Pancreatic neuroendocrine tumors (PNETs) in hereditary syndromes pose a significant challenge to clinicians. The rarity of these syndromes and PNETs itself make it difficult to directly compare them with sporadic PNETs. Despite research suggesting differences between these two entities, the same approach is used in hereditary and sporadic PNETs.We included 63 patients with hereditary PNET (GpNET) and 145 with sporadic PNET (SpNET) in a retrospective observational study. Clinical and genetic data were collected in two Polish endocrine departments from January 2004 to February 2020. Only patients with confirmed germline mutations were included in the GpNET cohort. We attempted to establish prognostic factors of metastases and overall survival in both groups and genotype–phenotype correlations in the GpNET group.Patients with GpNET were younger and diagnosed earlier, whereas their tumors were smaller and more frequently multifocal compared with patients with SpNET. Metastases occurred more frequently in the SpNET group, and their appearance was associated with tumor size in both groups. GpNET patients had longer overall survival (OS). OS was affected by age, age at diagnosis, sex, grade, stage, tumor diameter, occurrence and localization of metastases, type of treatment, and comorbidities. In the MEN1 group, carriers of frameshift with STOP codon, splice site, and missense mutations tended to have less advanced disease, while patients with mutations in exon 2 tended to have metastases more frequently.Direct comparisons of GpNET and SpNET demonstrate significant differences in the clinical courses of both entities, which should force different approaches. A larger group of patients with GpNET should be assessed to confirm genotype–phenotype correlations. Pancreatic neuroendocrine tumors (PNETs) are a rare type of neoplasms that constitute approximately 1–2% of all pancreatic cancers. The incidence of PNETs has substantially increased in recent years and is now estimated at 0.01–0.8 cases per 100,000 per year . It is pLess than 10% of PNETs arise in the context of familial syndromes. Hereditary syndromes associated with PNETs are Multiple Endocrine Neoplasia type 1 (MEN1), Von Hippel–Lindau disease (VHL), Neurofibromatosis type 1 (NF1), and Tuberous Sclerosis Complex (TSC). The prevalence of PNETs in these syndromes is 30–80% in MEN1 , less thStudies that directly compare cohorts of patients with familial and sporadic PNETs are scarce , 19, 20.Because of the sparsity of these syndromes, it is challenging to establish evidence-based guidelines, especially in terms of treatment. Patients with PNETs associated with germline mutations are underrepresented in phase III trials of drugs used in sporadic PNETs , 22. We The heterogeneous disease course with a growing number of genetic mutations and lack of evidence from well-established studies concerning the treatment in hereditary PNETs should lead to careful adaptations of therapeutic schemes used in sporadic PNETs. Nevertheless, these schemes of sporadic endocrine tumors have been used in such cases .Direct comparisons of sporadic and hereditary PNETs were performed on small groups of patients; thus, we assumed that larger groups might reveal additional information about the differences and prognostic factors that could result in different management decisions. From our previous work , we knowBecause of all the above-mentioned reasons, we performed a comprehensive assessment of Polish patients with PNETs associated with germline mutations (GpNETs) and compared this group with patients with sporadic PNETs (SpNETs) and evaluated prognostic factors of metastases and survival in both groups. We also attempted to establish a genotype–phenotype correlation in the GpNET group.We retrospectively analyzed the medical data of patients with sporadic and hereditary PNETs treated from January 2004 to February 2020 in the following departments:Department of Nuclear Medicine and Endocrine Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, PolandDepartment of Internal Diseases and Endocrinology, Medical University of Warsaw, Warsaw, PolandMEN1 and VHL genes. We also excluded these patients (with MEN1 or VHL phenotype but without confirmed mutations) from the analyzed group of sporadic PNETs.We searched our databases for patients with a genetic syndrome with described susceptibility to the development of PNET: MEN1, VHL, NF1, and TSC. All the familial syndromes were diagnosed according to present guidelines –41. We dth Edition (2017) of TNM for PNETs from the American Joint Committee on Cancer (AJCC).The diagnosis of PNET was based on histological confirmation  or radiological findings  or magnetic resonance imaging (MR) and increased pathological uptake in Galium-68 positron emission tomography/CT) if no histological sample was available. Tumor grading was based on present European Neuroendocrine Tumor Society (ENETS) guidelines, and clinical staging was based on the 8th edition, site of metastases, type of treatment, additional diseases (including other neoplasms), and types of mutations in the case of MEN1 and VHL patients. Other neoplasms were defined as neoplasms other than typical for the particular hereditary syndrome/disease, described in the diagnostic criteria. Neuroendocrine tumors were accounted separately.We assessed the following variables: age, sex, time of observation, age at PNET diagnosis, tumor features , clinical staging according to AJCC’s 8VHL and MEN1 genes was performed in the Laboratory of Molecular Diagnostics and Functional Genomics at the Department of Nuclear Medicine and Endocrine Oncology and at the Department of Genetic and Molecular Diagnostics of Cancer. The VHL gene was analyzed by Sanger sequencing and targeted next-generation sequencing (NGS), while the MEN1 gene analysis was performed by HRM (High-Resolution Melting), Sanger sequencing, and targeted NGS. Analysis of large deletions and duplications of the MEN1 gene was performed using the MLPA (Multiplex Ligation-dependent Probe Amplification) technique. When genetic alterations  were detected, first degree relatives were also included in genetic testing. Mutation types were divided by their effect on the DNA sequence into: missense, nonsense, splice-site, duplication, frameshift + STOP codon, whole exon deletion. Nonsense mutations were characterized by the substitution of a single base pair that leads to the appearance of the premature STOP codon which results in shortened and likely non-functional, protein. Frameshift + STOP codon mutations were characterized by deletion and/or insertion of a few nucleotides that resulted in change in DNA sequence leading to appearance of the premature STOP codon which may also result in shortened and likely non-functional, protein.The study of the The details concerning genetic testing are presented in http://www.r-project.org). A two-sided p-value <0.05 was considered statistically significant, and p-value <0.10 was considered close to statistical significance.Categorical variables were summarized as frequencies and percentages, and continuous variables were shown as median values with interquartile ranges  and as mean values with standard deviation ranges as well with min/max ranges, unless otherwise stated. Pairwise comparisons between patient subgroups were performed by Fisher’s exact test for categorical variables, and odds ratio was calculated. For continuous variables, comparisons between two groups were determined using Wilcoxon rank sum test, and for more than two patient subgroups, comparisons were performed by Kruskal–Wallis H test. The cut-off points for SpNET, GpNET, non-functional SpNET (NF-SpNET), and non-functional GpNET (NF-GpNET), as well as sensitivity and specificity, were determined by metastases status (present or not) using receiver-operating characteristic (ROC) curves. Youden Index was used to determine the cut-off point with the highest combination of sensitivity and specificity. Overall survival (OS) was defined as the time from diagnosis until death from pancreatic neuroendocrine tumor, or the last known date alive. Survival curves were plotted with the Kaplan–Meier method and compared using the log-rank test. Point-biserial correlation coefficient was assessed to examine the correlation between variables. Factors associated with survival endpoint were investigated by Cox proportional hazards model. All analyses were performed using R software package version 4.0.1  were diagnosed with PNET. Eventually, 63 patients met the inclusion criteria for the GpNET group. This group comprised 58 patients with MEN1-related PNET and five patients with VHL-related PNET. Out of 190 patients with sporadic PNET according to the medical database, 12 were excluded because of clinical or genetic diagnoses of MEN1 or VHL, and 33 were excluded because of inappropriate diagnoses of PNET. Eventually, 145 patients with SpNET were included in the analysis. Out of 109 patients with a clinical diagnosis of MEN1, 65 (60%) were diagnosed with PNET, although only 58 of them had confirmed germline vs. 64.0 ± 12.3 years; p < 0.001) and were diagnosed with PNET earlier . There was no difference in sex distribution between the groups. Patients in the SpNET group were significantly more often affected by additional diseases , but there were no significant differences in terms of the prevalence of other neoplasms or other neuroendocrine tumors. Median time of follow-up was longer (p = 0.005) in the GpNET group  than in the SpNET group . The patients in the GpNET group were younger  than those with NF-GpNET. We did not observe this in the SpNET group. The age at diagnosis did not differ significantly with sex, stage, grade, and death rate in both GpNET and SpNET groups.Upon univariate analysis, we found that patients in the GpNET group with functional tumors (F-GpNET) were diagnosed earlier  and more often multifocal than those in the SpNET group (OR = 49.636). We did not observe any significant differences in terms of hormonal function. vs. 22%, p = <0.001 (OR = 4.355)], although there was no significant difference in terms of the location of the metastases. i.e., III and IV (OR = 5.211)] than those in the GpNET group, although there were no significant differences in terms of grade. The two groups differed significantly in terms of the basis for PNET diagnosis (p < 0.001). In the GpNET group, it was most often typical radiological findings, whereas in the SpNET group, histological confirmation outweighed. The tumors in the GpNET group were smaller  and the GpNET group . The same correlation was observed in NF-SpNET patients  and NF-GpNET patients . We established cut-off points for tumor diameter, above which the metastatic rate increased significantly. They are 4 cm for both GpNET and NF-GpNET, 2.3 cm for SpNET, and 1.9 cm for NF-SpNET.Moreover, we showed that with increasing grade, the metastatic rate increased significantly (p = 0.038 for the GpNET group and p < 0.001 for the SpNET group), and only in the case of SpNET, an increase in tumor diameter was observed (p = 0.007). We also observed a tendency toward decreased rate of functional tumors with increasing grade and stage in both groups.vs. 44%; p = 0.01 (OR = 1.673)], pharmacotherapy , peptide receptor radionuclide therapy (PRRT) , and chemotherapy . No significant differences in radiotherapy were noted.We found that patients with SpNET more often underwent surgery  and shorter survival  than those in the GpNET group. Upon univariate analysis, survival was associated with age at diagnosis, sex, grade, stage, tumor diameter, rate and localization of metastases, type of treatment, and comorbidities. The worse survival in the SpNET group was determined by the following factors: age at diagnosis older than 60 years, higher grade, higher stage, bigger tumor diameter, present metastases, concomitant hepatic and nodal metastases, only pharmacological treatment in comparison to surgery, and absence of other neoplasms. Additional analysis of the subgroup of patients with SpNET diagnosed after the age of 60 showed a significantly lower survival in patients with no other neoplasms but no impact of comorbidities  on survival. In the GpNET group, the presence of other neoplasms signified worse survival. Regarding tumor diameter, a cut-off point of >2.3 cm in the SpNET group implied worse survival. In the analysis of the subgroups with non-functional tumors, there was no significant difference in terms of tumor size and survival in both the GpNET and SpNET groups. As no significant difference was also observed in GpNET with regard to cut-off established by ROC method, we analyzed the impact of arbitrarily established cut-off of 2 cm. In this analysis tumors with diameter >2 cm implied worse survival.During the 140 month observation period, patients in the SpNET group experienced significantly more deaths [17 A comparison of both groups revealed that the following features differentiate them in terms of survival: age at diagnosis, sex, grade, stage, hormonal status, presence of other neoplasms, and diseases. Patients with GpNET, patients of the female sex, diagnosed before the age of 40, with a functional tumor, with no other neoplasms, and additional diseases had better survival than those with SpNET having the same features.Upon multivariable analysis, we assessed the impact of the following groups of variables in both SpNET and GpNET on survival separately:group 1: age, age at diagnosis, sex, tumor diameter, and other diseasesgroup 2: tumor diameter, metastases, grade, and hormonal statusgroup 3: tumor diameter, metastases, surgery, pharmacotherapy, and recurrence after surgeryAmong the variables from the first group in GpNET, older age, bigger tumor size, and the presence of other neoplasms and neuroendocrine tumors were observed more often in patients with a higher mortality rate. In the same group of variables, only older age at diagnosis appeared to be significantly associated with a higher mortality rate in the SpNET group. In the second group of variables, only the presence of metastases in the SpNET group was observed more often in patients with a higher mortality rate. In group 3, no significant differences were found in the SpNET group. After selection, no patients from the GpNET group were included for this analysis. The most significant univariate correlations are presented in e.g., NFpNET) or do not exclude patients with MEN1 or VHL in the case of “PNET” analysis, which makes it less significant when compared. To the best of our knowledge, we managed to directly compare one of the biggest cohorts of patients diagnosed with GpNET and SpNET.The main goal of our study was to compare the clinical data of patients with GpNET to those of patients with SpNET and to assess prognostic factors in both groups of patients. Additionally, an attempt to perform a genotype–phenotype analysis in the GpNET group was made. Surprisingly, despite much attention on the subject of PNET, only a few direct comparisons on small groups of patients were published. We assume that differences based on comparisons between different studies evaluating GpNET and SpNET separately could be prone to bias. Additionally, these studies often either analyze only a particular subgroup  points were established , 51–56. In the case of GpNET, similar results had been published by others  but mostAlthough a trend toward a positive correlation between tumor diameter and metastatic rate in both groups seems undoubtful, cut-off points probably must be established more carefully regarding a particular cohort of patients. Moreover, we have to look for other factors favoring metastases since patients with small tumors and metastases are also described , 64, so We found that overall survival was worse in the SpNET group than in the GpNET group. PNETs associated with MEN1 and VHL are believed to be indolent, although published results concerning survival are discordant. A few authors , 65, 66 The variables associated with worse survival in SpNET in our study were also described by others , 71, 72,We observed that tumor diameter over 2.3 cm in SpNET and 2.0 cm in GpNET led to worse survival. The same trend as for SpNET was observed in the NF-SpNET group. Similar results had been reported by others in SpNET , 55, altIn the GpNET group, mostly NFpNET in the context of MEN1 syndrome was evaluated. In this subgroup, the negative impact of tumor size over 2 cm was described , 76–78. Interestingly, we found a completely opposite influence of other neoplasms on survival in SpNET and GpNET. An extended analysis of a subgroup of 30 patients with SpNET and other neoplasms revealed that 17 out of 20 patients (where information about the time of diagnosis of other neoplasms was available) had other neoplasms diagnosed before or during the same year as NET. Broad-spectrum imaging diagnostics during neoplasm diagnosis and further follow-up screening could lead to the earlier diagnosis of lower-stage NET, which could impact the survival rate. A similar assumption could be made in patients with additional diseases who probably sought medical advice more often, which is why their tumors could be diagnosed earlier. Opposite results in terms of neoplasm in GpNET could be a result of early screening in almost all the patients with the diagnosed syndrome, which decreases the above-mentioned influence of follow-up described in SpNET. Moreover, in MEN1 patients, other potentially lethal tumors are known to present more often than in general populations, which could also play a role in increased mortality . Names oMEN1 gene implied more advanced disease. Although no genotype–phenotype correlation is established in MEN1, one can find promising results in the literature  which could have impact on the clinical course in MEN1-related PNETs. Confirming that in a larger cohort of patients could lead to the profiled therapy and follow-up according to genetic changes, which not only could improve patients’ quality of life, but probably also lower the cost of management.In summary, we found that Polish populations of GpNET and SpNET differ among many factors, not only when compared with each other but also when compared to other described populations. This should lead to different approach when managing GpNET or SpNET and encourage assessing each country/region populations of PNETs, having in mind possible differences and impact of a founder effect. We observed different, from previously described, cut-off points of tumor diameter that correlate with metastatic spread and worse survival in both GpNET and SpNET. In the light of other prognostic factors, controversies in therapy protocols , and stuOur study has some limitations. First, the retrospective design and the collection of data in different centers could lead to some bias. Still, we managed to comprehensively assess a large group of GpNET and SpNET patients, which is a difficult task considering the rarity of the disease and would be hardly possible in a prospective manner. Second, the GpNET group consisted mostly of MEN1 patients, and the results might not apply to VHL-, TSC-, and NF1-related PNETs. Nevertheless, we assume that the rarity of PNET in the rest of the syndromes suggests that these patients would not change the big picture of GpNET if analyzed together. Third, we assessed only the overall survival, not the disease-related one. In the light of the favorable impact of additional diseases and neoplasms in SpNET, we could assume that deaths were mostly associated with PNET.We showed that patients with SpNET and GpNET differ significantly, and one should consider this difference when deciding on the management. The proposed prognostic factors should be confirmed in larger cohorts of patients, and, by then, applied carefully with an individualized approach to every patient. International collaboration is needed to establish any reliable genotype–phenotype correlation in GpNET.przemyslaw.soczomski@io.gliwice.pl.The datasets presented in this article are not readily available because data is anonymized, and according to our rules, available only for patient and treating physician. Requests to access the datasets should be directed to Ethical review and approval were not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.PS—design of the study, data collection, data analysis, manuscript writing, and literature analysis. BJ-L—design of the study, data collection, and critical review. AK—statistical analysis and graphical presentation of results. AC—statistical analysis. SZ—data collection. NR—data collection. MO-W—genetic analysis and interpretation. AP—genetic analysis and interpretation. TB—data collection. BJ—critical review. All authors contributed to the article and approved the submitted version.AC was co-financed by the European Union through the European Social Fund (grant no. POWR.03.02.00–00–I029).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.


Aedes mosquito, expanding at an alarming pace around the world. Recently, Pakistan has witnessed some major dengue outbreaks, affecting thousands of individuals across the country. As there is no specific cure or vaccine, prevention and vector control remain the key methods to avoid dengue infection. In Pakistan, dengue control activities are mainly focused on information-sharing through mass media and communication materials such as pamphlets and posters. The main challenge is a lack of community participation that can create an enabling environment for communities to follow the desired behaviors. There is a strong need to design and implement community-led behavior change approaches to ensure community participation and translate the knowledge into practices. This study was conducted to better understand the effectiveness of a community engagement approach, ‘positive deviance’, on dengue prevention and control. The study was carried out in two slums affected by the recent dengue outbreak in Islamabad, Pakistan. A total of 112 persons participated in the study, which was conducted from June–October 2020. The community discovered already-existing positive behaviors surrounding dengue prevention and control, which were shared with other participants through interactive activities. The study demonstrated positive changes in knowledge, attitudes, and practices, and could be a potential tool for dengue prevention and control programs worldwide.Dengue is a mosquito-borne infection caused by the Dengue is a mosquito-borne, viral disease that has emerged as a global health concern in recent years. In the absence of specific antiviral treatment and vaccines, prevention remains the key strategy for dengue control. Therefore, innovative and community-driven approaches are required to improve the vector control practices. This study applied and evaluated the positive deviance (PD) approach on dengue prevention and control in selected slums of Islamabad during June–October 2020. The two most dengue-affected slums, the Faisal colony and France colony, were purposively selected as intervention and control groups, respectively. A total of 112 participants (56 for the intervention and 56 for the control group) participated in the study. The intervention group was exposed for two months to locally identified role model behaviors through weekly interactive sessions, dengue sketch competitions, and role plays. Another two months enabled the community to practice these behaviors without any external support in order to explore the intervention’s sustainability. Three surveys were conducted: before the intervention, after two months, and after four months, to assess any changes in the knowledge, attitudes, and practices of participating communities. Results found that the PD intervention had a significant positive impact on dengue knowledge, attitudes, and practices in the intervention group. PD could offer an empowering and efficient community engagement tool for future dengue prevention and control, both in Pakistan and more globally. Aedes aegypti mosquitoes [Dengue, a mosquito-borne, viral disease, has emerged as a global health concern in recent years. Dengue is prevalent in 128 countries, mostly in the tropical and subtropical regions of the world [squitoes . Dengue squitoes . Populatsquitoes ,6,7,8.Dengue has spread dramatically in Pakistan in recent years ,10. The Currently, there is no antiviral treatment available for dengue. Although several dengue vaccines are in the clinical development process, however, it will take them years to be rolled out in Pakistan to provide protection against dengue ,16. TherAs the breeding of dengue vectors depends on human behavior, there is a dire need to involve local communities as active partners in the design, implementation, and monitoring activities of dengue control programs ,22. The Positive deviance (PD) is a community engagement approach to behavior change. PD was initially envisioned on nutrition studies and operationalized to improve nutrition outcomes in Vietnam. The successful nutrition experience was later replicated in over 40 countries all over the world ,26,27,28The PD premise is that in every community, there are a few ‘positive deviant’ persons who deviate from social norms and practice uncommon behaviors that help them and their families to enjoy better health outcomes than their peers and neighbors with whom they share similar risks and resources. PD emphasizes that solutions to most health and social problems already exist in the same communities. In contrast to the need-based problem-solving approaches which look at what is missing and try to fix it, PD focuses on what is working and building on the existing strengths. These local, accessible, and acceptable solutions are then shared with other community members through an interactive implementation program to foster positive changes in their behaviors. These PD individuals or ‘role models’ have strong ownership and acceptance of their fellow community members, who can better relate to their messages and behaviors than those which are delivered by external bodies. Expert-driven approaches often fail, as the community members do not relate to those external messages and behaviors and discontinue them as soon as the externally designed and delivered intervention is complete . On the Despite a widespread application of positive deviance as an empowering tool on a variety of public health issues, PD has never yet been employed on dengue prevention and control. PD could offer an empowering and efficient community engagement tool for dengue prevention and control. This study aims to assess the effectiveness of the PD approach on dengue prevention and control in the selected slums of Islamabad. As dengue is a newly emerging disease, there is a limited understanding and evidence of the role of communities on dengue control in Pakistan.Therefore, this PD study will pave the way for further community engagement research and will provide rich insights to the concerned partners on the importance of community participation in dengue control and spread. Two low-income communities often referred to as slums, Faisal colony and France colony, were purposively selected for the study. The estimated population of Faisal colony was 4000 persons (450 households) and the estimated population of France colony was 4500 persons (500 households). In 2019, Pakistan experienced one of the worst dengue outbreaks, with 50,535 dengue cases and 83 deaths. An estimated 43% cases were reported from Islamabad and Rawalpindi. The two selected communities were among the most-affected areas of the recent dengue outbreak. Faisal colony was selected to receive the intervention, with France colony selected as the control group. The population of the selected slums were predominantly Christian with similar socioeconomic characteristics. The geographical distance between the two communities was around 4 KM.βBeta error, where power = (1-Beta error): 0.8αAlfa error rate: 0.05E Effect size: 0.59NSample size: 92A mixed method quasi-experiment was conducted in two purposively selected, high-risk dengue slums in Islamabad during June–October 2020. Convenience sampling was used to recruit 112 respondents; 56 were assigned to the intervention arm and 56 were assigned to control group. The study participants were selected based on the list of households. The households were contacted to ask for their willingness to participate in the study. One person was selected per identified household for the study. The estimated sample size was calculated using a power analysis with G*Power 3.1 . The effThe total sample size included 92 participants, where 46 participants were divided into two groups. After calculating the drop-out rate of 20%, the total sample size was 112, which resulted in 56 participants per group. ANOVA: repeated measures, between–within interactions. Sample size calculation:Effect sizeThe questionnaire formerly used for a previous PD study in Cambodia was modified for this study . Face-toFor the qualitative component, eight focus group discussions (FGDs) were carried out with male and female community members to explore in depth their knowledge, perceptions, and practices regarding dengue. Ten in-depth interviews (IDIs) were conducted to identify and select the positive deviance role model behaviors from the communities. Topic guides were developed in the local language (Urdu) to conduct face-to-face interviews with the participants. The findings of the qualitative component formed the basis of the PD-informed intervention.Local college students with some previous experience in the research were recruited for the study. Two days of training were organized, covering informed consent, research ethics, interviewing skills, probing and notetaking skills, topic guides , and the survey questionnaire. 2) tests and Fisher’s Exact tests were performed to examine differences between the intervention and control group at the baseline. Based on a total number of correct answers, new variables were created to examine dengue knowledge (0–48), attitude (0–32), and practice (0–24). To the options for the attitude statement answers, ‘Strongly agree’, ‘Agree’, ‘Disagree’ and ‘Strongly disagree’ were assigned points of 4, 3, 2, and 1, respectively. For scoring purposes, negatively worded items were reverse coded. For the purposes of descriptive analysis, the answers to the statements related to dengue attitudes were collapsed into a 3-point scale . A repeated-measures mixed ANOVA, with one within-subjects factor (time) and one between-subjects factor (group), was conducted to compare the mean differences in total dengue knowledge, attitude, and practice scores between the intervention and control group over time, i.e., baseline, midline after two months, and end-line after another two months.The data were entered in the Epi Data 3.1 software , cleaned, and then exported to the Statistical Package for Social Science (IBM SPSS Statistics 25) for detailed analysis. During the statistical processing of data, standard methods of descriptive statistics were used. Variables of interest were tested for normality, mean and median were used to describe continuous data, and frequencies and percentages were used to describe categorical data. Chi squire . All the respondents were informed about the voluntary nature of the participation, possible risks and benefits, and the expected duration of the interview. Written informed consent was taken from each participant. The Government of Pakistan’s Standard Operating Procedures (SOPs) for COVID-19 were carefully followed during the interviews.The positive deviance study was carried out in two phases; (1) One-week PD process; (2) Two-month implementation of PD intervention. The details of the PD implementation are as follows:Community sensitization meetingThe interactive one-week PD process helped mobilize and sensitize the communities for dengue prevention and control. The PD process enabled communities to understand the normative behaviors around dengue and discover uncommon positive deviant behaviors and strategies of role models that were already being practiced in the communities. The following activities were carried out in the PD process:A community sensitization meeting was held with key community stakeholders including religious leaders, teachers, and influential persons to introduce the PD concept through different interactive activities such as storytelling and conceptual games in the selected communities. Interested community members were identified as volunteers to provide support in the next step, i.e., the situation analysis  with colorful sketches and inserted into the cardboard box house. The community members were invited one by one to take out the paper and read the behavior. After sharing the PD behaviors, a simple action plan was developed to explore ways to enable other community members to follow these simple behaviors  materials. After completion of the exercise, the best sketch was used in the IEC material to reinforce the key messages. Interactive PD sessionsPD sessions were organized by the trained volunteers in the intervention group on a weekly basis. The PD role models were also present in the PD sessions and shared their local, simple behaviors and strategies to avoid dengue, which served as social proof for the other community members. Role plays, storytelling, and locally made IEC materials were used in these sessions. On average, 20 persons participated in each session  and endline (after four months), the number of participants in the control group decreased by two.At the baseline, there were no statistically significant differences found in sociodemographic characteristics such as sex, age, marital status, religion, education, occupation, and average monthly income between intervention and control groups .An equal number of respondents in the control and intervention groups knew that dengue is mosquito-transmitted (67.9%). There was a statistically significant difference in knowledge of three or more dengue symptoms between groups at the baseline where 53.6% of respondents from the intervention group knew three or more symptoms compared to 19.6% of respondents from the control group. However, no statistically significant differences were found between groups in terms of knowing about mosquito breeding sites and mosquito and dengue prevention methods. An independent sample t-test revealed that there were no statistically significant differences between the intervention and control group at the baseline in the total knowledge score, as well as in the total attitude and practice scores .An improvement in knowledge over time was observed for almost all examined variables, even in the control group. At the baseline, 67.9% of respondents from the intervention and control group knew that dengue is mosquito-transmitted compared to 100% of respondents from the intervention group and 83.3% of respondents from the control group at the endline. At the endline, 96.4% of respondents from the intervention and 64.8% of respondents from the control group knew that dengue mosquitoes most often bite during the day, compared to 26.8% of respondents from the intervention group and 17.9% of respondents from the control group at the baseline. Furthermore, 53.6% of respondents from the intervention and 19.6% of respondents from the control group knew three or more dengue symptoms at the baseline, compared to 96.4% of respondents from the intervention group and 70.4% of respondents from the control group at the endline .p < 0.001, ηp2 = 0.450) and group  = 81.518, p < 0.001, ηp2 = 0.430), on knowledge scores. In addition, there was a significant interaction between group and time  = 19.037, p < 0.001, ηp2 = 0.150). For the pairwise comparisons, Bonferroni-adjusted paired t-tests were performed. Statistically significant differences in dengue knowledge between the control  and intervention  group were not found at the baseline (p = 0.071). After two months of the positive deviance intervention, the intervention group  had a better statistically significant improvement regarding dengue knowledge compared to the control group  (p < 0.001). Furthermore, after another two months at the end line, knowledge regarding dengue transmission, prevention practice, and symptoms not only persisted but continued to improve with statistically significant differences between the control group  and intervention group  (p < 0.001). Estimated marginal means are visualized in the profile plot, where an increase in knowledge over time can be seen in both groups, especially in the intervention group  = 88.492, on group ..Attitude towards dengue was good overall among the respondents from the intervention and control groups. The vast majority of respondents from both groups agreed that dengue is a serious infection, that removing empty containers can protect from dengue infection, that using bed nets, repellents, and long sleeves can protect from mosquito bites, and that communities should participate in controlling dengue .p < 0.001, ηp2 = 0.191) and a non-significant main effect of group  = 0.538, p = 0.465, ηp2 = 0.005), on attitude scores. There was a significant interaction between group and time  = 4.577, p = 0.011, ηp2 = 0.041). For the pairwise comparisons, Bonferroni-adjusted paired t-tests were performed. Statistically significant differences in dengue attitude between the control group  and intervention  group were not found at the baseline (p = 0.668). Furthermore, at the midline, after two months and positive deviance intervention, statistically significant differences in dengue attitude between the control group  and intervention  group were also not found (p = 0.269). After another two months at the end line, attitudes towards dengue improved significantly in the intervention group  compared to the control group  (p = 0.018).Results showed that there was a significant main effect of time  = 25.431, Estimated marginal means of dengue attitudes are visualized in the profile plot, where an increase in dengue attitudes between baseline and midline for the intervention and control group is quite similar, but between midline and end line, control-group attitudes remain almost horizontal compared to increased intervention-group attitudes .At the endline, an improvement in practice was observed related to dengue preventive methods, especially in the intervention group, such as sleeping under a bed net during the day, using insecticide spray, repellent, mosquito coil, and smoke to drive away mosquitoes. At the endline, 53.6% of respondents from the intervention group were covering all water containers, compared to 10.7% at the baseline. At the endline, 55.4% of respondents from the intervention group were changing the storage water once a week compared to 25% at the baseline. Interestingly, an improvement in practice was observed not only in the intervention group but also in the control group .p < 0.001, ηp2 = 0.294) and group  = 20.070, p < 0.001, ηp2 = 0.157), on practice scores. In addition, there was a significant interaction between group and time  = 18.117, p < 0.001, ηp2 = 0.144). For the pairwise comparisons, Bonferroni-adjusted paired t-tests were performed. Statistically significant differences in dengue practice between the control group  and intervention  group were not found at the baseline (p = 0.184). Furthermore, at the midline, after two months and positive deviance intervention, statistically significant differences in dengue practice between the control group  and intervention  group were also not found (p = 0.070). After another two months at the endline, practice regarding dengue improved significantly in the intervention group  compared to the control group  (p < 0.001)  = 45.019, < 0.001) .The estimated marginal means of dengue practice are visualized in the profile plot, where an increase in dengue practice between baseline and midline is quite similar for the intervention and control group, but between midline and endline control-group practice remains almost horizontal, compared to increased intervention-group practice .To our knowledge, this is the first study that has applied and evaluated the positive deviance approach on dengue prevention and control. The study was aimed to determine the effectiveness of the PD approach on dengue prevention and control in the urban slums of Islamabad.The study revealed that there were significant changes in the knowledge, attitudes, and practices in the intervention group compared to the control group. After two months of intervention, the intervention group demonstrated a statistically significant improvement in dengue knowledge compared to the control group. Furthermore, after another two months at the endline, knowledge regarding dengue transmission, prevention practices, and symptoms not only persisted but continued to improve, with statistically significant differences between the intervention and control group. Interestingly, there were also some improvements in knowledge in the control group, which could be attributed to the Directorate of Malaria Control Pakistan, which conducted health promotion activities in all the affected communities after the dengue outbreak. There could also be some possibilities of contamination, as some of the members of the intervention group were frequently visiting the control group area to meet their relatives.After the first two months of intervention, there were no significant changes observed in attitudes and practices of the intervention communities. After another two months, the evaluation showed that there were significant changes in the attitudes and practices of the intervention community compared to the control community. The improvements in attitudes and practices in the intervention group can be attributed to the PD-informed behavior change intervention, which transformed knowledge into practices in the intervention group, which is validated by a behavior change intervention study conducted in Cambodia . Despite“if he/she can do it, why can’t I”. The Information, Education, and Communication (IEC) materials were also developed by the community members using colorful sketches on flip charts (large paper) which had strong ownership of the communities. The previous studies also verified the fact that culturally sensitive and context-specific behavior change communication approaches were very effective at improving awareness and practices on dengue prevention and control [In the PD study, the community was considered as an active partner, where they led the design and planning, and had a role in decision-making, which helped create interest, acceptance, and sustained community participation (no drop-out in intervention group) throughout the PD intervention, which is consistent with previous studies ,21,22. E control ,38,43. M control ,44,45,46 control .The PD approach has tremendous potential as an effective behavior change and community engagement tool for dengue prevention and control. The approach has been very successful in engaging communities and received very positive feedback from a small-scale evaluation of a malaria study conducted in Cambodia . The PD Another key reason for the active participation of the community in the study was the community-based interactive activities, such as small competitions. For example, the community members were engaged in competitions to develop sketches/drawings or develop songs on those messages or behaviors they heard in the last two months. This generated great interest, as they involved their families and neighbors in the competition to come up with good drawings and songs, which in turn mobilized the community and reinforced dengue behaviors at the community level. Community members were acknowledged with some small souvenirs (worth 1 USD per souvenir) for their best drawings and songs in front of the large community, which boosted their confidence and maintained their motivation throughout the intervention. Therefore, as Atkinson’s study discussed, small incentives such as souvenirs should be considered to enhance participation and motivation in the vector control programs .The study was conducted on a small scale due to scarce financial resources. As the study used quasi-experiments using convenience sampling methodology, the findings therefore cannot be generalized; however, the study still provides some excellent insights on the process and evaluation of the approach. As the study was conducted in slum areas, the findings may only be relevant to a similar context.The findings revealed that the positive deviance study had a significant impact on dengue knowledge, attitudes, and practices in the target communities, even in the short span of the implementation period. The study recommends that well-informed and community-led behavior change approaches are needed to ensure community participation and sustained behavioral changes in dengue prevention and control programs. The study demonstrated that locally identified solutions and community-made IEC materials had strong ownership and acceptance from the community. PD is an ‘inside-out’ community-led behavior change intervention that ensures active community participation throughout the process, which is a key requirement of vector control programs. Therefore, PD should be further replicated and scaled up to better determine the effectiveness of the approach. Positive deviance could be a potential behavior change tool to be adopted for dengue prevention and control in Pakistan and elsewhere.


Changes in the serum gastrin and PG levels before and 4 weeks after administration were examined. Patient factors associated with the alteration of serum PG or gastrin levels were identified. The median serum levels of gastrin, PGI, and PGII before the administration of the acid secretion inhibitors were 110.5 pg/mL, 36.4 ng/mL, and 8.9 ng/mL, respectively; after administration, the levels increased to 300 pg/mL, 64.7 ng/mL, and 15.8 ng/mL, respectively (P < 0.01). Univariate analysis revealed that PCABs led to a more significant increase in the serum gastrin and PG levels as compared to PPIs. Furthermore, the PG levels were significantly increased in patients with previous Helicobacter pylori infections than in those with current infections. In conclusion, the serum gastrin and PG levels increased after the use of acid secretion inhibitors. This elevation was affected by the type of drug used, whereas the elevation in PGs was affected by the patient's background as well.Acid secretion inhibitors, such as proton pump inhibitors (PPIs) and potassium competitive acid blockers (PCABs), are used to treat ulcers after endoscopic submucosal dissection (ESD) for early gastric cancer. These drugs can influence serum gastrin and pepsinogen (PG) levels; however, their definite effects remain unclear. This open-label, randomized study investigated the effect of acid secretion inhibitors on the serum gastrin and pepsinogen levels. In total, 76 patients were enrolled in the study. They underwent gastric ESD and received a PPI ( Endoscopic submucosal dissection (ESD) for gastric cancer is a minimally invasive and highly curative treatment that has gained popularity globally. However, bleeding from stomach ulcers  created following excision of the lesion has been a complication linked with ESD . Thus, eHelicobacter pylori (H. pylori) infection status [H. pylori, may impact their blood levels. Therefore, the increased PG level after consumption of acid secretion inhibitors may not allow an effective histological evaluation of the gastric mucosa, thereby hindering diagnosis [Gastrin, especially amidated gastrin-17 (G17), is only secreted by G cells and is the main circulating form in most mammals. Gastrin and pepsinogen (PG) reflect the function and state of the gastric mucosa and are considered representative biomarkers of the gastric physiology . Thus, Pn status  and thatn status . As per iagnosis .Acid secretion inhibitors are widely used; some patients consume them for a long time before the disease is cured. Thus, the influence of gastric acid inhibitors on blood gastrin and PG and the correlation between them should be considered . In thisH. pylori infection were excluded: these are patients with no endoscopic gastric atrophy, no histologic atrophy of the gastric gland, no histologic inflammation of the gastric mucosa, no histologic H. pylori infection, and negative anti-H. pylori antibody titers.In this retrospective cohort study, we enrolled 167 patients who underwent blood tests before and after ESD for gastric cancer between July 2017 and March 2019 at the Hiroshima University Hospital. Patients were excluded for PPI or PCAB usage before ESD; the use of anticholinergic drugs, antigastrin drugs, or histamine receptor-2 antagonists during the observation period; having the Zollinger–Ellison syndrome; having a history of gastrointestinal resection or vagus nerve ablation; and having autoimmune gastritis. Patients without an H. pylori infection status were compared between the two groups. Posteradication and naturally eradicated cases were designated as previous infection. Patients who were positive for endoscopic gastric atrophy and negative for HP antibody cases were classified as previous infection patients, whereas patients who were positive for both endoscopic gastric atrophy and HP antibody cases were classified as current infection patients. This study was registered as a retrospective cohort study (UMIN ID: UMIN000030407) and approved by the ethics committee of Hiroshima University (e-30518).To investigate the factors associated with the elevation of serum gastrin and PG levels after PPI or PCAB administration, the median amount of change in gastrin and PG levels was used to classify the group as large if it was higher than the median value and small if it was lower. The age, sex, drug type, degree of endoscopic atrophy (Kimura–Takemoto classification), and H. pylori antibody titers  were evaluated [To fully evaluate the degree of changes in gastrin and pepsinogen caused by acid inhibitors, the values of these serum markers before and after administration were compared. Additionally, to examine the changes in G7 levels before and after administration, 10 cases from each group, the PPI group and PCAB group, were randomly selected for analysis. Fasting sera were collected on the day of the ESD and 4 weeks later and stored at -20°C until analysis. The levels of serum gastrin , G17 , and PG  and the anti-valuated .χ2 test and Fisher's exact test to analyze categorical data, as appropriate. Multivariate logistic regression analyses were performed to assess the factors associated with increased serum gastrin and PG levels. Confidence intervals were computed using normal approximation of the binomial distribution. P < 0.05 was considered statistically significant for each test. The JMP statistical software  was used for all statistical analyses.To compare the numerical data before and after medication, we used the Wilcoxon signed-rank test. We used the Finally, as shown in H. pylori infection status, and gastrin, PGI, and PGII levels before administration among the therapy groups , y groups . After ty groups . Before y groups . After aP < 0.001) after administration of the PPI and PCAB. Then, we examined the alteration in G17, the most significant subfraction of human gastrin. The serum G17 levels in patients treated with acid secretion inhibitors are presented in Figures P = 0.001). Univariate analysis revealed that the drug type was the only host factor that contributed to an increased level of gastrin.The large and small groups were then compared to examine the host factors that contributed to the differences in the extent of changes in the gastrin and PG levels. In the case of gastrin , 89% of H. pylori infection status between the two groups. Moreover, univariate analysis revealed significant intergroup differences in these two factors.Conversely, in the case of PGs Tables  and 5, sP < 0.001) and higher in women than in men. Although there was no observable difference between men and women in our study, the levels tended to be higher in women, similar to that in Shiotani et al.'s report. It may be related to the difference in the number of research participants and period of administration.In this study, we found that PPI or PCAB usage for ulcers caused by ESD increased serum gastrin and PG levels. These findings are consistent with the findings of several previous clinical trials and control studies , 16, 17.Various adverse effects caused by the long-term use of PPI or PCAB are considered to be attributed to the characteristics of the drug and the subsequent biological changes. Hypergastrinemia may result from a long-term use of acid inhibitors in patients with chronic atrophic gastritis . In animr = 0.85, P < 0.001), as shown in In recent years, Western countries have demonstrated that the serum level of G17, which is secreted from the antral G cells, has been used to evaluate the topography of gastritis by GastroPanel –26. HoweH. pylori-associated gastritis, which further upregulates the gastrin levels [Factors that lead to increased serum levels of gastrin and PG should be investigated among PPI or PCAB users. Gastrin and its derivatives have long been considered cell growth factors and have been reported to have regulatory effects (such as antiapoptotic and proliferative effects) on some cells (including the gastric epithelium and cancer cells). Furthermore, some cytokines that induce G cells to secrete gastrin, such as ammonia and tumor necrosis factor-alpha, are released in n levels . In thisn levels . The incH. pylori, severity of gastric atrophy, and inflammation may be the determinants of the serum PG levels. The reasons for the increase in PGs in PPI/PCAB users are unclear; however, possible causes may include hypertrophy or reproduction of the gastric acid glands and pyloric glands caused by high circulating gastrin and/or gastrin, which promote the release of PG in the gastric mucosa [H. pylori eradication and less gastric atrophy led to an increase in the PG levels. In patients with moderate-to-severe atrophic gastritis, the average PG level was 16.3 ng/mL before eradication; this increased to 25.7 ng/mL after eradication [The presence of c mucosa , 11, 25.dication . Kishikadication  reportedThis study has a few limitations. First, the sample size was relatively small, especially in PPI cases, since the patients who had taken PPI or PCAB before ESD were excluded from this study. There were more PPI users than PCAB users among the patients. Thus, the PPI group became smaller. Second, our research is a short-term study. Thus, the effect of long-term medication on serum gastrin and pepsinogen levels and the results need to be further confirmed in the future. Third, we targeted ESD patients as study subjects since we intended to assess how gastrin and PG levels changed in those who were at high risk of developing gastric cancer.In summary, this study was conducted in a group of cases with high potential of carcinogenesis that developed to gastric cancer. In such population, PCAB resulted in a rapid increase in gastrin compared to PPI. This point should be considered when selecting PPI and PCAB; however, further consideration is required for its long-term effects.


In the early stages of the COVID-19 pandemic, Japan conducted contact tracing extensively and published detailed records of thousands of anonymized patients. We leveraged the registry data to perform an exponential random graph model (ERGM) network analysis to examine demographic and symptomological homophilies of SARS-CoV-2 transmission networks in Hokkaido and Kanagawa. Our analysis showed: (1) Age, symptom, and asymptomatic status homophilies in both prefectures; (2) Asymptomatic infections increased as the virus was passed from primary cases to secondary and tertiary ones; (3) Transmission was mostly seen at the primary and secondary levels, with none occurring beyond quaternary; (4) Transmission occurred primarily in healthcare settings, as well as in families.n = 4392). Exponential random graph model (ERGM) network analysis was performed to examine demographic and symptomological homophilies. Age, symptomatic, and asymptomatic status homophilies were seen in both prefectures. Symptom homophilies suggest that nuanced genetic differences in the virus may affect its epithelial cell type range and can result in the diversity of symptoms seen in individuals infected by SARS-CoV-2. Environmental variables such as temperature and humidity may also play a role in the overall pathogenesis of the virus. A higher level of asymptomatic transmission was observed in Kanagawa. Moreover, patients who contracted the virus through secondary or tertiary contacts were shown to be asymptomatic more frequently than those who contracted it from primary cases. Additionally, most of the transmissions stopped at the primary and secondary levels. As expected, significant viral transmission was seen in healthcare settings.Kanagawa and Hokkaido were affected by COVID-19 in the early stage of the pandemic. Japan’s initial response included contact tracing and PCR analysis on anyone who was suspected of having been exposed to SARS-CoV-2. In this retrospective study, we analyzed publicly available COVID-19 registry data from Kanagawa and Hokkaido ( Epidemiological studies of COVID-19 have provided mounting evidence that a significant number of individuals infected with SARS-CoV-2 are asymptomatic ,4,5. HowSince the index case was confirmed on 16 January 2020, the Japanese government has been publishing demographic, clinical, and epidemiological data on each individual who has tested positive for the virus. One unique feature of the data is the transmission paths revealed through the contact tracing efforts of the public health centers (PHCs) ,8,9. AltWe utilized publicly available data from the two prefectures, Hokkaido  and KanaThe primary objective of the current study was to construct SARS-CoV-2 transmission networks and to analyze the characteristics of viral transmission both descriptively and statistically. In particular, we examined symptom, age, and sex “homophilies”, i.e., whether an infector (the source patient) and the infectee(s) tended to experience similar symptoms, be both asymptomatic or belong to the same age or sex group. Although the results of such analyses do not provide direct evidence about the variations of the virus, the findings shed light on the heterogeneity of SARS-CoV-2 transmission that may be partly explained by viral variants, as well as by how government intervention strategies and the population’s behavior at the time of the pandemic influenced the spread of the virus.We queried the government registry data for Hokkaido and Kanagawa prefectures. The registry data from Hokkaido contained 1269 cases  covering the period between 14 February and 22 July 2020, while the data from Kanagawa contained 3123  cases covering the period between 15 January and 6 August 2020. The final data contained information about 4392  patients. These cases were originally confirmed by the local PHCs that report to the Ministry of Health, Labor, and Welfare. The Ministry standardizes and publishes the data it receives from the PHCs as part of the comprehensive data contained in the national registry [The final data included the information on sex; age ; the city of residence, or the testing site; the dates of PCR and the onset of symptoms; symptoms experienced (if any). In Kanagawa, 100 patients were non-Japanese citizens who resided on a US military base. Symptomatological data on these patients were not publicly available, thereby reducing the sample size to 3023 for the analysis of symptomatological data. Similarly, 48 patients did not provide age, reducing the sample size for the analysis involving age to 4344. Data on viral transmission paths were available for 1365 patients (371 cases (29%) and 994 (32%) cases in Hokkaido and Kanagawa, respectively). After excluding those patients whose symptomatological data were missing, 1310 patients (355 patients in Hokkaido and 955 in Kanagawa) remained in the viral transmission networks. For Kanagawa, the likely settings through which transmission occurred were also available for 457 (15%) patients. These included: (i) at medical facilities; (ii) through family; (iii) through friends; (iv) at work; (v) through travel .t- and chi-square tests, respectively. To investigate the factors correlated with viral transmission and asymptomatic states, logistic regression was performed with the binary dependent variables recording the presence of either viral transmission or asymptomatic states. The factors explaining the viral transmission counts were examined using Poisson regression with the number of infectees per patient as the dependent variable. To examine the difference between the two prefectures, the interaction term between Kanagawa and asymptomatic status was included in the regression model. For the age analysis, the patients aged between 50 and 59 were the reference group, as the preliminary analysis indicated that the group had the lowest proportion of asymptomatic patients. For the month fixed effects, July was the reference month, as the month signifies the end of the first phase of COVID-19 for both prefectures and the beginning of a second wave for Kanagawa. All statistical analyses were performed in STATA . Statistical significance was defined by p ≤ 0.05 unless noted otherwise.Patient characteristics observed in Hokkaido and Kanagawa were compared using t-tests for continuous and chi-square tests for nominal variables. Depending on the distribution of a continuous variable and the sample size of a nominal variable, Wilcoxon Mann–Whitney and Fisher’s exact tests were used to replace We defined asymptomatic cases as those cases who met at least one of the following criteria: (i) the note in the registry indicated the case as an “asymptomatic patient”; (ii) the note indicated “no symptoms”; (iii) there were no symptoms recorded while all other information  on the patient were present. While these cases may be pre-symptomatic, the notes in the registry data frequently included updated information, indicating, for instance, “the patient reported a fever of (degree) on (date)” after the initial recording. These updates appeared to have been made during the aforementioned 14 day-monitoring periods. Our definition conforms to the current WHO’s guidelines for the determination of asymptomatic cases, i.e., PCR-positive COVID-19 patients without overt symptoms at the time of the laboratory-confirmed infection.To visually inspect the patterns of viral transmission, we constructed viral transmission networks using the records of the patients whose infectors or infectees were known in the registry data. The network construction and visualization were done using Gephi (v0.9.2). To examine the prevalence of “homophilies” in the viral transmission networks, we applied exponential random graph models (ERGMs), which are well-established models to statistically analyze social and other network data. We specifically investigated several types of homophilies in the networks including: (i) sex homophily, which represents the situations where an infector and the infectee(s) belonged to the same sex; (ii) age homophily representing the situations where an infector and the infectee(s) belonged to the same age group; (iii) symptom homophily where an infector and the infectee(s) had the same symptom; (iv) asymptomatic homophily where both an infector and the infectee(s) were asymptomatic. The first two analyses were to investigate the demographic homogeneities/heterogeneities in the networks, while the last two were to examine the symptomological homogeneities/heterogeneities.Gastrointestinal issues: Stomach ache, nausea, digestive, diarrhea, vomiting, and loss of appetite;Mild/upper respiratory issues: cough, pharyngitis, and rhinitis;Severe/lower respiratory issues: pneumonia, phlegm, dyspnea, and fatigue;Sensory disruption: loss of taste (ageusia) and loss of smell (anosmia).Other symptoms that were not grouped included fever, headache, and body ache. All ERGM analyses were run using the programming language R (R Core Team).ERGMs essentially test whether infector-infectee chains with a specific type of homophily were more prevalent than those chains without the homophily, i.e., “heterogeneous” chains, in the networks. The heterogeneous class was the reference group in the analysis. In the homophily analysis of sex, we compared the 2 homophily classes of infector-infectee chains to 1 heterogeneous class. The 2 homophily classes were: (a) the  class, which represented the chains with the sex homophily, while the heterogeneous class contained both  and  cases, representing the chains without sex concordance between infectors and the infectees . AsymptoThe result section is structured with the following sub-sections: (1) the comparison between Hokkaido and Kanagawa patient profiles; (2) factors correlated with being asymptomatic; (3) factors correlated with the viral transmission; (4) viral transmission networks; (5) demographic and symptomological homophilies in viral transmission networks.p < 0.001) and were more likely to be asymptomatic  compared to the Hokkaido cases. Among all symptoms experienced in both prefectures, loss of smell (anosmia) and chills were the only symptoms seen more frequently in Kanagawa . The symptoms seen more frequently in Hokkaido included rhinitis , fatigue , diarrhea , pneumonia , dyspnea , and body aches . The average number of symptoms experienced  and the average number of infectees per patient  were statistically significantly higher for the Hokkaido patients. The proportion of the patients who infected at least one person was also higher in Hokkaido .Overall, the Kanagawa patients were younger . Similarly, the patients aged between 80 and 89 as well as 90 and above were 2.18 (p < 0.001) and 2.62 (p < 0.001) times more likely to be asymptomatic, respectively, compared to the reference group . Males were about 34% less likely to be asymptomatic compared to females , and Kanagawa patients were 41% more likely to be asymptomatic . With respect to the seasonal effects, using the number of COVID-19 cases in July as the comparator, we found that the likelihood of observing asymptomatic patients was lower in March  and April , but was higher in May  and June . The likelihood was also higher in August , although the observations for August were from Kanagawa only. There were no asymptomatic cases reported in February (n = 86).We statistically examined the relationship between age and the likelihood of being asymptomatic, adjusting for patient’s sex using a logistic regression on the data from both prefectures . The resp-values in the figures correspond to the hypothesis testing examining the equal rate of asymptomatic patients between the two prefectures for the month . Additionally, for males, the proportion was statistically significantly higher in Kanagawa for May (p < 0.001) and June (p = 0.03). For females, the proportion was higher in Kanagawa for May with a 10% significance level (p = 0.07). Overall, Kanagawa demonstrated an upward trend of the asymptomatic case proportion between March and June. The proportion dropped in July and increased again in August. The trend was less clear for Hokkaido, although the proportion of asymptomatic female patients showed an upward trend between March and June.To better understand the seasonal effect, we separated the data by prefectures to examine whether the proportion of the asymptomatic cases varied by month in each prefecture, adjusting for sex i,ii. Thehe month . The p-vp = 0.02). The likelihood of viral transmission was statistically significantly lower in May and June compared to July  and again in August . The likelihood of viral transmission by asymptomatic patients differed significantly between Hokkaido and Kanagawa. In Hokkaido, asymptomatic patients were 71% more likely to transmit the virus  while, in Kanagawa, asymptomatic patients were 85% less likely to transmit the virus compared to their symptomatic counterparts (OR = e (ln(1.71) + ln(0.09)) = 0.15, p < 0.001).To identify the factors correlated with the viral transmission, we performed a logistic regression with the binary dependent variable representing the patients who infected at least one individual (p < 0.001), while in Kanagawa, the average count was about 80% less among asymptomatic patients compared to symptomatic patients (IRR = e (ln(5.61)+ln(0.04)) = 0.20, p < 0.001). In both prefectures, the viral transmission rate was higher in April  and lower in May and June  compared to July. The transmission rate was lower in August than in July . The average count of infectees was 26% higher among males compared to females . In general, younger patients were infecting fewer people  compared to those aged between 50 and 59 (the reference group), while older patients were infecting more individuals  compared to the patients aged between 50 and 59.The results of the Poisson regression shown in Transmission of the virus ranged from one to four levels (primary to quaternary) in both prefectures. p = 0.02 for Hokkaido and p < 0.001 for Kanagawa). Relative to symptomatic patients, asymptomatic patients were more concentrated in the secondary  and tertiary  transmission, while symptomatic patients were more concentrated in the primary cases (34% vs. 16% in Hokkaido and 38% vs. 13% in Kanagawa). The results of a logistic regression confirmed this (p < 0.001) and 3.2  times more likely to be asymptomatic than primary cases, respectively.The distribution differed significantly between symptomatic and asymptomatic patients . Orange and blue circles represent the tertiary and quaternary infectees. Most of the networks consist of only two individuals.p < 0.001).Separately, we visualized the transmission networks by age and sex, which revealed no discernable patterns and thus are not presented here. For Kanagawa networks, we also visualized the viral transmission networks by setting . The figp < 0.001), which indicated that the gastrointestinal homophily chains were 64% less likely than the heterogeneous chains. The gastrointestinal homophily chains were more likely than the heterogeneous chains in Hokkaido , showing differences in disease manifestation between the two prefectures. For all other homophilies, the results were consistent between the prefectures. In particular, the asymptomatic homophily and the sensory disruption homophily chains were statistically more likely than the heterogeneous chains in both prefectures. Concerning the asymptomatic homophily, the asymptomatic chains were 5.21 times and 3.67 times more likely than the heterogeneous chains in Hokkaido  and Kanagawa , respectively. Regarding the sensory disruption homophily, the chains were 2.02 and 2.09 times more likely in Hokkaido  and Kanagawa , respectively. The fever homophily chains were also more likely in both prefectures , although for Hokkaido, no-fever homophily chains  was also more likely . Several additional  class homophilies were significant in Hokkaido. These included body ache , mild/upper respiratory issues , and severe/lower respiratory issues . There was no statistically significant sex homophily in either prefecture (p > 0.10). In terms of the age homophily, the age ≥60 homophily was observed in both prefectures, indicating that viral transmissions between older (≥60) patients were more likely . In addition, the Kanagawa networks indicated the presence of age <30  and 31–59  homophilies.The ERGM analyses examined the prevalence of sex, age, and symptom homophilies in the viral transmission networks. The current retrospective study analyzed publicly available secondary data of 4392  individuals who were PCR-positive for SARS-CoV-2. The comparison of the results from the two prefectures has shown similarities, as well as differences. In both prefectures, asymptomatic cases were about 20% and were more likely to be female, and in either the younger (<20) or older (≥80) age group. The rate of asymptomatic infection observed in the current study is comparable to that report in prior literature ,17,18. TThe primary difference observed between the prefectures was the viral transmission rate among asymptomatic patients. In Hokkaido, asymptomatic patients were more likely to transmit the disease, while, in Kanagawa, symptomatic patients were more likely to transmit the virus. Other studies have also reported varying results about the viral transmissions by symptomatic and asymptomatic cases, ranging between 0% and 2.2% for asymptomatic transmission and between 0.8% to 15.4% for symptomatic transmission ,31,32,33Another explanation may be the differences in the climate and temperature. Hokkaido is farther north and significantly colder than Kanagawa, especially during the winter, and experienced its first COVID cases during the winter months, peaking in April (mean temperature 5 °C). Given that the seasonality of respiratory viral diseases and the impact of temperature and humidity on the body’s response to these pathogens is well-established , it stanConsistent with other studies, our network analysis showed that, both in Hokkaido and Kanagawa, nosocomial infections gave rise to large transmission networks (36 cases in Hokkaido and 74 cases in Kanagawa). High levels of SARS-CoV-2 transmission in health care settings have been observed by others as well ,36,37,38Transmission clustering has also been reported in the family setting. These studies have shown that within-family transmissions are often localized and that the risk of transmission in the setting is comparatively high . Our stuTo our knowledge, no prior studies have examined demographic and symptomological homophilies of the SARS-CoV-2 viral transmission networks. Homophilies, in this case, refers to the similarities between the infector and infectee. Our ERGM analysis revealed the presence of age homophily among older (≥60) patients in both prefectures. This may be at least partially attributable to the age grouping of individuals in nursing homes and care facilities, as well as the forms of social interactions  among older adults, which may have led to more viral transmission to their confreres. In Kanagawa, additional homophilies were detected in the patients’ aged <30 and 31–59, likely reflecting the generational differences in social behavior, especially in an urban setting such as Kanagawa.In addition to age homophily, we also observed symptomatic and asymptomatic homophilies. Symptomatic infectors were more likely to give rise to symptomatic infectees, while patients who got the disease from an asymptomatic infector were likely to also be asymptomatic. Although the reason behind this homophily remains unclear, it could be the result of a lower viral load in patients with mild disease, which would result in fewer shed viral particles and a consequent lower infectious dose delivered to an infectee. However, whether asymptomatic patients have a lower viral load is controversial, with some studies showing lower levels and others showing no difference ,51. RelaHomophily of sensory disruption  was observed in the networks of both prefectures. Moreover, we observed that homophily chains were more prevalent than heterogeneous chains in the network. These findings suggest that genetic variations of SARS-CoV-2 may be underlying the variance in symptoms and that the transmission of virions from a particular genetic lineage from an infector to an infectee may result in a similarity of symptoms between these two groups. Phylogenetic analyses of SARS-CoV-2 sequences from these cases are warranted to explore this hypothesis.The study has several limitations in addition to the aforementioned unavailability of viral samples. First, the current study is a retrospective secondary data analysis, and thus, the authors are unable to ensure the quality of the data. In particular, the viral transmission data are subject to systematic bias if contact tracing was performed disproportionately in specific cases or cohorts. The guideline published by the Japanese government stipulates that all individuals who were in “close contact” with the confirmed cases be subject to an “initial (PCR) screening test”. While it is likely that the guideline was still closely followed during the study period of February to July 2020, it is possible that the level of compliance was somewhat compromised as the pandemic got worsened. It is also possible that individuals in certain settings were followed up more completely than the individuals in other settings due to accessibility. For instance, it is easier to identify those cases who were in “close contact” with the patients in medical facilities than those who were in “close contact” with cases who contracted the virus while traveling. Secondly, as mentioned in the methods section, our asymptomatic patients could include pre-symptomatic cases. Even though the notes in the registry data appeared to have been updated during the 14 day-monitoring periods, we are unable to ensure the completeness of such updates.We analyzed the records of 4392 PCR-confirmed COVID-19 patients in two prefectures, Hokkaido and Kanagawa, during the early stages of the pandemic in Japan. The network analysis of the viral transmission chains revealed that demographic and symptomological homophilies exist in both prefectures. In particular, age homophily existed in both prefectures, especially between older adults, but more prevalently in the Tokyo area. No sex homophily was observed in either prefecture. Most importantly, similar patterns of symptom homophilies were seen in both prefectures, with the most striking being the homophily between asymptomatic infectors and infectees. This result substantiates the logic behind contact tracing and testing of “close contact” cases, even in the absence of the symptoms, to contain the spread of the virus. Furthermore, as with COVID-19, control of future pandemics will likely also greatly benefit from public education to promote testing in “close contact” cases, as well as from the establishment of an efficient testing system during the early stages of outbreaks.


N-terminal probrain natriuretic peptide (NT-ProBNP) combined with a simplified Geneva scale for the prognosis of acute pulmonary embolism (APE).  To explore the predictive value of mean platelet volume (MPV) and plasma n = 45) and a poor prognosis group (n = 23). The clinical data, laboratory clinical indexes, and simplified Geneva scale scores were recorded for the two groups. The risk factors of poor prognosis were analyzed by binary multivariate logistic regression analysis; the predictive ability of each index on the prognosis of patients with APE was analyzed by the ROC curve.  The clinical data of 68 patients with APE admitted to our hospital from October 2017 to October 2019 were collected. According to the prognosis, the patients were divided into a good prognosis group (P < 0.05). PLT, platelet distribution width (PDW), MPV, and plasma NT-ProBNP in the poor prognosis group were higher than those in the good prognosis group (P < 0.05). The simplified Geneva scale score of the poor prognosis group was higher than that of the good prognosis group (P < 0.05). PDW, MPV, plasma NT-ProBNP, and simplified Geneva scale were all independent risk factors for the poor prognosis of APE patients (P < 0.05). The AUC of MPV in predicting the prognosis of APE patients was 0.818 (95% CI: 0.712–0.925). When the optimal cutoff value was 0.571, the sensitivity was 77.1%, and the specificity was 80.0%. The AUC of plasma NT-ProBNP in predicting the prognosis of APE patients was 0.762 (95% CI: 0.634–0.891). When the optimal cutoff value was 0.475, the sensitivity was 71.5%, and the specificity was 76.0%. The AUC of the simplified Geneva scale in predicting the prognosis of APE patients was 0.749 (95% CI: 0.618–0.879). When the optimal cutoff value was 0.469, the sensitivity was 82.9%, and the specificity was 64.0%. The AUC of MPV and plasma NT-ProBNP combined with the simplified Geneva scale in predicting the prognosis of APE patients was 0.907 (95% CI: 0.826–0.988). When the optimal cutoff value was 0.726, the sensitivity was 88.6%, and the specificity was 84.0%.  The incidences of deep vein thrombosis, diabetes, and hyperlipidemia in the poor prognosis group were higher than those in the good prognosis group ( MPV, plasma NT-ProBNP, and simplified Geneva scale have a certain predictive value for the prognosis of APE. Compared with a single index, the combination of the three indexes has a significant improvement in predicting the prognosis of APE and has better clinical value. Acute pulmonary embolism (APE) refers to a variety of emboli that block the pulmonary artery and its branches, leading to pulmonary circulation disorders, resulting in a variety of pathological and physiological changes. APE is mainly manifested as sudden chest pain, dyspnea, hemoptysis, and other manifestations. It has a rapid onset and rapid development and has the characteristics of low specificity and poor prognosis , 2. In rN-terminal pro-brain natriuretic peptide (NT-ProBNP) is a metabolic substance in the process of myocardial cells producing BNP, which can reflect the state of the body's heart function. The higher the level of NT-ProBNP, the larger the area of the embolized blood vessel, the more severe the degree of right heart dysfunction and myocardial damage, the worse the prognosis of patients. NT-ProBNP has a slower clearance in the blood and a long half-life, and the concentration of NT-ProBNP in plasma is higher than that of BNP, and it has no biological activity. Its detection is not easy to be affected by drugs, and the determination results are more accurate and sensitive and have been applied in the diagnosis and prognosis of a variety of diseases [Mean platelet volume (MPV) is an indicator of platelet function, which can reflect the production and activation of platelets, and plays an important role in the diagnosis of acute pancreatitis, colorectal cancer, respiratory diseases, and other diseases –7. N-terdiseases . Studiesdiseases . The simdiseases .The objective of this study was to investigate the predictive value of MPV and plasma NT-ProBNP combined with a simplified Geneva scale in predicting the prognosis of APE.The clinical data of 68 patients with APE admitted to our hospital from October 2017 to October 2019 were collected. Among them, 39 were males, and 29 were females, with an average age of (56.23 ± 11.86) years.① Symptoms: the clinical manifestations were complex and diverse, with low specificity, most of which were dyspnea, chest pain, syncope, hemoptysis, and other symptoms. ② Signs: mainly the signs of the respiratory system and circulatory system, manifested as increased respiratory rate (>20 beats/min), increased heart rate (>90 beats/min), cyanosis, and hypotension. ③ Pulmonary artery CTA: the image conforms to the following manifestations: direct signs: (1) partial thromboembolism, the thrombus was free in the vascular lumen, and the surrounding contrast agent surrounds and presents a circular low-density shadow. (2) Complete thromboembolism, the distal blood vessels were not visible, and the official cavity was completely blocked into a cup or irregular club. (3) Annular mural thrombus, showing mural filling defect .The diagnostic criteria of APE were met. All patients were diagnosed by CT angiography, radionuclide pulmonary ventilation/perfusion scan, and pulmonary artery angiography. Onset time <24 h; age ≥18 years; and the medical history data were complete.The exclusion criteria were as follows: chronic thromboembolic pulmonary hypertension; anticoagulant or thrombolytic therapy had been performed before admission; heart, liver, and kidney insufficiency; severe respiratory infections; severe blood system disease; blood indicators that have not met the requirements; previous cerebral infarction; patients who had undergone coronary artery bypass grafting or stenting; pregnant and lactating women; mentally ill; and unable to follow visitors.In this study, clinical data of study subjects were retrospectively analyzed, and since there were no intervention activities for patients in this study, the process of signing informed consent could be exempted in this study.n = 45) and a poor prognosis group (n = 23).All patients were followed up for 1 month, and the prognosis of the patients after discharge from the hospital was recorded. Poor prognosis was defined as adverse events such as death (death due to various reasons), deterioration of the disease (increased severity of the disease), APE recurrence (after recovery and discharge and readmission to APE), mechanical ventilation, and tracheal intubation. According to the prognosis, the patients were divided into a good prognosis group , smoking history, drinking history, predisposing factors, and primary diseases of all patients were recorded.The laboratory clinical indexes of the patients were recorded 24 h after admission: white blood cell count (WBC), red blood cell count (RBC), hemoglobin (Hb), platelet count (PLT), platelet distribution width (PDW), MPV, plasma NT-ProBNP, and so on.The simplified Geneva scale score was recorded for all patients, with a total of 9 indicators, a total score of 0–10 points. The higher the score, the greater the risk of APE. The specific scoring operation of this scale was carried out by nurses in our department . The incidences of deep vein thrombosis, diabetes, and hyperlipidemia in the poor prognosis group were higher than those in the good prognosis group . PLT, PDW, MPV, and plasma NT-ProBNP in the poor prognosis group were higher than those in the good prognosis group . When the optimal cutoff value was 0.571, the sensitivity was 77.1%, and the specificity was 80.0%; The AUC of plasma NT-ProBNP in predicting the prognosis of APE patients was 0.762 (95% CI 0.634–0.891). When the optimal cutoff value was 0.475, the sensitivity was 71.5%, and the specificity was 76.0%. The AUC of the simplified Geneva scale in predicting the prognosis of APE patients was 0.749 (95% CI 0.618–0.879). When the optimal cutoff value was 0.469, the sensitivity was 82.9%, and the specificity was 64.0%; The AUC of MPV, and plasma NT-ProBNP combined with simplified Geneva scale in predicting the prognosis of APE patients was 0.907 (95% CI 0.826–0.988). When the optimal cutoff value was 0.726, the sensitivity was 88.6%, and the specificity was 84.0% .As an acute and severe disease with frequent clinical occurrence, APE is characterized by atypical clinical manifestations, the rapid development of the disease, and poor prognosis; its prevalence of APE increases with age; and it has a higher risk of death . The stuThe results of this study showed that the incidence of deep vein thrombosis, diabetes, and hyperlipidemia in the poor prognosis group were higher than those in the good prognosis group. This suggested that deep vein thrombosis, diabetes, and hyperlipidemia can all affect the prognosis of APE patients. The possible reasons are: when deep vein thrombosis is formed, the thrombus can fall off and can travel along the bloodstream to the lung, causing the blood vessel to block, which in turn leads to an increased risk of APE recurrence and poor prognosis. In addition, the blood of patients with diabetes and hyperlipidemia is often in a state of hypercoagulation; the blood of patients is relatively viscous, prone to the formation of thrombosis, and can damage the blood vessel wall, leading to the thrombus falling off, thereby affecting the prognosis of APE patients .As a parameter indicating the volume and size of platelets, MPV can reflect the function of platelets and is closely related to the production of thrombus. Once suffering from APE, the patient's body will produce a variety of inflammatory factors, thereby destroying the endothelium of the pulmonary vessels, resulting in the production and activation of platelets, thereby increasing the level of MPV . Gunay'sIn addition, the ROC curve results showed that the AUC of MPV, plasma NT-ProBNP, and simplified Geneva scale in predicting the prognosis of APE patients were 0.818 (95% CI 0.712–0.925), 0.762 (95% CI 0.634–0.891), and 0.749 (95% CI 0.618–0.879), respectively, and the AUC of MPV and plasma NT-ProBNP combined with simplified Geneva scale in predicting the prognosis of APE patients was 0.907 (95% CI 0.826–0.988). The results suggested that MPV, plasma NT-ProBNP, and simplified Geneva scale have a certain predictive value for the prognosis of APE. Compared with a single index, the combination of the three indexes has a significant improvement in predicting the prognosis of APE, which has better clinical value.In summary, MPV, plasma NT-ProBNP, and simplified Geneva scale have a certain predictive value for the prognosis of APE. Compared with a single index, the combination of the three indexes has a significant improvement in predicting the prognosis of APE and has better clinical value. This study has the limitation of the small number of included cases, and the other influencing factors of patients were not comprehensively observed. Therefore, we need to collect a larger sample of cases for further verification in the future and exclude other factors for a comprehensive discussion of the prognosis.