on the skin surface are identical but without any needle penetrating the skin. The placebo sticker retention time will be the same as in the acupuncture group, totaling 4 consecutive days Figs.  and 3.2.12Both groups of participates will also receive the prescribed analgeasic medication and/or muscle relaxants. The frequency of the prescribed medicine is 3 to 4 times a day along with meals and before sleep for 7 days. The purpose of the medication is for pain relief, therefore, the participants can discontinue the medication at will.2.13The main outcome measurement will be the pain levels of both rest and mobile status for the BCT patients . The patient will measure their pain according to 3 subjective pain scales, namely the NRS, and FRS before treatment, 30 minutes after treatment and 4 days after the press tack needles/placebo intervention. Furthermore, a follow-up will assess the NRS pain scale telephonically at 14 days and 3 months after the initial intervention.3 per second to elevate. 1200 cm3 is the highest score and indicates good exhalation power. The above process will be done before intervention, 30 minutes after intervention and 4 days after the intervention. The patient will also answer the VSH sleep scale in Mandarin to evaluate the sleep quality of the night before the clinic visit. They will complete the questionnaires accordingly at every clinic visit, for a total of 2 times (on day 1 and day 4). Finally, on the 4th day after the initial intervention, participants will bring back the prescribed medication, including analgesics and/or muscle relaxants that were left unused, to be measured for the amount of medication used.Secondary outcome measurements will include the improvement of respiratory function, sleep quality, and amount of medication used . We used the portable triflow flowmeter and VSH sleep scale as objective tools for the aforementioned purposes. The patients will be educated on the use of the flowmeter by the affiliated thoracic surgeon. Patients will be allowed as much time as needed to practice the use of the flowmeter before the first measurement is taken. When the patient is ready, the study personnel will commence the measurements of 3 attempts, and will record the best 2 attempts. The triflow flowmeter measures the amount of air the patient can exhale; it has 3 chambers with their own balls that require air pressures from 600 to 1200 cm2.14After the initial visit to the chest surgical out-patient clinic, the participates in both the Acu and Con groups will be expected to return 4 days after acupuncture/placebo treatments for needles/placebos withdrawal along with chest plain film, NRS, FRS scores, flowmeter, respiratory function, VSH sleep scale assessments, and amount of medication used. On the 14th day and at 3 months after the initial intervention, a study personal will arrange a telephonic consultation to enquire about the pain scale (NRS) and any adverse effect related to the acupuncture treatment and the chest trauma . The demographic data between Acu and Con groups including gender, age, and clinical characteristics will be compared using the Student's U and the Wilcoxon sign rank test will be implemented accordingly. Missing data will be analyzed using the pairwise deletion method.Subgroup analysis will be done based on the following: age, sex, number of treatments complete, number of hours of needle retention, number of rib fractures, pulmonary complications, hospitalization, number of days from patient's injury to the first treatment, Triflow score, medication use, body mass index, and ISS. In cases of small sample size, the Mann–Whitney 3 In the case of BCT, nociceptive signals are transmitted to the brain following peripheral tissue damage. In terms of the 1 to 10 NRS pain scale, the patient's pain levels on the first recorded day of injury can reach up to 9 to 10 points, whereafter the pain sensation gradually decreases and is subsequently recorded at reduced levels of 2 to 3 points after 15 days. However, the long term effects of pain resultant from physical injury usually display concurrent overlapping conditions related to the physical, psychological, and even socio-economic function ability of patients, and can last up 12 months after initial injury.The nociceptive response is a reflexive bodily response of the body aimed at providing protective mechanisms. In short, pain creates awareness of pathological conditions resultant from injury or harm, and may vary in intensity, quality, duration, and referral. Accordingly, pain is categorized according to 4 distinct types: nociceptive pain, inflammatory pain, neuropathic pain, and functional pain.–19 In terms of acute pain, acupuncture has displayed promising analgesic effects in a wide array of diseases, with particular emphasis on emergency medicine.–22 Furthermore, acupuncture has displayed tendencies of increased efficacy in the treatment of bone fractures as shown in elders in the acute stage of hip fracture. In addition, patients who received acupuncture treatment in the ambulance en route to hospital, reported reduced pain sensations, less anxiety, and lower heart rates. They also stated a higher overall satisfaction regarding the emergency ride to the hospital.Acupuncture treatment is well known for its analgesic potential, with proven efficacy particularly in chronic pain conditions. Furthermore, the therapeutic benefits of this treatment are extended to complicated conditions of maladaptive pain, such as myofascial pain, tension headache, irritable bowel syndrome, etc. Other possible explanations of acupuncture analgesia include the evident reduction in common inflammatory mediators such as substance P, IL-1β, IL-8, IL-10, and TNF-α, all of which are over-expressed in nociceptive hypersensitive states, specifically inflammatory pain, and functional pain conditions.The analgesic effects of acupuncture have been further biochemically described via research obtained from various animal studies. The underlying molecular mechanisms of acupuncture analgesia are commonly associated with an increase in adenosine and an upregulation of the A1 receptors that are largely associated with anti-nociceptive effects.,25 In the randomized control trial, Ho et al focused on the patients with 2 or more rib fractures requiring hospital admission (level 3). These patients were usually well monitored and treated with adequate analgesic mediations during their hospital stay. When patients classified according to level 1 or level 2, without rib fractures or with less than 2 fractures, respectively, are treated in the out-patient clinic, the pain control measures are limited, especially when intravenous (IV) medications are not available.Current literature contains limited information with regards to the use of acupuncture treatment in cases of BCT. Accordingly, only 1 randomized control trial and 1 case report about the benefit of acupuncture for the blunt chest injury was discovered. Doctors discovered that the injuries of internal organs or the torso could be treated via the stimulation of the distal skin surface, such as the limbs, ears, or skull. They drew lines to connect specific points, and developed a map of the 14 meridians, each of them is related to a specific organ system. In the present study, we utilize this concept through the use of distal point stimulation of 4 limbs to ease the chest pain associated with traumatic incidences without directly applying needles at the site of injury.To this end, acupuncture provides suitable, reliable, and effective forms of relief for these patients. The efficacy of Chinese Medicine in the treatment of various conditions has been proven over thousands of years. For this protocol, we had chosen the press tack needles and press tack placebo due to their simplicity and similarity which allows for effective blinding. The press tack needles look identical to the press tack placebo, whereby one can only see a difference at the time of needle insertion and withdrawal upon extremely close inspection of the needles, and thus they can serve as an ideal device to generate the “blindness” effect to both the patients and the acupuncturist. The “De Qi” phenomena, which is usually achieved through manipulation of the acupuncture needles via rotation is considered by some as a major part of the acupuncture effect, and might be lost in the application of press tack needles, thus being regarded as the press tack needles’ biggest disadvantage.,30 However, as we want to apply the use of acupuncture in a conventional allopathic, we believe that the press tack needles can provide a simple to use and safe treatment option for all modalities of medical care. In this study protocol, we decided to implement the following acupoints: GB 34 (YangLingQuan), GB 36 (Waiqiu), LI 4 (HeGu), LU 7 (LieQue), ST 36 (Zusanli), TH 5 (Waiguan), as a result of similar theoretical affiliations. Specifically, the concept associated with these specific points is directed at the fact that most chest trauma occurs on the frontal and lateral areas of the chest. Accordingly, Chinese medicine theory describes the frontal area of the chest as being controlled by the yang ming layer (stomach and large intestine meridians), to which end the acupoints: LI 4 (HeGu) and ST 36 (Zusanli) belong to that layer and can potentially generate an analgesic effect within the specified area. The lateral side of the chest is purportedly controlled by the shao yang layer , whereby the acupoints GB 34 (YangLingQuan), GB 36 (Waiqiu), and TH 5 (Waiguan) can potentially improve Qi and blood flow within this specific region and alleviate pain.,31 The addition of the acupoint LU 7 (LieQue) was designed to treat the lung organ and improve lung functions. The acupoints ST 36 (Zusanli) and LI 4 (HeGu) were found to decrease incisional pain and improve post-operative rest in post abdominal surgery patients. The acupoints LU 7 (LieQue), LI 4 (HeGu), ST 36 (Zusanli), TH 5 (Waiguan) also showed a general analgesic benefit and increased post-operative recovery.With regards to the manipulation of acupuncture needles for increased therapeutic benefit, a multitude of options are available, including manual acupuncture, electro-acupuncture, press tack needle, laser acupuncture, etc.3.1The study provides an effective intervention but is limited to a shallow acupuncture needling depth of the superficial subcutaneous layers and cannot be associated with the benefits caused by the deeper stimulations commonly associated with most acupuncture interventions. Furthermore, the point selection in this study only concentrates on anterior and lateral BCT locations. Lastly, the follow-up method of telephone calls at 14 days and after 3 months can prove problematic, and a high loss to follow-up is anticipated.In this study, we offer a simple, low-cost form of acupuncture that, if it will prove superior analgesic effects in comparison to the placebo, can provide a safe and reasonable treatment alternative to BCT patients.We would like to acknowledge the Seirin Corporation for providing the acupuncture and placebo press tack needles. We would also like to acknowledge Dr Bernice Lottering for her assistance in the editing of this paper.Analysis and interpretation of the data: Ho Wen-Chao, Eyal Ben-Arie, Kao Pei-Yu.Conceptualization: Pei-Yu Kao, Eyal Ben-Arie, Yu-Chen Lee, Fang-Pey Chen.Data curation: Pei-Yu Kao, Wen-Chao Ho, Fang-Pey Chen.Design: Eyal Ben-Arie, Kao Pei-Yu, Lee Yu Chen, Fang-Pey Chen.Formal analysis: Wen-Chao Ho.Funding acquisition: Kao Pei-Yu, Fang-Pey Chen.Investigation: Pei-Yu Kao, Ting-Yu Lu, Yu-Sen Lin, Chien-Kuang Chen, Jian-Xun Chen, Tzu-Min Huang.Methodology: Pei-Yu Kao, Eyal Ben-Arie, Wen-Chao Ho, Yu-Chen Lee, Fang-Pey Chen.Patients enrollment: Kao Pei-Yu, Ting-Yu Lu, Yu-Sen Lin, Chien-Kuang Chen, Jian-Xun Chen, Tzu-Min Huang.Project administration: Pei-Yu Kao, Eyal Ben-Arie, Yu-Chen Lee, Fang-Pey Chen.Resources: Pei-Yu Kao, Yu-Chen Lee, Fang-Pey Chen.Software: Eyal Ben-Arie, Kao Pei-Yu, Ho Wen-Chao.Supervision: Pei-Yu Kao, Yu-Chen Lee, Fang-Pey Chen.Validation: Wen-Chao Ho, Kao Pei-Yu.Visualization: Pei-Yu KaoWriting – original draft: Pei-Yu Kao, Eyal Ben-Arie.Writing – review & editing: Pei-Yu Kao, Eyal Ben-Arie, Yu-Chen Lee, Fang-Pey Chen.


Coronavirus disease (COVID-19) has reached millions of people worldwide and is responsible for millions of deaths around the world. Research on fatalities in rural communities remains limited. In addition, the scientific literature has not yet reported on the distribution of vaccines in Canada and compared the findings to the age distribution of COVID-19 fatalities in Canada to see whether the vaccines have been distributed to the highest age category populations. This research article used data from the Government of Ontario and Statistics Canada to analyze the number of cases, fatalities, case fatality rates (CFRs) by demographic factors, such as age, gender, urban-rural status, and compared the findings to national vaccination rates by age. As of June 11, 2021, this study found that among the 528,819 cases among 14.8 million people. Among this population, there were 8875 fatalities in Ontario with 82.208% (n=7296) of fatalities occurred in people over 70 years, and 93.183% in people over 60 years . Additionally, the odds ratio of a fatal event was 9,652 times higher in people over 90 years  as compared with less than 20 years. Men had a higher number of fatalities  compared with women , and a higher odd of fatal events only when adjusted for age and gender . Urban areas had 92.034% of fatalities  and had a CFR of 1.632%. In contrast, rural areas comprised 4.451% of total fatalities (n=395) and had the highest CFR (2.267%). The unadjusted odds of a fatality were 1.41  in rural areas compared with urban areas. Across Canada as of May 29, 2021, people over 80 years old received 1,530,318 vaccines with 91.98% of this population age group receiving at least one and 457,664 being fully vaccinated (27.51%). In Ontario, as the number of people with at least one vaccine increased for people over 90 years, the number of fatalities was reduced from about 8 per day prior to vaccines to approximately two per day. Furthermore, once the vaccination rates exceeded 75% in ages 60 years and over 50% in the younger age groups, the number of fatalities per day among all age groups was approximately one per day. In summary, age was found to be a significant factor for COVID-19 mortality in Ontario and vaccine uptake in Ontario was followed by decreases in COVID-19 mortality. As of June 7, 2021, coronavirus disease (COVID-19) has reached over 173 million cases and over 3.7 million deaths globally . At thisThough the worldwide pandemic has brought a significant emphasis on studying COVID-19, research on rural populations remains limited . AccordiThe vaccinations began on December 15, 2020 , and theDue to data availability, data from Canada’s most populated province, Ontario, was used to calculate COVID-19 statistics from January 1, 2020, to June 11, 2021 .To classify cases as urban, rural, or mixed urban-rural areas, the public health unit that reported the COVID-19 case was used. Regions were classified by rurality based on Statistics Canada’s peer groups used to categorize health regions . This clData from Canadian vaccination databases were retrieved from December 19, 2020, to May 29, 2021, to compare vaccine distribution by age group . Male anAs of June 11, 2021, the study found that among 538,651 COVID-19 cases in Ontario, there were 538,551 people with complete data for age. Out of the 14,789,778 people in Ontario from April to June 2021, this represents 3.642% of the population having been positive for COVID-19 during the pandemic [Results by age and sexPercent of Positive COVID-19 Cases by Age Over a Seven-Day PeriodIn the earlier phase of the pandemic near March 2020, the percentage of people with a positive COVID-19 test was relatively similar across age groups , 80 to 89 years OR=5,328 , and 70 to 79 years, OR=1777   as compared with women . This was equivalent to a CFR of 1.721% for men and 1.692% for women. By gender, the logistic regression adjusting for gender and age found that there was a statistically significant difference between gender and the odds of COVID-19 fatality . As shown in Figure As shown in Figure Urban-rural statusUrban areas had the majority of cases , followed by mixed rural-urban regions , and lastly rural areas   occurred in urban areas, 4.451% (n=395) in rural areas, and 3.515% (n=312) occurring in mixed rural-urban areas. The case fatality rate was lowest amongst mixed rural-urban areas (1.569%), followed by urban areas (1.632%), and highest in rural areas (2.267%). The unadjusted odds ratio of a COVID-19 fatality in rural vs. urban areas was 1.41 . Pearson’s chi-square test found that there was a statistically significant difference between rural-urban status and fatalities .Most of the fatalities were reported by the Toronto public health unit (n=3362), followed by York (n=770), and Peel n=756)  , which found people over age 85 had an 8700 higher odds of fatal events compared to the reference group of age 5-17 . The CDCMoreover, our analysis showed that there was a temporal relationship between vaccinations and lower rates of fatal COVID-19 events among older age groups. Prior to vaccinations, people over age 80 and 90 consistently had much higher fatalities from COVID-19 at around 8 to 10 fatalities per day during the peaks of the pandemic in March 2020 and January 2021 Figure . HoweverUpon additional analysis, Canada's strategy as a whole reflects a similar approach to Ontario where more data were available for analysis. As reported by Statistics Canada, vaccines were given to >90% of people over 70 years and >85% of people over 60 years as of June 11, 2021 . In CanaFrom a global perspective, this research also raises questions about health protection for the broader global community as advocated by the World Health Organization . When maResearch from mathematical modeling studies has suggested that vaccinating the most vulnerable saves not only the greatest number of lives but also protects against the greatest number of years lost due to COVID-19 . The resResults of the urban-rural analysis suggest that most of the COVID-19 cases and fatalities occurred in urban areas  rather than rural areas . However, when adjusting for population size, the CFRs were higher in rural areas . A study in the United States examining COVID-19 fatalities from February 2020 to June 2020 found that COVID-19 fatalities were highest among urban compared with rural areas . Yet, thEvidence from Peters et al. suggests that rural areas may be at higher risk of COVID-19 fatalities because they tend to have fewer physicians, less access to healthcare services, and older populations . Other eStrengths of this research include the large dataset and comprehensive data collection system that allowed for the inclusion of more than a million confirmed cases of COVID-19. Furthermore, the database contained information on cases collected for more than a year and a half since the inception of the pandemic, allowing for a greater understanding of how the pandemic has changed over time. This study also examined the temporal relationship between vaccination rates and fatalities by age, showing that lower fatality rates from COVID-19 fatalities followed vaccine uptake. Additionally, the study included geographic data that allowed for the association of COVID-19 cases and rurality. This evidence showed that though urban areas had more fatalities, rural areas had the highest case fatality rates.Limitations of this dataset are primarily related to the lack of data. Since there was no readily accessible data on cases and fatalities throughout Canada, only data from Ontario could be used to compute summary statistics on fatality rates. Moreover, the Ontario dataset did not contain data on comorbidities such as obesity, kidney disease, cardiovascular disease, and respiratory conditions that may be confounders regarding fatality rates . Lastly,In conclusion, this study further contributes to the literature by describing the temporal relationship between vaccine uptake among elderly people and lower daily fatalities from COVID-19. This study also calculated odds ratios between different age categories using a large amount of data to further emphasize the importance of protecting elderly people. The vaccination strategy in Ontario was in prioritized this group and the lower fatality rates were most evident when vaccination rates exceeded 80% in people over 60 years, and over 50% in those other age groups. This research article also found that COVID-19 fatalities were largely distributed in urban areas, but rural areas had higher case-fatality rates, suggesting further research is needed. During the peaks of the pandemic, people in the younger age categories were at higher risk of testing positive for COVID-19 while those older were more likely to experience fatal events.The findings discussed in the article reflect the viewpoints of the authors only and not of their respective institutions.


The studies were selected from the PubMed (MEDLINE), Scopus and Web of Science databases. From these searches, a screening was carried out, selecting studies that compared the effects of HIIT and SIT protocols on 2max/peak. A total of 19 studies were included in the final analysis. Due to the homogeneity between studies (I2 = 0%), fixed-effects analyses were performed. There was no significant difference in the 2max/peak gains between HIIT and SIT for the standardized mean difference , including studies that presented both measurements in mL·kg−1·min−1 and l·min−1; and raw mean differences  were calculated only with data presented in mL·kg−1·min−1. We conclude that the literature generates very consistent data to confirm that HIIT and SIT protocols promote similar gains in cardiorespiratory fitness. Thus, for this purpose, the choice of the protocol can be made for convenience.Lack of time is seen as a barrier to maintaining a physically active lifestyle. In this sense, interval training has been suggested as a time-efficient strategy for improving health, mainly due to its potential to increase cardiorespiratory fitness. Currently, the most discussed interval training protocols in the literature are the high-intensity interval training (HIIT) and the sprint interval training (SIT). Objective: We investigated, through a systematic review and meta-analysis, which interval training protocol, HIIT or SIT, promotes greater gain in cardiorespiratory fitness ( Lack of time has been acknowledged as one of the main barriers to maintaining a physically active lifestyle in humans . Physica2max/peak) interspersed with periods of low-intensity recovery/or pause [2max/peak in very short periods of time. Here these short-bout protocols are referred to as sprint interval training (SIT) [In this sense, high-intensity interval training (HIIT) has been proposed as a time-efficient alternative strategy for maintaining a physically active lifestyle, since it promotes benefits equal to or even greater than traditional continuous aerobic training ,5,6. HIIor pause ,7,8,9. Ing (SIT) ,10.The prescription of either HIIT or SIT is complex and involves the manipulation of several variables, including duration of the effort and recovery phases, intensity of effort and recovery, and total number of efforts/recovery ,10,11.2max, maximum power output, Vmax, etc.) [2max after 8 weeks of HIIT and SIT, evidencing that both programs are effective to improve cardiorespiratory fitness [From the manipulation of these variables, a range of protocols may be designed, based on well-known protocols, such as Wingate, which consists of performing efforts lasting 30 s at all-out intensity, to protocols using intensities close to maximum   and durax, etc.) ,12. The x, etc.) . When co fitness .Previous studies seem to confirm that the manipulation of duration and intensity of the effort determines the energetic and metabolic stress of the exercise session, which constitute the driving force that triggers physiological and cellular processes that, in turn, lead to chronic adaptation to exercise training ,15.2max have been associated with training at longer-duration bouts close to that of the 2max [2max.Higher gains in the  V˙O2max ,11,16. T V˙O2max . Thus, d V˙O2max . These f2max/peak).Therefore, the aim of this study was to investigate, through a systematic review and meta-analysis, which interval training protocol, HIIT or SIT, promotes greater gain in cardiorespiratory fitness , Scopus and Web of Science databases, with the following descriptors for protocols: high-intensity interval training, high-intensity interval exercise, high-intensity interval aerobic, interval training, sprint interval training, high-intensity intervals, repeat sprint training, high-intensity intermittent exercise, repeated sprint exercise, high-intensity intermittent exercise and aerobic interval training. The descriptors for duration of effort were exercise dose, short extent, long extent, long time, short time, long volume and short volume. The descriptors for the outcomes were maximal oxygen uptake, peak oxygen uptake, cardiorespiratory fitness and The studies were screened by two research evaluators to select those containing both HIIT and SIT protocols. Quality assessment was performed by using the TESTEX scale  that was2max or peak (2max/peak), conducted in animals or review studies were excluded. Studies were also excluded when HIIT and SIT protocols were not directly compared and they presented their data in a graphical mode that did not allow for data extraction via software.Studies written in English that compared HIIT to SIT training were included in this meta-analysis. Articles not containing data from both the pre- and post-No restrictions were applied to the different ages, sex, body composition, comorbidities and levels of physical activity of the subjects included in each survey. Studies involving subjects with spinal cord injuries or individuals with special health conditions were excluded.2max/peak before and after the intervention period were excluded. To be included, studies should have subjects assigned to both the HIIT group and the SIT group. In the present study, for the purpose of comparing protocols, we made use of the classification suggested by Bucchet and Laursen (2013) [2max, HR, etc.).Studies with interventions lasting at least two weeks, with a weekly frequency of at least two days, were selected. Studies that did not present measurements of n (2013)  that con2max or peak, were manually extracted for descriptive and statistical analysis purposes. Data were recorded as mean and standard deviation. In studies that did not present such data, the authors were contacted to provide the information.The main outcomes data of each time-point and group and characteristics of the selected population, such as age, sex, height, weight, physical activity level, health conditions and the Egger’s test, together with the visual analysis of the funnel plot, was used to analyze the risk of publication bias .2) test and Cochran’s Q test and p-values were taken as parameters for this decision. Different I2 values above 25% were adopted as an indicator of significant heterogeneity between studies; however, the p-value > 0.05 of the Q test was analyzed primarily as an indicator of low heterogeneity [The choice of the analysis model was made by observing the heterogeneity between the studies. For this, the I-square (Iogeneity .−1·min−1) or absolute (L·min−1) 2max/peak units according to their standard deviation. The SMD and raw mean differences (RMD) were based on the difference between the HIIT and the SIT intervention variation (post-training minus pre-training). In addition, a subgroup analysis of RMD was performed, including only studies providing relative 2max/peak data (mL·kg−1·min−1). The data were summarized by using the forest plot graph, representing the results of the SMD in the overall analysis and RMD for the subgroup analysis, and a 95% confidence interval was used for both (95% CI). Moderate correlation (r = 0.5) between pre- and post-training data and a fixed effect model were adopted for the analysis.Data analysis was performed by using the Comprehensive Meta-Analysis software version 3 for Windows. The main results were presented as standardized mean difference (SMD), relativizing both the data in relative , age and physical-activity levels (moderately trained vs. sedentary). Furthermore, a sensitivity analysis was performed for a subgroup of high-quality studies, in accordance with TESTEX (≥10).After we removed the replicated studies, those that did not include interval-training protocols and those involving animal models, 593 studies were selected for the writing of their abstract and title. After, in a second step, studies were selected based on inclusion and exclusion criteria. Studies that presented just one of the protocols and results in graphical mode that did not allow for data extraction by software were excluded ,23,24,25The characteristics of the studies included are detailed in p = 0.119)  . There wp = 0.999 for SMD and p = 1.000 for RMD and I2 = 0 for both), fixed effects were assumed for both analyses. There was no significant bias of publication (p = 0.828), so there was no asymmetry in the funnel plot , and there was no significant risk of publication bias ). For these reasons, the results obtained were very consistent and suggest no need for further exploration of differences between the studies. The high consistency may be explained by the proximity of the experimental design of each study, as well as by the similarity of the tests used in each study to measure the 2max/peak [No significant differences were found for the nel plot  and Eggemax/peak .2max/peak. Furthermore, there was no difference between HIIT and SIT within the subgroup of high-quality studies (TESTEX ≥ 10).Nonetheless, we explored the potential effect of some confounding factors by subgroup and sensitivity analysis. It reinforced that different sexes, level of physical activity and duration of intervention did not influence the main effects observed on 2max/peak gains when comparing HIIT and SIT corroborates the findings of Rosenblat et al. (2020) [2max. In the present study, only two categories were created for the interval training group (HIIT and SIT), according to the delimitation proposed by Bucchet and Laursen (2013) [The absence of significant differences for . (2020) . Their mn (2013) . For the2max/peak may be explained by the fact that both current protocols are predominantly focused on oxidative metabolism, since they are constituted by successive repetitions of effort/short pause that, when combined, prolong the total duration of the oxidative predominance in an exercise session [Similar gains in HIIT and SIT on the  session .2max that were related [Although the aim of this study was not investigate potential physiological mechanism underlying the HIIT and SIT protocols, based on current evidence, we highlighted some mechanisms related to the obtained results. Both types of protocols lead to high physiological stress, the high recruitment pattern of type I and II fibers and the vigorous muscle contraction during physical activity, which unbalances the ATP/ADP relationship and increases the activation of the PGC1-α ,15,28. A related .2max/peak was found for HIIT and SIT, these protocols may lead to different magnitudes of other adaptations related to aerobic fitness, such as neuromuscular, musculoskeletal tension, cardiovascular work, anaerobic glycolytic energy and cardiac autonomic stress, causing adaptations in other variables besides 2max [2max and larger effect size for stroke volume for HIIT. On the other hand, only the SIT program led to a significant increase for hematocrit.Although a similar increase in  V˙O2max ,30,31. U V˙O2max  found a  V˙O2max  reported V˙O2max  demonstr2max in organic systems of the body, hormonal tissue and cells [In humans and animal models, HIIT and SIT also improve body composition and the lipid profile by decreasing LDL cholesterol (low-density lipoprotein) and increasing HDL cholesterol (high-density lipoprotein) ,27,35,36nd cells ,13. Khalnd cells  demonstrnd cells , and thind cells . A meta-nd cells  found thnd cells  demonstrnd cells , total cnd cells  and inflnd cells , as wellnd cells ,42. Morend cells , reductind cells ,44,45.2max/peak in the protocol comparisons. However, given the similar improvements between HIIT and SIT, such a limitation has little relevance to the adaptations of 2max/peak.A limitation found in the present meta-analysis is the format chosen individually by each study included in the meta-analysis to report the methods used. For some of these studies, it was not possible to calculate the amount of external workload performed and not even the caloric expenditure. Thus, it was not possible to infer the impact of the differences between the volumes of the protocols in the answers found for the HIIT and SIT are time-efficient protocols that lead to similar gains in cardiorespiratory fitness. Thus, the choice between these training protocols should be made according to the availability of time, aptitude to perform intense physical activity and specificity of the physical conditions of each individual to practice exercise.Future studies are encouraged to compare the effect of manipulation of other training variables, such as recovery time, number of bouts and different types of HIIT exercises , using equalized caloric expenditure and/or the total work performed for a comprehensive comparison between HIIT and SIT protocols.


Laboratory viral nucleic acid testing (NAT), such as the nasopharyngeal swab test, is now recommended as the gold standard for the diagnosis of Coronavirus disease-2019 (COVID-19). However, the nasopharyngeal swab testing process may cause some discomfort.To investigate the influence of nasopharyngeal swab tests on the anxiety and pain felt by psychiatric medical staff.A total of 174 psychiatric medical staff  and 27 controls were included in the current study. A self-designed questionnaire was used to collect their general demographic information  as well as their subjective experience, such as nausea, vomiting, coughing, worry, fear, etc, during nasopharyngeal swab collection. The Numerical Rating Scale (NRS) and the State-Trait Anxiety Inventory (STAI) were used to assess the subjects’ pain and state anxiety, respectively.There were no statistical differences (p>0.05) in age, marriage, smoking history, a history of anxiety and depression, pain scores, and anxiety scores between different professions and genders. The results of partial correlation analysis (controlled for gender and history of depression or anxiety) indicated that the male gender was negatively correlated with being anxious  and nervous (r=-0.171 p=0.016), although there was no significant difference in pain and anxiety between men and women. In addition, marriage might help women resist negative emotions.1) There will be mild discomfort during nucleic acid testing, but not enough to cause pain and anxiety; 2) women are more likely to be anxious and nervous during the nucleic acid testing. Coronavirus disease-2019(COVID-19) has been spreading globally since the end of 2019. As of March 10, 2020, the global number of confirmed cases of COVID-19 has surpassed 118 000, and most cases (68.42%) occurred in China . To idenNasopharyngeal swab tests can be performed on several types of upper respiratory specimens, including washes, swabs, and aspirates , howeverThis cross-sectional study was conducted with psychiatric medical staff from Shanghai mental health center between July 2 and 9, 2020. The inclusion criteria were as follows: 1) participants had taken a nucleic acid test within the past week; 2) nasal and pharyngeal swabs were tested simultaneously; 3) participants had to be Shanghai Mental Health Center staff, including doctors, nurses, and administrative staff; and 4) they were willing to be investigated. Exclusion criteria were as follows: 1) nucleic acid tests took more than a week; 2) non-psychiatric related major; 3) only nasal or pharyngeal swabs were performed; 4) the onset of anxiety and depression; or 5) participants refused to be investigated. Finally, 174 psychiatric medical staff working in Shanghai mental health center and 27 controls  were enrolled in the study.Ethical approval was issued by the Ethics Committee of Shanghai Mental Health Center, and all the participants had signed informed consent before the study was initiated.By using a self-designed questionnaire, we have obtained the general demographic information of the respondents, including their age, gender, marriage, occupation, profession, smoking history, alcohol consumption history, tea drinking history, previous history of anxiety and depression, as well as their subjective experience, such as nausea, vomiting, coughing, worry, fear, etc during nasopharyngeal swab collection.The Numerical Rating Scale (NRS) and the State-Trait Anxiety Inventory (STAI) were used to assess the subjects’ pain and state anxiety, respectively. The numeral assessment scale represents the pain degree by 11 Numbers from 0 to 10, 0 means no pain, 10 means the most pain, and the subjects will select one of the Numbers according to his/her personal pain feeling, to represent his/her pain degree . The NRSIn the current study, we used the Electronic “Questionnaire Star” as the surveying tool, and information was collected through WeChat friends circle forwarding. “Questionnaire Star” is a specialized online platform for questionnaire evaluation, voting, and other purposes. Compared with the traditional survey methods, “Questionnaire Star” has the obvious advantages of being a fast, low cost, and easy to learn, surveying tool .We used standardized questionnaires to collect the general demographic data of the respondents, such as their age, gender, profession, marital status, and feelings during nucleic acid testing, such as nausea, vomiting, coughing, and so on. All of the questions regarding the feelings during nucleic acid testing were answered as “yes” or “no”.The continuous variables were expressed as the mean ± standard deviation, and the categorical variables were represented by frequency (%). The one-sample Kolmogorov-Smirnov test was utilized to explore whether the data were normally distributed. The chi-square test was used to compare the categorical variables, while the t-test and Mann-Whitney U-test were used to compare the continuous variables that did and did not have a normal distribution, respectively. Partial correlation analysis was used to assess the association between worry/fear and gender, and we had controlled for profession, smoking, and drinking tea. Correlation analysis was used to explore the relationship between NRS and STAI, and single factor ANOVA analysis was used to explore the impact of marriage on NRS and STAI scores in women. IBM SPSS Statistics for Windows, version 22.0  was used for the statistical analysis. A p-value < 0.05 was considered significant.We enrolled 201 participants in this study. Of them, 97 were doctors, which accounted for 48.3%, 68(33.8%) were nurses, nine (4.5%) were administrators, and 27(13.4%) were others. 118 (58.7%) felt nausea, 109(54.2%)felt nervous, 80(39.8%) felt anxious, 34(16.9%) coughed, 22 (10.9%) vomited, 5(2.5%) felt bronchospasm, 7(3.5%) felt dyspnea, and 7(3.5%) worried about pharyngeal infection. vs 3.22 ± 1.783) and STAI (31.57 ± 10.847 vs 29.70 ± 7.032) scores between the two groups, suggesting that there was no difference in the tolerance of medical personnel and non-medical personnel to nucleic acid testing.Next, we classified 97 doctors, 68 nurses, and nine administrative staff into the medical staff group and the remaining 27 participants into the non-medical staff group, and compared the NRS and STAI scores between the two groups. Finally, we found no statistical difference (p>0.05) in NRS  indicated that the male gender was negatively correlated with feeling anxious  and nervous (r=-0.171 p=0.016).In order to explore the impact of marriage on women’s NRS score and STAI score, we then applied one-way ANOVA analysis LSD test, and finally found that married women scored less on NRS and STAI than unmarried women, while there was no statistical difference between the divorced group and the unmarried group, suggesting that marriage might help relieve women’s pain and anxiety. To my knowledge, this is the first study to explore the level of discomfort associated with the detection of COVID-19 by nasopharyngeal swabs among Chinese psychiatric medical staff, and we have got some interesting results: 1) there was mild discomfort during nucleic acid testing, but not enough to cause pain and anxiety; 2) there was no significant difference in discomfort between medical staff and non-medical staff during the process of nucleic acid testing; 3) women were more likely to be anxious and nervous during the nucleic acid testing; and 4) marriage might help relieve women’s pain and anxiety.COVID-19 is associated with human-to-human transmission and has recently been found in the saliva of infected patients. Salivary diagnostics may provide an easy and cheap platform for early and quick diagnosis of COVID-19 , so the Because of the closed working environment in psychiatric hospitals, which are more prone to cluster infections, the Chinese government requires employees in every psychiatric hospital to undergo nucleic acid testing. In the current study, we investigated the pain and anxiety levels of psychiatric medical staff in Shanghai mental health center during nucleic acid testing  and found that the most common symptoms during nasopharyngeal swabs were nausea, nervousness, anxiety, coughing, and vomiting. However, these symptoms were mild and did not cause significant pain or anxiety. In addition, we investigated the emotional responses of medical staff and non-medical staff during the nucleic acid testing process, and we found no difference in pain and anxiety between the two groups, suggesting that the nucleic acid testing process did not cause too much pain and panic.Next, we explored the factors that influence feeling anxious and nervous, and the results of partial correlation analysis (controlled for gender and history of depression or anxiety) indicated that women were positively correlated with feeling anxious and nervous, which was consistent with previous findings . HoweverThere are several mechanisms that might explain why women are more prone to negative emotions. First, women tend to show high anxiety and adopt negative ways to deal with negative emotions . Second,Finally, through correlation analysis, we found a positive correlation between the total score of NRS and the total score of STAI Figure 2We have to admit that our study has certain limitations: first, it was just a cross-sectional study that could not establish a causal link between gender and emotional response; second, our sample size was relatively small, which reduces the reliability of the study.The discomfort of COVID-19 detected by nasopharynx swab is mild, and will not cause obvious pain and anxiety, however, it is still necessary to pay attention to the adverse emotional reactions of women.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Ethics Committee of Shanghai Mental Health Center. The patients/participants provided their written informed consent to participate in this study.WL and GL contributed to the study concept and design. QG and HZ collected the data. WL analyzed the data and drafted the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by grants from the Clinical research center project of Shanghai Mental Health Center (CRC2017ZD02), the Cultivation of Multidisciplinary Interdisciplinary Project in Shanghai Jiaotong University (YG2019QNA10), and the curriculum reform of Medical College of Shanghai Jiaotong University, the Feixiang Program of Shanghai Mental Health Center(2020-FX-03).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Arrhythmogenic right ventricular cardiomyopathy (ARVC) is one of the leading causes of sudden cardiac death amongst young people and athletes. In this genetic disease, arrhythmia and fibro-fatty changes in the right ventricular myocardium are the main characteristics of the disease.Here, we report a case of ARVC in a 12-year-old boy who was previously diagnosed with epilepsy, the patient’s condition manifested sporadically and was complicated by rapid progression, and unfortunate fatal deterioration after admission into the pediatric emergency room due to fatigue, dizziness and palpitation.A diagnosis of ARVC was established, even though a family history was absent. Due to possible rapid deterioration, as described in this case, we recommend immediate primary and secondary prevention of arrhythmias in these patients, and to take in consideration of the potential risks of using sodium valproate in these patients. Arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic right ventricular dysplasia (ARVD) is an inherited—in most of the cases—genetic heart muscle disorder characterized by arrhythmia and fibro-fatty changes in the heart wall, with estimated prevalence of 1:2500 to 1:5000 in both sporadic/familial cases, with male predominance.The common genetic causes known to be associated with ARVC are DSC2, DSG2, DSP, JUP, PKP2 and TMEM43. Less common genetic causes include CTNNA3, DES, LMNA, PLN, RYR2, TGFB3 and TTN. A subset of these 13 genes encode components of the desmosome in addition to the known genetic loci that have been associated with ARVC are 14q23-q24 (ARVC1), 1q42-q43 (ARVC2), 14q12-q22 (ARVC3), 2q32 (ARVC4), 3p25 (ARVC5), 10p12-p14 (ARVC6), 10q22, 6p24 (ARVC8) and 12p11 (ARVC9).The main symptoms of ARVC are palpitations, syncope, atypical chest pain, dyspnea and right heart failure. Its prevalence is estimated to be 1 in 2000 to 1 in 5000 of the population. ARVC is a disorder that is often diagnosed between the ages of 10 and 50 with a mean age of 30 .Here, we present a case of a young male who was first diagnosed with epilepsy and was treated accordingly. A diagnosis of ARVC was established, even though a family history was absent.A 12-year-old Syrian male was admitted to the pediatric emergency room with fatigue, dizziness and palpitation. A previous neurological examination led to the diagnosis of epilepsy as the child manifested recurrent seizures. Also, we performed EEG that revealed centro-parietal theta rhythmic activity with 2–3 hz generalized waves and spikes, which is a characteristic EEG pattern in infants and children with primary generalized seizures.However, the child did not exhibit any particular subtype of epilepsy, and since the first incident of seizures, the child took sodium valproate daily with a dosage of 500 mg repeated twice.On physical examination, the patient was responding well to the examiner. His blood pressure measurement was 90 over 60. His pulse was feeble and rapid. Electrocardiography (ECG) showed sustained wide QRS tachycardia (ventricular tachycardia) that mimics a left bundle branch block (LBBB) morphology in the superior axis, that is, negative QRS in leads II, III and AVF, and positive in lead AVL. The patient was initially given Amiodarone with a loading dose of 5 mg/kg over 20 to 60 minutes repeated twice up to a maximum dose of 15 mg/kg. The patient did not respond well to the initial treatment. Synchronized direct-current (DC) was carried out, which successfully restored sinus rhythm.Following hemodynamic stability, biochemical testing was performed. Complete blood count (CBC), K+, Ca2+, Mg2+, Na+, Cr and TSH values were normal. On the other hand, 12-lead resting ECG showed multiple abnormalities, including right bundle branch block (RBBB), T-wave inversion and Epsilon waves on precordial leads V1 up to V5. Transthoracic echocardiography (TTE) revealed structural alteration of the right ventricle (RV) and blood stagnation. More specifically, the parasternal short-axis (PSAX) right ventricular outflow tract (RVOT) value was 35 mm, along with regional dyskinesia ofRV.Afterward, the patient was discharged on Amiodarone and Bisoprolol, along with regular monitoring, which revealed progressive structural alteration of the right ventricle on TTE and atrial fibrillation (AF) on ECG  Fig. 2)Fig. 2).After one year of follow-up, the patient was admitted to the pediatric emergency with fatigue, dizziness and cyanosis. On physical examination, the patient’s systolic/diastolic blood pressure measurement was 80 to 60. ECG revealed rapid atrial fibrillation with premature ventricular contractions (PVCs)  and 4. TARVC is an inherited cardiomyopathy that affects a significant number of first-degree relatives of the proband. However, many patients with ARVC remain clinically silent and asymptomatic for decades, making the disease difficult to recognize, especially in sporadic cases with no documented familial involvement. Moreover, ARVC is characterized by a clinical presentation that includes documented arrhythmia and myocardial structural abnormalities. Meanwhile, the progression of the disease over time and predictors of arrhythmias are still to be defined.Here, we report a sporadic case of ARVC in a 12-year-old boy who was previously diagnosed with epilepsy. However, there was no documented familial involvement. Very few cases in the literature mention mutations in apparently sporadic ARVC patients whose parents did not exhibit genetic mutations or cardiac manifestations , 8. In oThe diagnostic process involved generating a differential diagnosis to rule out the common causes of palpitations. Blood tests revealed no signs of hyperthyroidism or ion disturbances, which could have caused palpitations. Moreover, the absence of infection and associated symptoms in lab findings and in child’s medical history ruled out myocarditis and Chagas disease. Furthermore, there was no evidence of extracardiac symptoms like lymphadenopathy, shortness of breath or dry, hacking cough and considering the rarity of childhood sarcoidosis, which is most frequently diagnosed between 20 and 29 years of age, we did not consider sarcoidosis as a potential cause. Also, the normal findings on chest X-ray and the absence of any signs of infection in the child or his family members made cardiac tuberculosis unlikely. However, we could not perform a cardiac biopsy as a confirmatory test due to both technical and financial reasons. Furthermore, postmortem myocardial biopsy was not performed as it was against the family’s wishes, which made the exclusion of sarcoidosis and tuberculosis ultimately impossible.ECG findings ruled out Wolff-Parkinson-White (WPW) syndrome, supraventricular tachycardia (SVT), long QT syndrome (LQTS), and Brugada syndrome. Furthermore, characteristic ECG and TTE findings led us to consider a diagnosis of ARVC according to the modified Task Force Criteria . CorrespAn implantable cardioverter-defibrillator (ICD) implantation was planned due to the progressive structural alteration of RV, as was reflected by TTE and ECG findings during follow-up. However, the rapid progression of the disease from the first onset of symptoms to severe right heart failure over the course of only one year, along with the surrounding circumstances in Syria imposed by the ongoing crisis, made an ICD implantation infeasible, for both financial and logistic reasons.Finally, considering that cardiovascular side effects of sodium valproate are reported in 1–5% of the patients, which include hypertension, tachycardia and palpitations, we think that sodium valproate could have introduced potential risks in this patient .To our knowledge, this is a rare case of ARVC in which the condition manifested sporadically and was complicated by rapid progression, and unfortunate fatal deterioration, in a patient who was previously diagnosed with epilepsy. Thus, we recommend immediate primary and secondary prevention of arrhythmias in ARVC patients, and to take in consideration of the potential risks of using sodium valproate in these patients.


The aim of the following research was an analysis of the occurrence of common equine viral infections in a Hucul herd, based on serological studies. This study provides epidemiological data concerning animals representing a semi-isolated herd, devoid of any specific prophylaxis. The obtained results provide a source of information on a primitive breed of horses, as well as giving an insight into viruses  circulating within a local ecosystem.Equus caballus) are an old breed of primitive mountain horses, originating from the Carpathian Mountains. To the best of our knowledge, data concerning the epidemiology of viral infections observed within this breed are sparse. The objective of this study was to estimate the serological status of a semi-isolated, unvaccinated Hucul herd, with respect to both common equine viral infections and horse-infecting arboviruses, the presence of which was previously reported in Poland. Twenty horses of the Hucul breed, living in a remote area in Poland, were studied in 2018 from March to May. Using nasal secretion swabs as a specimen source, isolation attempts were negative regarding ERAV, EHV-1, EAV, and EIV. According to the virus neutralisation method, in the sera obtained from the animals, antibodies against the following viruses were detected: EHV-1 in 12 horses , EIV A/H7N7 in 13 , EIV A /H3N8 in 12 , USUV in 5 , and ERAV in 1 . Antibodies against EAV, EIAV, and WNV were not present in the tested sera. The detected presence of specific antibodies associated with five out of the eight equine viruses investigated indicates that the Hucul herd, due to its partial separation and lack of specific prophylaxis, could serve as a sentinel animal group for the detection of equine viruses/arboviruses present within the local ecosystem. The detection of common equine viral infections within the herd provides additional epidemiological data concerning the breed.Huculs ( Equus caballus), also known as Carpathian horses or Carpathian ponies, are a breed of primitive, small, mountain horses [Huculs , equine herpesvirus 1 , equine rhinitis A virus , and equine influenza A virus  [Flaviviridae), West Nile virus , and equine infectious anaemia virus  are of recently increasing importance [The most common viral infections observed in equids are caused by viral agents belonging to different taxonomic families, including equine arteritis virus  ,8. Additportance ,10.Culex pipiens, causing severe encephalitis and death in horses, birds, and humans [Equine viral arteritis (EVA), caused by EAV, is a global infectious disease of horses characterised by abortion in pregnant mares. Other clinical signs like anorexia, depression, conjunctivitis, respiratory signs, and ocular discharge, as well as oedema of the eyelids, abdomen, prepuce and scrotum, or mammary glands, can also be observed ,11. Infed humans . The pred humans ,18. Blood humans .It was established that animal populations can serve as sentinels for the detection of environmental health threats . AccordiThe objective of this study was to analyse the virological and immunological status of a herd of Hucul horses living in semi-natural conditions  with respect to common equine viral infections and horse-infecting arboviruses, the presence of which was previously reported in Poland. The method of maintenance and lack of medical intervention makes the studied herd, despite its small size, a useful model of sentinel animals/surveillance.The blood samples and nasal swabs used in this project were taken for the routine diagnosis of EAV infections. The methods for the specimens’ collection were carried out in accordance with article 37ah–37ak of the Pharmaceutical Law act  from September 6th 2001 and the Experiments on Animals Act  from 5 July 2019. In light of these regulations, approval of the Ethical Committee was not required. Informed consent was obtained from the owner of the animals.A herd of 20 Hucul horses in total  aged between 5 and 10 years, located in southwestern Poland , was tested from March to May 2018. The animals had no contact with either other horses or wild equines, and they were kept on extensive pasture distant from inhabited areas throughout the year. None of the horses showed clinical symptoms at the time of sampling. There was no sign of clinical infection reported during the year prior to sampling, except for two incidents of abortion (for non-infectious reasons) and a single case of mild respiratory symptoms that was not diagnosed. All the horses were therefore considered healthy on the basis of physical examination and haematological and biochemical analyses (data not shown). None of the Huculs were vaccinated against any equine viral disease.g for 10 min, then the obtained sera were transferred into fresh tubes. Nasal swabs taken from the animals were transported to the laboratory in tubes containing EMEM supplemented with antibiotics, at 4 °C. The swabs were processed by pressing against the tube walls and vortexing, using the transport medium. The obtained fluid was centrifuged for 10 min at 3000× g. The secured supernatants were transferred into fresh tubes.For serological tests, blood samples were collected from all the horses. Blood specimens were allowed to clot and were then centrifuged at 3000× ® CCL-37TM, ATCC, Manassas, VA, USA) or green monkey kidney  cell lines were inoculated with the processed swab specimens (50–100 μL into each well) [2 and observed daily for 7–10 days, for the development of a cytopathic effect (CPE), using an inverted microscope . In the absence of visible CPE, up to 5 blind subsequent passages were performed. Attempted virus isolation of EIV was carried out in embryonated chicken eggs (ECEs) [Attempted virus isolation of EAV, EHV-1, and ERAV from nasal swabs was performed using standard isolation procedures. Twenty-four-well polystyrene plates containing rabbit kidney  . Plates s (ECEs) . The samSera obtained from all the horses were tested for the presence of antibodies against EAV, EHV-1, ERAV, EIV (H7N7 and H3N8), USUV, WNV, and EIAV. Virus neutralisation (VN) tests were performed using the Bucyrus, Rac-H, and V1722/70 reference strains for the detection of EAV , EHV1 2, and ERAA microneutralisation assay was applied for the detection of antibodies against USUV and WNV, using the previously described procedure ,27. The All the VN and HI tests were carried out in the presence of control sera (positive and negative) from the in-house collection.Statistical analysis was conducted in PQStat version 1.6.8  at a significance level of 5% using Fisher’s test. The correlation between the age and seropositivity to individual pathogens was evaluated. For this purpose, the animals were divided by age into two groups: 5 years old (group of youngest horses in the herd) and over 5 years old.According to the results of the virus isolation, all the nasal swabs were negative for the presence of EAV, EHV-1, ERAV, and EIV. Specific antibodies were detected for five out of the eight examined equine viruses. Detailed results of our serological testing are shown in Of the 20 Huculs tested, 12 (60%) were positive for antibodies to EHV-1 with titres ranging from 1:8 to 1:32. Antibodies to equine influenza viruses A/H7N7 and A /H3N8 were found in the sera of 13 (65%) and 12 (60%) horses, respectively, with titres ranging from 1:20 to 1:80 against both viruses. USUV seropositivity was detected in five horses (25%) with titres ranging from 1:10 to 1:80. Only one (5%) animal had antibodies to ERAV (titre of 1:8). None of the horses had detectable antibody levels for EAV, EIAV, or WNV.p > 0.999), ERAV (p > 0.999), H7N7 (p = 0.3498), H3N8 (p = 0.1698), and USUV (p > 0.999). Due to the negative results of the serological investigation, statistical analyses for age vs. antibody presence for EAV, WNV, and EIAV were not performed.Statistical analysis showed no significant correlations between the variables of age group and antibody presence for viruses EHV1  was reported in different breeds of horses . In EnglIn the present study, a high percentage of EIV seropositivity was detected against subtypes H7N7 (65%) and H3N8 (60%). Since the first isolation in 1963 in the USA, the subtype H3N8 (Miami 63) of EIV has continued to circulate among horses, causing epidemics and minor outbreaks of equine influenza respiratory disease in Europe and North America ,43,44. TEquus hemionus hemionus) in Mongolia, performed in 2015, showed that two of the tested animals were positive for the H7 virus type. While cross-reaction with the H7N9 strain was excluded in both cases, antibodies obtained from the horses were assigned as H7N7 using a protein microarray (PA) technique, but when one of the sera was additionally tested via single radial haemolysis assay, it proved to be H7N3 positive. The authors suggested co-circulation of both subtypes, which are of equine and avian origin, respectively [The EIV H7N7 subtype (Prague 56) was first isolated in 1956 from horses in Eastern Europe . This suectively . Antibodectively , where aectively . Moreoveectively . Both scIn Europe, the USUV was isolated for the first time from bats in Germany, and the first human infection with this virus took place in Italy in 2009; three years later, in Germany, research showed that 1 out of 4200 patients had antibodies against USUV ,54,55. TPasser domesticus) and 12.1% in Eurasian tree sparrow (Passer montanus)) of anti-WNV antibodies in the sera of the tested birds [The first report of the appearance of WNV in Poland comes from the years 1995–1996, when Juricova et al. conducted research on two sparrow species and stated a relatively high prevalence , cannot be extrapolated with regard to the whole Hucul population in Poland . In ordThe present study provides useful epidemiological data regarding viral infections in Hucul horses, supplementing the sparse information on the matter available to date. Partial isolation of the tested herd, in addition to the fact that it was also devoid of any specific prophylaxis, allowed us to analyse the circulation within a local ecosystem of viruses causing infections in horses. Among these investigated viruses were those transmitted via vectors. The fact that the tested animals were apparently healthy at the moment of sampling and throughout the year prior suggests that the detected antibodies are a result of earlier exposures, but it may also be related to the natural resistance of Huculs, as indicated by other authors ,5. In su


BK virus nephropathy in kidney transplantation is widely recognized as animportant cause of graft dysfunction and loss. In the case of transplants oforgans other than kidney, BK virus nephropathy in native kidneys has beenrecognized as a cause of chronic kidney disease, which is related withimmunosuppression; however, the diagnosis is usually late because the renaldysfunction is attributed to other causes, such as toxicity by anticalcineurinicdrugs, interstitial nephritis due to medications, hemodynamic changes, diabetes,hypertension, etc. We report a case of BK virus nephropathy in a patient whounderwent heart transplantation due to peripartum cardiomyopathy. The kidneybiopsy reported active chronic tubulointerstitial nephritis associated with latestage polyomavirus nephritis and the blood viral load for BK virus was positive(logarithm 4.5). The immunosuppressive treatment was reduced, and after twoyears of follow-up, the patient had stable renal function with a serumcreatinine of 2.5 mg/dL (GFR of 23.4 mL/min/1.73m2). We recommend that the BKvirus be considered as a cause of renal dysfunction in heart transplantrecipients, with the aim of detecting its replication in time to reduceimmunosuppressive therapy before irreversible compromise of renal function maymanifest. Reactivation of the virus can occur in immunosuppressedpatients, particularly in patients receiving immunosuppressive therapies,,At present, the exact route of transmission is not known, but it is believed that thevirus is usually acquired via the air in childhood,In recent years, cases of BK virus nephropathy have been reported in native kidneysof patients who have undergone bone marrow transplantation, as well as intransplantation of other non-renal solid organs, such as heart, liver, and lung2 during the first year post-transplant. Management wasexclusively performed by the cardiac transplant group and routine monitoring ofpolyomavirus with viral load BK or urine cytology was not done. In 2016, shepresented an elevation of serum creatinine up to 1.9 mg/dL, with a GFR of 32.6mL/min/1.73m2. At that time, tacrolimus trough level was 7.2 ng/mLand everolimus, 5.2 ng/mL. Toxicity by anticalcineurinics was suspected; therefore,tacrolimus was reduced to 4 mg daily and creatinine value returned near to thebaseline value ; no kidneybiopsy was performed. In March 2017, creatinine raised to 2.69 mg/dL, with a TFG of21.4 mL/min/1.73m2, for which she was hospitalized. The patient statedshe did not present any symptom. At physical examination, she was observed in goodgeneral condition, heart rate of 80 beats per minute, blood pressure of 130/90 mmHg,respiratory rate of 15 per minute, afebrile. Additional studies were conducted:ultrasound of the renal tract showed normal renal size, but increased echogenicity;urinary microscopy and culture analyses were negative, with no hematuria, pyuria orcasts; echocardiogram with adequate cardiac function; serological tests for HIV,syphilis, hepatitis virus B and C were negative; tacrolimus trough level of 5.2ng/mL, and everolimus of 5.98 ng/mL  of 102mL/min/1.73m98 ng/mL . Managem2.The kidney biopsy revealed active chronic tubulointerstitial nephritis, associatedwith late stage polyomavirus nephritis . PCR for14, and it can lead to terminal chronic kidneydisease of the native kidneys,Polyomavirus nephropathy is a severe opportunistic infection that occurs in kidneytransplant patients. In rare cases, it also affects the native kidneys of transplantrecipients of other organs8,16. Vigil D et al. reviewed theliterature on heart transplants with BK virus infection. Eleven patients werereported, nine males, 81% of cases associated with rejection, of which 72% hadterminal chronic kidney disease, with a mortality of 27%8. In the casereported here, the patient was a heart transplant recipient, with a previous episodeof acute rejection, so she was strongly immunosuppressed. In addition, she presenteda progressive increase in creatinine, initially attributed to toxicity byanticalcineurinics, but due to the poor response to the initial therapy, a renalbiopsy was performed, and viral load was requested for BK virus, which was positive.These findings allowed the diagnosis of BK virus nephropathy, and due to the latediagnosis, the patient developed stage 4 chronic kidney disease,,In the context of cardiac transplantation, BK virus infection of the urinary systemhas been reported mainly during rejection episodes, associated with an increase inimmunosuppressant drugs. In some studies, BK viruria of up to 19% has been reportedin heart transplant recipients, and viremia up to 5%, but BK virus nephropathy isunusual in this population. It has been suggested that additional damage to thenative kidneys is required for the development of BK viralnephropathy12 but thisstudy was not performed on the patient because initially this diagnosis was notconsidered. Electron microscopy in urine samples has a sensitivity and specificityof 100% but is not available in many centersDetection of tubular or urothelial cells with inclusions of BK virus cells in urineis a useful tool for the diagnosis of this infection in the urinary system. Thesecells are known as Decoy cells for their similarity with tumor cells in Pap smears.Decoy cells have a sensitivity of 25% and a specificity of 84%,-Kidney biopsy is considered the "gold" diagnostic standard. It is usually indicatedwhen viremia is greater than 10,000 copies/mL, with or without creatinine elevation,and with kidney dysfunction without recognizable causein vitro , butthey have not yet shown significant results in clinical studies,,Currently, there is no standard therapy for BK virus nephropathyIn summary, BK virus nephropathy in transplant patients other than kidney transplantrecipients is a silent entity that can lead to chronic kidney disease with increasedmorbidity and mortality. We therefore propose to consider the BK virus infection asa cause of renal dysfunction in heart transplant recipients, with the aim ofdetecting its replication in time to reduce immunosuppressive therapy beforeirreversible impairment of renal function may manifest.


Oxidative stress is involved in the pathophysiology of nonalcoholic fatty liver disease (NAFLD). However, reliable biomarkers of NAFLD in relation to oxidative stress are not available. While paraoxonase 1 (PON1) is an antioxidant biomarker, there appears to be mixed data on PON-1 in patients with NAFLD. The aim of this meta-analysis was to assess the current data on PON1 activity  in patients with NAFLD. A PubMed, CENTRAL, and Embase search identified 12 eligible articles. In the meta-analysis, the paraoxonase activity was low in patients with NAFLD (mean difference (MD) −27.17 U/L; 95% confidence interval (CI) −37.31 to −17.03). No difference was noted in the arylesterase activity . In a subgroup analysis, the paraoxonase activity was low in biopsy-proven nonalcoholic steatohepatitis , while the activity in NAFLD as diagnosed by ultrasonography or laboratory data was similar  to that of non-NAFLD. In summary, the PON1, especially paraoxonase, activity could be a useful biomarker of NAFLD. Further studies are warranted to ascertain the relevance of PON1 measurements in patients with NAFLD. Nonalcoholic fatty liver disease (NAFLD) is receiving a great deal of attention as a common cause of chronic liver disease . In addiOxidative stress is recognized as a causative factor of NAFLD, resulting in inflammation and fibrosis in the liver ,4,5. AltParaoxonase 1 ) is known as an esterase molecule associated with apolipoprotein A-I and clusterin, which circulates in a high-density lipoprotein (HDL) particle . PON1 hySeveral studies have provided persuasive arguments for the role of PON1 in cardiovascular context in clinical settings ,18. PON1As PON1 is mainly produced in the liver ,17, PON12 = 99%; 2 = 0%; In the present meta-analysis, the paraoxonase activity among the patients with NAFLD was significantly low in comparison to those with non-NAFLD (mean difference (MD) –27.17 U/L; 95% confidence interval (CI) –37.31 to –17.03; Ip < 0.00001; Considering the overall low level of paraoxonase in patients with NAFLD, while the low activity was reported in five studies ,31,33,34The present meta-analyses revealed that the paraoxonase activity was significantly low and that the arylesterase activity was unaltered in patients with NAFLD in comparison to those with non-NAFLD. The paraoxonase activity was also observed to be significantly low in biopsy-proven NASH. These findings indicated that the PON1 activity, especially paraoxonase, may be a useful biomarker when studying the pathophysiology of NAFLD.Liver diseases, including NAFLD, may lead to enhanced catabolism and/or the inactivation of PON1 molecules , which iIn addition, since the PON1 levels may also be measured using other substrates , as its lactonase activity is presumably more physiological, further studies that measure the lactonase activities can provide different insight into the understanding of the pathophysiology of NAFLD in comparison to studies measuring the paraoxonase and arylesterase . No studAlthough the use of PON1 protein levels as biomarkers may be envisioned, one study showed dissociated results—that is, the PON1 protein levels increased as the liver diseases progressed, even though the PON1 activity decreased, pointing to the production of faulty molecules and/or their inactivation in the circulation . A studyLiver fibrosis and steatosis are detected in NASH, an advanced form of NAFLD. The management of NASH is, therefore, an issue. A study found that paraoxonase activity is inversely correlated with hepatic fibrosis in particular . The preWe must acknowledge some limitations to the present meta-analyses. First, the number of articles that were eligible for inclusion in the present review was limited. Second, the number of patients with biopsy-proven NASH was small. Furthermore, the reference range of PON1 measurements still has not been formally determined.A search of the PubMed, CENTRAL, and Embase databases was conducted using generic terms ” (MeSH Terms) OR (All Fields) OR “paraoxonase” (All Fields)) AND (“steatohepatitis” (All Fields) OR “fatty liver disease” (All Fields)) for the literature published up to April 2021. After duplicate records were removed, sixty-three articles were found to be potential matches. After the search was limited to original articles on human studies and studies written in English, 50 articles were excluded. We analyzed the remaining 14 articles that reported PON1 activity levels in patients with and without NAFLD ,37,42,432 statistic > 50%), the possible source of the heterogeneity was explored in a subgroup analysis [Furthermore, based on the eligible articles, random-effects meta-analyses of the PON1 activity among patients were performed using the generic inverse variance method in Review Manager 5.4.1 (RevMan 2020) . The MD analysis , and theThe present meta-analyses demonstrated that the PON1, especially paraoxonase, activity was low in patients with NAFLD. The low paraoxonase activity was also observed in biopsy-proven NASH. The paraoxonase activity could be a useful biomarker of NAFLD. On the other hand, further studies are warranted to ascertain the relevance of the PON1 measurements in patients with NAFLD. Particularly, studies to see the association between PON1 activity and the stage of NAFLD or longitudinal cohort and intervention studies with the PON1 measurements will be required in patients with NAFLD. In the measurements, measuring PON1 with an array of substrates is recommended.