Several studies have highlighted associations between adverse life events and the dysphoric character of dream experiences. This degree of continuity between waking-life and dream content seems partly attributed to the emotional and personal attachment linked to the incorporated waking experiences. Numerous changes in the processing of emotion-related stimuli are also reported across different human developmental stages. Therefore, we were interested in testing whether age would modulate the impact of recent troubling experiences on dream characteristics. Two hundred sixty participants, evenly distributed in five developmental stages, matched for gender and their exposure to a troubling experience, were selected from a large sample collected for a previous normative study of dreams of Canadians. Participants completed a dream questionnaire from which independent judges subsequently scored the dreams. We observed no interactions between the experience of troubling events and age. However, individuals who experienced a recent troubling event reported a higher frequency of nightmares and their dreams were more emotionally negative. Participants who experienced a moderately severe troubling event were also more likely to experience a dream whose maximal threat severity was of moderate intensity. Adolescents and young adults had dreams with a higher level of oneiric threats compared to older adults (>40 years old). Young adults also reported a higher frequency of nightmares compared to older adults. Our findings have implications for modern dream theories. They also suggest that dysphoric dreams might serve as potential proxies of mental health status and developmental stages. Future studies are now needed to explore the implications of these findings for psychological adaptation. There is evidence for a certain degree of continuity between waking-life and dream content. It is postulated that dream features reflect waking-life experiences and/or that dreams impact psychological adaptation. The former concern dream formation theories and the latter dream function theories. Several specific proposals on how this occurs have been formulated and fall under the umbrella of what is best known as the continuity hypothesis (CH) of dreams [see an overview by ]. ResearAlong the same line, stressful life experiences have been shown to be preferentially incorporated into dreams , 15. TheAccording to the Threat Simulation Theory (TST), dreaming is thought to have evolved as an adaptive mechanism to simulate oneiric threats drawn from waking-life experiences, and the repetition of these threats in dreams were thought to improve survival skills . AlthougNightmares are defined as elaborated and highly dysphoric dreams whose content is threatening and accompanied by intense negative emotions . While sAlthough there are no theories to explain these age-related differences, neurodevelopmental changes associated with brain maturation and aging may explain differences in perceptual processing and memory storage of negative stimuli. For instance, compared to older adults, adolescents demonstrate greater activity in areas of the brain responsible for processing emotions, specifically areas implicated in the fear response , when viewing negative stimuli –51. ThesAlthough associations have been found between adverse life events and the disturbing and threatening nature of dreams, it remains unclear if those who have experienced a common  and recent  troubling personal event would report more nightmares, have a higher level of threat and negative emotions in their dreams. Furthermore, the degree to which there is continuity between the severity of recent adverse events and the threat severity of dreams remains unclear in a community-based population. Finally, despite observations of age-related differences in negative dream characteristics, studies have yet to take a developmental approach.The main objective of the current study was thus to investigate the potential interaction between age and the experience of a recent troubling event on the dysphoric characteristics of dreams. In terms of dream characteristics, we were interested in the frequency of nightmares, the “threatening tone” of dreams, and the level of positive and negative dream emotions. We selected these variables as they measure the dysphoric experience of dreams at the level of monthly occurrence, actual threatening content, and emotions, respectively. Finally, our last objective was to assess which relevant dream theory  would best explain our findings.The CH  and TST The NMN , 38 propThe neurodevelopmental paradigm highlights multiple changes in the perception and processing of emotion-related stimuli from adolescence to older ages –63, and SD = 21.3) and were devised into five age groups according to key developmental stages: adolescence (12–17 years old), early adulthood (18–24 years old), adulthood (25–39 years old), middle adulthood (40–64 years old), and late adulthood (65 years old and older). There were 52 participants who were matched for gender and exposure to a recent troubling experience within the past year in each age group . Of those who experienced a recent troubling event over the past year, most experiences were categorized as psychological, social, or economic adverse events , followed by minor events , deadly , and physical . All age groups included 52 participants who were matched for gender  and their exposure to a troubling experience within the past year . Chi-square tests confirmed that the proportion of gender (χ2(4) = 0.25, p = 0.99) and exposure to a troubling experience (χ2(4) = 3.45, p = 0.49) were similar across age groups. The study was approved by the Research Ethics Boards (REB) at the University of Ottawa.Two hundred sixty participants were selected from a large sample collected between 2004 and 2017 for a normative study of the dreams of Canadians , 65. TheParticipants were recruited using the following approaches: through personal contacts at school boards, advertisements displayed at a Canadian university, advertisements on social media, at public presentations and conferences, at retiree associations, and word of mouth. All participants were unaware of the purposes of the study and provided written consent. After obtaining participant's consent, they were instructed to complete a dream questionnaire using pen and paper until at least two dreams were reported, for a maximum period of ten days. The dream questionnaire (DQ) included several sections, some of them described below are based on existing questionnaires, most notably on dream recall and nightmare frequency. No new validation procedure was applied. It was developed for the Normative Study of the dreams of Canadians that has led to several publications see –66]. The. The66)]The DQ included a sociodemographic questionnaire in which the participants were asked to provide a detailed account regarding general information about them . Participants also had to report whether they had experienced any troubling events  over the past year and, if so, to describe them.Next, the questionnaire required the participants to self-report their monthly frequency of nightmares, similar to the one for dream recall frequency, by checking one of the following categories: Less than once a month, Approximately once a month, Approximately once every two weeks, Approximately once a week, Many times a week, and Almost every night. These categories were recoded from 1  to 6  and were used to conceptualize the frequency of nightmares.SD = 84.68). After describing the dream, they were instructed to assess the degree of joy, happiness, apprehension, anger, sadness, confusion, fear and anxiety [the dream emotion categories used by Hall et al.  average measure parametrized for an absolute agreement definition. All ICC values ranged from 0.90 to 0.94, suggesting excellent reliability between the judge's scoring. The same procedure was undertaken for the scoring of the troubling events experienced within the past year. The ICC for the severity level of threats was 0.78, suggesting good reliability. Following the scoring phase, the first dream containing a minimum of 50 words and a maximum of 550 words was retained for analyses. Five participants (1.92%) were excluded from analyses as they reported dreams with an insufficient word count. Therefore, 255 participants were retained and included in the main analyses.post-hoc tests. To examine whether the severity of a recent troubling event is associated with severity of oneiric threats, a 3 by 3  chi-square test of independence was conducted in those who experienced a recent troubling event and had dreams that contained threatening events. Only those with a threatening dream were included in this analysis as we were interested in whether the severity of troubling events during wakefulness was associated with the maximal severity of threatening events in dreams. This allowed us to test the degree of continuity between the severity of threatening experiences during wakefulness and dreaming. Bonferroni corrections were applied to post-hoc comparisons (0.05/3 = 0.0166). All statistical analyses were conducted using IBM SPSS v27  and figures were created using GraphPad Prism v9 (2021) for Windows.For the main analysis, a series of 2 (recent troubling event: yes or no) by 5  between-subjects ANOVAs were conducted to examine the relationship between experiences of recent troubling events and age on the threatening tone of dreams, frequency of nightmares, and emotional levels of dreams (positive and negative). Bonferroni adjustments were applied to *Power . Some participants were missing data due to variations in questionnaire packages over the duration of the data collection period for the normative study and thus did not have the opportunity to self-report on all outcomes of interest in the current study. Univariate outliers were winsorized. There were no multivariate outliers. Assumptions for the 2 (recent troubling event) by 5 (age group) between-subjects ANOVAs for the main analyses for normality and homogeneity of variance were examined through scatterplots and tests of homogeneity of variance. The assumption for homogeneity of variance was met across all outcomes. There were minor violations of normality; however, transformations were not applied considering that analysis of variance tests are robust to non-normality  = 0.55, p = 0.815, F = 8.94, p = <0.001, F = 1.31, p = 0.269, p = <0.001; 65 years old or older: p = <0.001). Similarly, 18–24 year old's had significantly more severe and frequent oneiric threats compared those who were 40 years old or older . No other age differences emerged.A 2 (recent troubling event) by 5 (age group) ANOVA demonstrated a non-significant main effect of recent troubling event, F = 4.74, p = 0.030, F = 5.66, p = <0.001, F = 0.67, p = 0.614, p = 0.030; see p = 0.005; 65 years old or older: p = 0.002). No other age differences emerged.A 2 (recent troubling event) by 5 (age group) ANOVA demonstrated a significant main effect of recent troubling event, F = 1.22, p = 0.270, F = 1.00, p = 0.407, F = 1.12, p = 0.348, A 2 (recent troubling event) by 5 (age group) ANOVA demonstrated a non-significant main effect of recent troubling event, .005 see , a non-sF = 5.55, p = 0.019, F = 2.23, p = 0.067, F = 0.71, p = 0.588, p = 0.046 (see A 2 (recent troubling event) by 5 (age group) ANOVA demonstrated a significant main effect of recent troubling event, .046 see .N = 125), a 3 (severity of troubling event) by 3 (severity of oneiric threat) chi-square test of independence was conducted to examine the association between severity of the event and maximal severity of threats in dreams. This analysis revealed that the severity of a recent troubling event and severity of threats in dreams are significantly associated, X2(4) = 11.09, p = 0.026. Post-hoc comparisons demonstrated that recently experiencing a moderately threatening event during waking was significantly associated with moderate severity for the maximal threat in dreams, p = 0.002   . TogetheCollectively, our findings suggest that the disturbing character of dreams, at the occurrence- and content-level, seem to deplete with aging. One could nonetheless speculate that the reduction in dream recall observed with advancing age  might exThe main limitation of our study is the fact that the participants were not required to report the date of when the troubling experience took place in the preceding year. Therefore, it was not possible to control for the potential acute effect of the recency of the adverse experience on dream features. Future studies could thus specifically assess how the level of recency of troubling experiences progressively influences subsequent dreams' dysphoric nature and the temporal sources of these dreams . AdditioOur findings lend partial support to the CH and TST but seem to favor the NMN with respect to dream formation. One exciting result is the observation of a specific mixture of oneiric emotional intensities in individuals having experienced a troubling personal event within the past year. This mixture, composed of a heightened level of negative emotions with a “normal” level of positive emotions, could serve an adaptive emotion regulation function. Future studies should investigate whether such an emotional mixture in dreams would predict better outcomes for this population's following morning mood. Furthermore, our findings may have implications beyond the understanding of dream formation to the mental health and developmental fields. Indeed, we highlighted the impact of experiencing common and recent troubling events on oneiric negative emotions and the monthly occurrence of nightmares. The recurrence of nightmares can induce waking-life distress during the following day . HoweverThe 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 the University of Ottawa. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.AL, JD, KB, and HB all contributed to the conception and design of the study. AL, HB, and EC carried out the analyses of the dreams. HB wrote an Honors Thesis in French on the basis of part of this study and collated the data in preparation of the statistical analyses. KB, AL, and HB carried out the statistical analyses. AL, KB, and JD prepared the final manuscript. JD obtained the funding for the study and acted as mentor the work. All authors contributed to the article and approved the submitted version.This study was supported by a grant from the Social Sciences and Humanities Research Council of Canada.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.


Prevalence of mucormycosis is growing with the increase of the population at risk. Current recommendations for its management are mostly based on retrospective studies. 3 study aimed to present the cumulative experience of an Infectious Diseases Department from a Portuguese hospital in the management of mucormycosis and discuss the potential gaps in the diagnostic and therapeutic approaches of this infection.  For the purposes of the study, the electronic hospital database was searched for adult patients with mucormycosis from 1996 to 2019 based on the definition provided by the Consensus Definitions of Invasive Fungal Disease. Demographic, clinical, treatment, and outcome data were collected and compared to what had been described in the related literature.  In total, 15 cases of mucormycosis were found, including 11 cases with sinus involvement , two pulmonary, and two gastrointestinal infections. Diabetes mellitus (n=7) and corticosteroid therapy (n=7) were frequent risk factors. Median duration of symptoms before the suspicion of diagnosis was 26 days (3-158). The diagnosis was confirmed in 12 patients mostly by histopathology (n=9); the culture was positive only once. Systemic antifungals and surgical debridement were the backbones of treatment; however, side effects, the need for therapeutic drug monitoring, and the anatomical location of lesions added complexity to management. Overall, seven patients died, two of them before the consideration of clinical suspicion.  More medications are becoming available for the treatment of mucormycosis. Nevertheless, we believe that its prognosis will only significantly change through the increase of awareness and reduction of the time to diagnosis. An effective multidisciplinary approach among surgeons, infectious diseases specialists, radiologists, microbiologists, and anatomopathologists is critical to the achievement of this goal.  Mucormycosis is a rare invasive fungal disease responsible for significant morbidity and mortality in immunocompromised patients, especially those with haematological malignancies, hematopoietic stem cell transplant recipients, and patients who undergo chronic high-dose corticosteroid treatment  -9. PoorIt should also be noted that despite its rarity, it has been increasingly reported in recent years  , 8-10.Overall prognosis of mucormycosis remains remarkably poor, with an associated mortality rate of up to 80%, depending on the underlying conditions and presentation  , 11. DThe recommended approach to invasive mucormycosis is mostly based on retrospective studies  , 11. BThis study aimed to present the cumulative experience of a Portuguese tertiary care center regarding the management of patients with invasive mucormycosis and discuss the potential gaps in the diagnosis and therapeutic approaches while sharing an approach suggestion. For the purposes of the research, a retrospective observational cohort study was performed at the Infectious Diseases (ID) Department of a tertiary care center in Oporto, Portugal. Electronic hospital database was reviewed for cases of mucormycosis and all adult patients (18 years) admitted until April 2019 were included (the first case was reported in December 1996). Moreover, the clinical records were used to obtain the demographic and clinical data of the patients. The disease was defined based on the infection site, including sinus or rhino-orbital-cerebral mucormycosis (SM), pulmonary mucormycosis (PM), gastrointestinal mucormycosis (GM), cutaneous (CM), and renal mucormycosis (RM). Moreover, the central nervous system (CNS) involvement was considered if there was an intracranial extension, cavernous sinus thrombosis, or internal carotid infarction. The disseminated disease was considered if two or more non-contiguous sites were involved. Diagnostic criteria were based on the Consensus Definitions of Invasive Fungal Disease  . ProbabTherapeutic regimens were analyzed for antifungals, surgical debridement, and adjunctive therapies . Evaluated clinical outcomes were survival or death . Ethical considerationsThis study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the institution that waived the informed consent of the patients. In total, 15 IM cases were identified, 11 of whom had been diagnosed over the last 10 years (2010-2019). Median age of the patients was 53 years (interquartile range : 22)and 10 out of 15 cases were male. Both DM (n=8) and corticosteroid treatment (n=7) were frequent risk-factors. The SM was the most common presentation (n=11), mostly with CNS involvement (n=10); sinusitis and unilateral ophthalmoplegia were the most frequent complaints (n=8) followed by headache, visual loss, and other cranial nerve palsies (n=7). Overall, 6 out of the 15 studied patients required ICU admission for reasons other than post-surgical management: septic shock (n=3), neurological deterioration (n=1), ketoacidosis (n=1), and respiratory failure (n=1). The IM was confirmed in 12 patients, and the culture was positive only once. Suggestive histopathological findings were found in nine patients while in eight of them, it was the only evidence for the diagnosis. The PCR was performed on five patients and was positive in three of them. Patients reported symptoms for a median of 26 days  before mucormycosis was suspected. Amphotericin B (AMB) was administered to all patients as soon as the hypothesis of mucormycosis was raised except for one patient who was transferred from another hospital. The antifungals were administered to this patient only when admitted to our institution which was 66 days after clinical suspicion. It must be noted that AMB nephrotoxicity was the most common side effect. Whenever a switch to oral therapy was possible, posaconazole was the most used medication (seven out of eight cases). In total, eight, four, and three patients underwent surgical debridement, needed multiple procedures, and required radical surgery with orbital exenteration, respectively. It should be mentioned that five patients received solely antifungal therapy, two of whom had SM, PM, and multifocal extensive lesions; therefore, no benefit was expected from surgery. One of them who had PM died the day before surgery due to massive hemoptysis and another patient with SM had a prohibitive surgical risk; moreover, one GM patient was not considered for surgery. It must be mentioned that only the last two patients survived. In patients who survived the first month of treatment (n=9), the median duration of antifungals was 16.8 months . It must also be noted that seven patients died (47%), six of them directly due to mucormycosis, and two of them before the suspicion of the diagnosis (mucormycosis was diagnosed on necropsy). Rarity of invasive mucormycosis has limited the generalization of epidemiological findings based on the related literature  -7, 9. The DM was consistently reported as an important risk factor in previous studies as was the case in the present research as well  , 14. DCorticosteroids were also frequent (n=7); therefore, conditions less commonly associated with mucor-mycosis, such as autoimmune diseases, should not be disregarded and corticosteroid use should be actively sought. The reported increase in mucormycosis incidence over the last decades was also evident in our series since a higher than three-fold increase occurred between the 2000s and the 2010s  , 19. GIntracranial involvement is reported in up to 55% of SM cases  , 23. IBacterial coinfection is often present and, while antibacterial treatment is advisable, we warn against stopping antifungals whenever the clinical and imaging findings support mucormycosis, even if preliminary microbiological data is negative for fungi. In the present series, multiple invasive samples for microbiology and histopathology were often required before a diagnosis was made; meanwhile, only bacteria were isolated in biopsy specimens. In these patients, antibacterial treatment was prescribed; however, antifungals were consistently maintained. Diagnosis of mucormycosis is challenging and relies on a combination of a suggestive clinical picture, predisposing factors, compatible radiological findings, and histopathological and/or microbiological evidence of Mucorales which is highly dependent on the available techniques and trained personnel  , 24-26In SM, a computed-tomography scan usually reveals mucosal thickening  , 27 whDiagnostic confirmation usually requires invasive sampling of lesions for histopathology, culture, and PCR  , 16. WMolecular methods still lack standardization and clinical validation; however, they have been increasingly supported due to their high sensitivity and specificity  , 11. ADespite the fact that the sensitivity of the cultures is suboptimal, it was worse in this study than reported in the literature up to 79%) as was the sensitivity of PCR  , 7. We9% as wasEarly empirical antifungal treatment is essential to prevent disease progression and death  , 5, 7The AMB is one of the most consistently active medications against Mucorales, and liposomal-AMB (L-AMB) 5-10 mg/Kg/day is currently the first-line treatment with high doses recommended if there is CNS involvement  , 15. OAzoles were used in eight out of nine patients who survived beyond the first month after diagnosis with good overall tolerability except for recurrent phlebitis in one patient on intravenous (IV) isavuconazole and severe nausea and vomit in another patient on oral posaconazole. Some of the most challenging aspects of azole management are medication interactions, interference with food, and therapeutic drug monitoring (TDM)  . ConcerOne SM patient was responding to L-AMB; however, acute kidney injury and difficult-to-manage hypokalaemia prompted a switch to isavuconazole. After 20 days, the MRI showed disease progression, and a new switch to IV posaconazole was made followed by good clinical and radiologic responses, not requiring any other surgical procedure. Maintenance treatment with oral posaconazole in this patient required doubling the recommended daily dose to achieve therapeutic levels. Isavuconazole TDM is not recommended routinely   and wasThere is no data to support the standard combination treatment, and it does not warrant better outcome nor prevent surgical debridement; however, it can be considered while the diagnosis is not confirmed or as salvage therapy. Susceptibility to antifungals may differ between species since some have shown better response to combination treatment in vitro, such as Mucor irregularis; however, the clinical relevance of these findings remains unproven  . CombinTreatment duration is not determined; nevertheless, it usually requires weeks to months  , 4, 7In addition to AMB, surgery has been successful to decrease mortality rates, particularly in SM and PM cases. It may also be crucial for the reduction of the fungal inoculum since extensive thrombosis, tissue infarction, and necrosis prevent access of antifungals to the affected tissue  , 37. RThe HBO may improve neutrophil function and healing process, inhibit fungal growth, and promote AMB action; besides, although data are missing, it might be beneficial, particularly to SM and CM cases  , 3, 5The overall mortality rate in our series was 47% which is in line with those of other series4647%) [ 47%  6,, 23. DThe present study had some limitations since it was retrospective and based on clinical records from a long time ago. It must be noted that since then the knowledge, recommendations, and available diagnostic techniques or treatments  have significantly evolved. Moreover, the diagnosis was not available to the species level, nor was antifungal susceptibility testing. Nonetheless, given the unlikely availability of data from randomized studies in the near future, every effort should be made to share information that contributes to the expansion of knowledge about the disease and its optimal management. This study aimed to present our experience with this demanding disease, share our cumulative knowledge, discuss some difficult cases, and emphasize the importance of having this diagnosis in mind. Moreover, it aimed to underline the importance of a rapid and comprehensive approach to treatment and pursuit of a diagnosis. Many aspects still need to be optimized in the management of mucormycosis; for instance, diagnostic methods should become faster and more effective. Furthermore, broader access must be available to antifungal susceptibility profiles and TDM. However, the authors strongly believe that a closer collaboration among ID specialists, surgeons, radiologists, microbiologists, and anatomopathologists is key to the improvement of the diagnosis, treatment, and prognosis of such a challenging infection. Not applicable.B.P.L. and I.A. contributed equally to this manuscript as joint first authors. Conceptualization: B.P.L., I.A, A.C.C., L.S. Methodology: B.P.L., I.A., A.C.C. Investigation: B.P.L., I.A. Writing – Original Draft: B.P.L., I.A. Writing – Review & Editing: B.P.L., I.A., A.C.C., A.S., L.S. Supervision: L.S.The authors declare that there was no conflict of interest in this study.There were no sources of funding for this study.


In terms of disease progression , the results were much the same. At day 14, the rate of patients with a negative RT-PCR test was 21% higher (from 5 to 36% higher) for ivermectin recipients than it was for the controls . Three studies (736 subjects) indicated that prophylaxis with ivermectin increased the likelihood of preventing COVID-19 compared to controls . Serious adverse events were rarely reported. Conclusions. There is limited evidence for the benefit of ivermectin for COVID-19 treatment and prophylaxis, and most of this evidence is of low quality. Further evidence is needed to fine-tune potential indications and optimal treatment protocols for ivermectin as a treatment for COVID-19.Background. Ivermectin has received particular attention as a potential treatment for COVID-19. However, the evidence to support its clinical efficacy is controversial. Objectives. We undertook a new systematic review of ivermectin for the treatment and prophylaxis of COVID-19, including new primary studies, outcomes other than mortality, and grading the quality of the available evidence following the Cochrane guidance for methodology. Methods. We searched electronic databases, repository databases, and clinical trial registries (up to June 2021). The measure of treatment effect was risk difference (RD) with 95% confidence intervals (CIs). The GRADE system was used to assess the certainty of the evidence. Results. The review includes 11 RCTs (2436 participants). The certainty of the available evidence was quite low or very low due to risk of bias, inconsistency, and imprecision. When the analysis was limited to patients with baseline mild or moderate disease , there were no differences in mortality between ivermectin and control groups (low level of certainty); in patients with baseline severe diseases , the use of ivermectin significantly decreased mortality compared to the controls (RD −0.17; 95% CIs, −0.24/−0.10;  Several drugs have been considered for the treatment of SARS-CoV-2, and various unconventional treatments have been hailed as potential cures for COVID-19 ,4. One oIn the past year, ivermectin has received special attention as a potential drug for the treatment and prophylaxis of COVID-19. Indeed, a number of clinical studies have been conducted in various countries, and there is a remarkable number of trials registered with ClinicalTrials.gov and with other clinical trials registries . RecentlThis systematic review was conducted according to recommended PRISMA checklist guidelines  21]. Th. Th21]. A computer-assisted literature search of the MEDLINE (through PUBMED), EMBASE, SCOPUS, OVID, and Cochrane Library electronic databases was carried out (latest search 1 June 2021) to identify clinical trials for the use of ivermectin for COVID-19. A combination of the following text words and MeSH terms was used: COVID-19/SARS- CoV-2 AND ivermectin. We also searched preprint repository databases  and clinical trial registries  for study details and study results. In addition, we checked the reference lists of the most relevant items  in order to identify potentially eligible studies not captured by the initial literature search.Studies were selected independently by two reviewers (I.P. and M.C.), with disagreements resolved through discussion and on the basis of the opinion of a third reviewer (F.M.). This review included RCTs published in full or as preprint. Observational non-RCTs were not considered. Studies evaluating both outpatients and inpatients (stratified by the severity of COVID-19) were included.The investigation group included patients with confirmed COVID-19 receiving ivermectin ± standard treatment (ST) as defined in the individual study; the control group included patients receiving ST and/or placebo .Primary outcomes were overall mortality, progression to severe disease , and serious adverse events. Secondary outcomes included viral clearance and overall occurrence of adverse events. Where available, the outcome measures were reported in different follow-up periods. In studies evaluating prophylaxis, the outcome was efficacy of ivermectin compared to control in preventing COVID-19 among contacts.The following data were extracted by two reviewers (I.P. and M.C.) independently: first author, year of publication, regimens under investigation, outcome measures, and main results. Measures of treatment effect were mean differences (MD) together with 95% confidence intervals (CIs) for continuous outcome measures and risk differences (RD) for binary outcomes. Disagreement was resolved by consensus and by a third reviewer (F.M.), if necessary.2, Cochran’s Q, and 2I statistics. The 2I statistic describes the percentage of total variation across trials due to heterogeneity rather than sampling error. In the case of no heterogeneity (I2 = 0), studies were pooled using a fixed-effects model. Where values of 2I were >0, a random-effects analysis was undertaken.The study weight was calculated using the Mantel–Haenszel method. We assessed statistical heterogeneity using twww.handbook.cochrane.org, accessed on 18 August 2021) . Version 5.4, The Cochrane Collaboration, 2020) [We used the principles of the GRADE system  . These tn, 2020) . The GRAWe present the following outcomes in the ’summary of findings’ table: overall mortality, disease progression, viral clearance, serious adverse events, and rate of infection in prophylaxis studies.-Mortality and disease progression in ivermectin and control group according to baseline clinical conditions ;-Mortality in ivermectin and control group according to the intervention regimen , and according to ivermectin dosage;-Virological data according to the observation period ;-Comparative efficacy of ivermectin in preventing overall COVID-19 and infections stratified by clinical severity.We anticipated heterogeneity in the design and reporting of studies and, to deal with heterogeneity, we planned to carry out subgroup analyses considering specific patients or the characteristics of interventions that may have an effect . TherefoOnce sufficient trials were identified, we planned to carry out a sensitivity analysis comparing the results according to methodological quality .The search yielded 208 potentially relevant studies  were with high risk of bias for one or more domains, and all the studies were with unclear risk of bias for 1 or more domains .We assessed two studies as being with high risk of selection bias due to the randomization by alternation of the two treatments and because the intervention allocations could have been foreseen in advance ,30. The Performance bias. Four studies (36%) were reported as open label and were graded as high risk of performance bias (blinding of participants and personnel); four studies (36%) were graded as with unclear risk of performance due to the lack of the information required to come to a judgement about ‘high’ or ‘low’ risk of bias related to the blinding of participants and personnel. Three studies were reported as double-blind.Detection bias. No study provided the information required to come to a judgement about ‘high’ or ‘low’ risk of bias related to the blinding of outcome assessors, and were graded as with unclear risk of detection bias.Two studies were deemed as having unclear risk of attrition bias because of the lack of information on the number of patients that completed the study, or because a high proportion of enrolled patients (10%) did not complete the study. The remaining nine studies (81%) were deemed as having low risk of bias.Selective reporting bias was low in nine studies (81%). One study was deemed to have an unclear risk of bias, and one study with high risk .Nine studies were deemed with low risk of other bias, and two studies with unclear risk of other bias.A summary of the outcomes reported in the included study is provided in p = 0.17)  .p = 0.26) , there were no differences in mortality between ivermectin and control groups  . The quap = 0.00001). The quality of the evidence was deemed low (downgraded twice for severe risk of selection biases).When the analysis was restricted to studies or subsets of patients with baseline severe diseases  ,26,30, tp = 0.08). As in the previous analyses, the certainty of the available evidence remains low.In sensitivity analysis, after the exclusion of the study by Elgazzar et al.  in the sp = 0.48; moderate quality of evidence; downgraded once for imprecision)  ,27,43, iecision) .p = 0.04; low quality of evidence due to risk of bias and inconsistency). Ivermectin, in single dose or 2–5 daily doses, was used as 400 µg/kg dose in four trials [In studies comparing ivermectin plus standard treatment vs. standard treatment, there were 14 deaths among 681 patients receiving ivermectin, and 53 deaths among 619 patients receiving standard treatment . The GRADE assessment showed very low quality of evidence due to risk of bias, inconsistency, and imprecision. At day 14, the rate of RT-PCR-negative patients was significantly higher among ivermectin recipients compared to controls .At day 10, ivermectin did not significantly increase the proportion of RT-PCR-negative patients . The size of the effect was more evident in the high-risk population (severely ill at baseline)  compared to the low-risk population (mild/moderate diseases)   was observed less frequently among ivermectin recipients compared to controls  , Table 2Few participants were reported undergoing a serious event in either Ivermectin or control groups . This cop = 0.78)  .p < 0.00001; very low quality of evidence; downgraded for risk of bias, indirectness, and inconsistency . Ivermesistency .Other meta-analyses have specifically examined the role of ivermectin for COVID-19 ,17,18. OThe current review includes 11 RCTs and 2436 participants. Studies were grouped into two main comparisons: (i) ivermectin as treatment of COVID-19; (ii) ivermectin as prophylaxis of COVID-19 in household and/or healthcare personnel contacts with COVID-19 cases. The certainty of the available evidence was quite low or very low, and at best moderate.p = 0.04; low level of certainty due to risk of bias and inconsistency).Pooled data for ivermectin compared with controls suggest that once the analysis was limited to studies or a subset of patients with baseline mild or moderate disease , there were no differences in mortality between ivermectin and control groups (low level of certainty). When the analysis was restricted to studies or a subset of patients with baseline severe diseases , the use of ivermectin significantly decreased mortality compared to controls (low level of certainty). An assessment of low-certainty evidence means that our confidence in the effect estimate is low, and the true effect may be substantially different from the estimate. In subgroup analyses, we found that in studies comparing ivermectin alone to placebo, mortality was comparable: 1 death (in the control group) out of 467 patients enrolled . In studies comparing ivermectin plus standard treatment vs. standard treatment, there were 14 deaths among 681 patients receiving ivermectin, and 53 deaths among 619 patients receiving standard treatment  were much the same. On average, it is unclear whether or not the use of ivermectin compared to controls decreases disease progression in the low-risk population . These results do not provide a reliable indication of the likely effect, and the possibility that the actual effect will be substantially different is very high. On the other hand, the rate of disease progression was significantly lower in the ivermectin group compared to control, but the quality of the evidence is once again low.Notably, our data indicate that ivermectin is more active in reducing mortality and clinical progression among severely ill patients, suggesting that the clinical utility of ivermectin may reflect an anti-inflammatory activity of the drug in the late stage rather than an antiviral activity in the early stage of COVID-19. This anti-inflammatory activity has already been demonstrated in animal models of infection and seems to be related to the inhibition of inflammatory cytokines ,16. HoweAt day 6–10, it was unclear whether or not the use of ivermectin compared to controls decreased the rate of patients with RT-PCT-negative test . By contrast, at day 14, the rate of patients with negative RT-PCR test was 21% higher (from 5 to 36% higher) among ivermectin recipients, but the quality of evidence was low. An early decrease of viral load in ivermectin group compared to controls was demonstrated in the study by Samaha et al., but the authors reported the cycle threshold values of RT-PCR test and not the rate of patients with a RT-PCR-negative test; therefore, we could not pool these data with those of the studies included in the reviewResults from three studies (736 subjects) showed that prophylaxis with ivermectin increased the likelihood of preventing COVID-19 compared to controls . Serious adverse events were rarely reported both in ivermectin and controls.The quantitative analysis conducted in this systematic review has, however, several limitations that do not allow us to draw definite conclusions about the efficacy of ivermectin in this setting. An important limitation is certainly related to the heterogeneity of the studies evaluated, which encompasses both clinical and methodological heterogeneity. Differences between studies in terms of clinical factors, such as setting , severity of COVID-19, doses and administration schedule of ivermectin and comparators, and methodological factors such as bias in the selection of patients and in the assessment and reporting of outcomes, were common. Even so, in this systematic review, we have highlighted these differences and addressed heterogeneity using a random effect model and performing subgroup analyses. Another important limitation of this review is that the assessments of ivermectin for COVID-19 continue to be published in preprints and protocol repositories, which do not follow the recommended processes to ensure high quality standards for publications [50 value of ivermectin is much higher than the maximum plasma concentration achieved after administration of the above-mentioned three doses of ivermectin [50. On the other hand, it is also conceivable that the in vitro findings do not correlate with in vivo findings, and that concentrations of the drug in lung tissue do not need to reach the IC50 for clinical benefit [Another important issue to be considered in trials with ivermectin is the drug dosage. Well-controlled dose–response studies need to be considered to carry out a clinical trial of ivermectin. Schmith et al.  carried ermectin , and, as benefit ,44.In this review, we carried out a subgroup analysis, according to the dose of ivermectin administered, the approved 200 µg/kg dose, or a 400 µg/kg dose: in neither case were there differences in the mortality rate between ivermectin recipients and controls. There is some evidence that ivermectin is safe, even at higher doses and frequency regimens . Doses oThe latest version of the WHO living guidance and IDSA guidelines recommends against ivermectin in patients with COVID-19 regardless of disease severity, except in the context of a clinical trial ,49. More


Physical activity (PA) and sports are efficient ways to promote the younger generation’s health and wellbeing. However, evidence is limited due to heterogeneous samples and measurements. This study aims to identify promoting and inhibiting correlates associated with children’s and adolescents’ non-organized PA participation and further demonstrate the complexity of PA and ecological factors. A systematic review and meta-analysis will be applied by following the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Seven bibliographic databases  will be systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. Inclusion criteria are that the study: (a) is not classified as a systematic review with or without meta-analysis; (b) is published in last 20 years; (c) includes children and adolescents; (d) quantitively measures PA; (e) includes review of ecological factors. The internal validity will be evaluated using a validated quality instrument. Calculations will be produced in SPSS 27.0 and Comprehensive Meta-Analysis 3.3. This study will provide evidence and address the questions regarding the factors that significantly impact children’s PA participation and limitations regarding the design, sampling, and measurement in currently selected studies. PROSPERO registration number: CRD42021244918. Daily active play and physical activity (PA) have traditionally been an essential part of life for children and adolescents, and are highly recommended due to the associated health and environmental benefits ,2,3,4. HChildhood and adolescence represent important developmental periods where lifelong habits can be established to promote healthy lifestyles and reduce chronic disease risk in early adulthood . FrequenThe primary influential factors on sports and PA participation during childhood and adolescence are tightly related to their surrounding environment, which has commonly been examined through ecological frameworks ,16,25. TMcLeroy and colleagues  proposedFurthermore, the SEM provides a theoretical framework to examine multiple factors influencing PA behavior ,39. The In light of the variety of ecological frameworks, this study will align with Bronfenbrenner’s  ecologicThis review protocol has been registered in the PROSPERO international prospective register of systematic reviews; the registration number: CRD42021244918. The Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) will serve as guidelines for reporting present protocol and subsequent formal meta-analysis. Electronic databases served as the primary method of identifying eligible studies. Manual searches of relevant papers will be also carried out. The current study will also conduct backward reference searches of other reviews and consult with experts in physical education and health education.The search strategy included use of the following databases: PubMed, SPORTDiscus, PsycInfo, MEDLINE Complete,  ERIC, Dimensions, and Academic Search Complete. The search strategy will align with the guidance of the Cochrane handbook. Keyword combinations employed in the search are listed in We will only include original empirical studies, which should not be classified as a systematic review with or without meta-analysis, published between 2001 and 2021. Type of studies include two categories, randomized controlled trials (RCT) and observational studies . More specifically, we will include cohort, case control, interrupted time series, cross sectional, case series, case report, and other types of observational studies. Furthermore, only quantitative data will be extracted if any mixed-method studies meet the inclusion criteria. Participants will include those that are 3–18 years old based on the definition of the time period of childhood and adolescence by the US Department of Health and the Food and Drug Administration (FDA) and Bright Futures (American Academy of Pediatrics). Subjects older than 18 years at the start of the study will be excluded, as will children and adolescents who are affected by a particular disease, disorder, injury, or trauma at the time of the intervention. Considering that the longitudinal study may meet the inclusion criteria, we will include the study if participants are ages 3–18 years at the start of the study, even if they turn 19 during the course of the study.We will accept all types of influential factors regarding Bronfenbrenner’s  ecologicAccording to the World Health Organization (WHO), the definition of PA is, “any bodily movement produced by skeletal muscles that require energy expenditure” . In thisDuring the initial screening stage, two authors will select the title and abstract of the literature. Recording and managing related literature will be accomplished with Mendeley software . Next, two authors will review full texts of selected studies with the inclusion criteria. Finally, two authors will synthesize their screening results and determine the preliminary study pool. If a study meets the inclusion criteria but does not report results in the suggested variables, we will remove the study in the validation process because study outcome(s) should include relative variables. Accordingly, we will narratively review the excluded study’s method and conclusion in our perspective paper. The project administrator will serve as the coordinator, dealing with potential disagreements. In this way, internal discussions and then consultation with an experienced researcher in public health and physical education are considered two solutions for disagreements. The aforementioned selection and screening process will be depicted in the preferred reporting items for systematic review and meta-analysis (PRISMA-P) flowchart see .In the selecting process, included study will accord with the PRISMA-P statement. The authors will remove duplicate studies from different databases by evaluating titles and abstracts, and then evaluate full texts of the eligible studies. Finally, the authors will conduct qualitative and quantitative evaluations on inclusion studies .The Cochrane Collaboration’s tools will be applied to assess confounding, selection of participation, classification of interventions, deviations from interventions, missing data, measurement of outcomes, and selection of the reported results in selected RCT and NRS . Each ofTo the best of our knowledge, there are sufficient studies published in last two decades, so the likelihood of a meta-analysis is well-supported. In the follow-up meta-analysis, the review management software Comprehensive Meta-Analysis  and SPSS  will be applied. The meta-analysis will include four procedures: first, for data entry, obtain correlations between PA and ecological factors along with sampling error variances; second, for data screening, screen for outliers, defined as correlations whose residuals had z-scores either greater than 3.29 or less than −3.29: a z-score of ±3.29 cut off 0.1% of scores with 99.9% of z-scores lying between −3.29 and +3.29, the threshold of normal distribution in this protocol ; third, r could serve as the effect size index [r, means, standard deviations (SDs), sample size, F-tests, t-statistics, p values, and effect size (odds ratios) will be extracted. If these are not applicable, other relative statistics will be extracted, to calculate effect sizes (summary correlation ′r), 95% confidence intervals, and standard errors (SEs) of the corelates. All effect sizes will be converted to Fishers’ Z and then summary ′r to allow for comparisons across studies. Specifically, we will use the following procedure to generate the effect size. First, input extracted data into Comprehensive Meta-analysis software; second, the program will calculate correlations to Fisher’s Z transformation and perform the analysis using this index; finally, Fisher’s Z will be conversed back to summary correlation ′r as the effect size [r by assigning qualitative descriptors as follows: 0–0.3 as small, 0.3–0.6 as moderate, and 0.6 and above as large.Furthermore, we will categorize all articles and extract data from the final sample. In studies that reported a correlation between two continuous variables, the Pearson’s correlation coefficient ze index . In thisect size ,53,54. Tect size  will be 2 statistics. Applying the recommendation of Cushing et al. [p > 0.01, I2 < 50%. Otherwise, a random effect model will be applied due to the high level of heterogeneity if p < 0.10, I2 > 50% [The heterogeneity test between studies will be assessed regarding the Q and Ig et al. , a fixedI2 > 50% . In addiSubgroup analyses will be performed on individual characteristics  and ecological systems . The purpose of subgroup analyses is to specify the effectiveness of ecological systems and factors in influencing non-organized PA participation in children and adolescents.The researchers will apply the co-occurrence analysis to demonstrate the similarities and differences within the selected studies via VOSviewer . This pThis study will be based on findings of previous studies so that ethics approval is not required. Further, the results will be submitted to a peer-reviewed journal of the relative field for consideration of publication.Following a year of social restriction because of COVID-19, motivating children and adolescents back to physical and social activity should be considered a priority in the coming post-pandemic era. Completing this protocol will provide evidence regarding child and adolescent non-organized or spontaneous PA participation and engagement. Furthermore, we believe that this study may lead to several recommendations for caregivers, physical educators, policymakers, and pediatric researchers, such as elucidating the influence factors that are significantly correlated with child and adolescent PA participation; how effective they are; what different effects result from those factors acting on child and adolescent PA participation, especially across different genders and ethnicities.Predicting PA during childhood and adolescence is a complex topic. To the best of our knowledge, this will be the first comprehensive systematic review and meta-analysis to shed light on the effects of ecological and socioecological factors on child and adolescent PA participation. The current study will be key to providing evidence for future research in examining child and adolescent non-organized or spontaneous PA participation and multiple layers of ecological factors. This will also aid agencies and organizations in effectively motivating children and adolescents back onto the playground and to remain physically active, which should be considered as the priority in the post-pandemic era.


Encephalitozoon cuniculi is a microsporidium belonging to the phylum Microspora. A few reports have described the clinical significance of E. cuniculi infection in young dogs. In American and Japanese household dog populations, the seroprevalence was found to be 21%, indicating its wide-spread existence. To evaluate the clinical significance of E. cuniculi in a cohort of young dogs with neurological signs, the presence of the organism and possible response to treatment were studied. Over a 1-year period, all young dogs (<3 years old) that were referred with neurological signs were examined for the presence of E. cuniculi. Dogs were selected if serology revealed a clearly elevated IgM titer (>100) and/or if an EDTA-blood sample and/or urine sample tested positive by polymerase chain reaction (PCR). Sixteen dogs with various neurological signs were included in this study. Additional work-up included magnetic resonance imaging and cerebrospinal fluid analysis, but these revealed no abnormalities or indication of infection. All dogs were treated with fenbendazole for 10–30 days. Neurological signs disappeared completely in five dogs, 11 dogs continued to show neurological signs, and five dogs deteriorated and were euthanized, after which necropsy was performed in three. At necropsy no evidence of an E. cuniculi infection was found. We concluded that, although IgM titers and PCR indicated an E. cuniculi infection, it is most likely of limited clinical significance in young dogs. Encephalitozoon cuniculi is a microsporidium belonging to the phylum Microspora . The renal form is characterized by chronic renal failure and its sequalae, such as weight loss, polyuria, polydipsia, and/or urinary incontinence. The ophthalmologic form is characterized by intraocular lesions, including cataract, uveitis, and hypopyon .E. cuniculi in dogs is small, these reports concern young or immunocompromised dogs. The clinical signs observed are the same as those reported in rabbits and are renal .Over a period of 1 year, all young dogs (<3 years of age) that were referred to the Department of Clinical Sciences at the Faculty of Veterinary Medicine, Utrecht University, The Netherlands, were examined for the presence of www.uvdl.nl) as well as serology for toxoplasmosis and neospora  was performed. E. cuniculi was evaluated by obtaining additional serum, EDTA-blood, and urine samples; these samples were examined for the presence of relevant antibodies (IgM and IgG) and of parasite antigen by means of an immunofluorescence antibody test (IFAT) and polymerase chain reaction (PCR), respectively (see section Treatment and Response to Treatment), at a commercial veterinary laboratory .After obtaining informed consent from each owner, a normal diagnostic work-up was performed. In all dogs, a complete hematology and biochemistry panel , cerebrospinal fluid (CSF) analysis, electromyographic studies (EMG), and/or specific DNA testing, if indicated. If any abnormality was found that was indicative for a specific treatment , the dog was not eligible for this study.Dogs were only included if the routine biochemistry was free of abnormalities, if toxoplasmosis and neospora titers were found to be negative, and if additional work-up  did not exclude an infection as a possible cause of the neurological signs. Hence, if the MRI and/or CSF analysis was indicative of an inflammatory disorder, the dog was eligible for this study.E. cuniculi if serology showed a clearly elevated IgM titer and/or if the PCR of the EDTA sample and/or urine sample was found to be positive. The IgM was considered elevated if the value was 100 or more, while a titer of <30 was regarded as negative.Dogs were only included and defined as possibly infected with Included dogs were treated with fenbendazole only, at a dose of 50 mg/kg bodyweight, for a period of 10 days, after which the clinical outcome was evaluated , 14. If E. cuniculi were grown on Vero or MRC cells using RPMI 1640 medium under 5% CO2. After cultivation, the spores were harvested, collected, concentrated, washed, and brought to a concentration of 109, after which they were suitable for use in IFAT and a soluble ELISA antigen tests . The ELISA antigen was titrated on Greiner of Costar strip plates after production using a checkerboard titration, with known high  and low titer (~450) sera and anti-rabbit horseradish peroxidase . After determining the optimal coating dilution, ELISA plates were coated and blocked, stabilized, and stored. A mixed coating was used for standard ELISA research. As a substrate, a 2-component substrate RTU from the EVL laboratory (www.evlonline.org) was used (Cat: TMBA-2019-06 and TMBB-2019-06 from the EVL Laboratory). The reaction was allowed to proceed for 10 min at 21°C; then, the reaction was stopped by adding 50 μl of diluted H2SO4, and the absorbance of the colored solution was read at 450 nm.The three strains of 20). To test field samples, two HRPO-conjugates of IgM and IgG and different controls were used. IgM determinations were only made after pre-absorption of IgG. Titrations  of the obtained samples were performed with IgM, starting at 1:50.To assess the results, a sample ratio (positive control vs. standard method) or cutoff titer (TG-ROC plot) and 95% confidence interval was used. Batch validation was performed with pools of wild-type infected, type-selected, lyophilized sera (10www.evlonline.org). Conventional PCR was performed for type identification, while real-time PCR with ultra-black probes was also performed. Lyophilized infected cell cultures were used as controls at two levels of two different types of PCRs .The PCR was based on an internal transcribed spacer and/or protein tyrosine phosphatase gene sequences . Descriptive statistics and a Pearson chi-squared test were performed. Results were considered significant when the Forty-two young dogs (<3 years of age) were eligible for this study, but only 16 met the final inclusion criteria. The dog breeds varied, with no breed overrepresented. The age of onset had a median of 8 months (range 3–39 months). The duration of illness had a median of 1 month (range 1–15 months) .Neurological signs in 14 of the 16 dogs were suggestive of at least an intracranial neuro-localization . Twelve Routine hematology and biochemistry revealed some abnormality in all dogs. Fourteen dogs had a positive PCR in their EDTA-blood sample, of which one also a PCR-positive urine sample (no other dog had a positive urine sample) . Of thesIn nine of the 16 dogs, an MRI scan and CSF analysis were performed. None of the MRI scans revealed any abnormality, and CSF was regarded to be normal in all nine dogs .All dogs were treated according to the protocol. Five dogs responded to the treatment, of which two responded within 10 days, two within 20 days, and one during the third period of fenbendazole treatment. All five dogs had signs suggestive of a multifocal or generalized neurological disorder. Two of these responders had a negative PCR, but a clearly elevated IgM titer. Two had a positive PCR and elevated IgM and/or IgG, while one dog only had a positive PCR, but without IgM and IgG elevation.E. cuniculi infestation.Eleven dogs did not improve, regardless of treatment. All these dogs received a second course of fenbendazole, but as they did not respond, an additional treatment, based on the presumed diagnosis, was started. Only one out of these 11 dogs did respond after the additional treatment with an anti-epileptic. The condition of five of these 10 non-responding dogs deteriorated, and euthanasia was elected. Three of these dogs were necropsied, but in none of these cases was the histopathology abnormal, and there was no indication of an p = 0.39), CSF protein level (p = 0.43), or treatment outcome and period (p = 0.82).In all dogs, serology and PCR were repeated after either 10 (the five responding dogs) or after 20 days (the 11 non-responding dogs), and in all dogs the PCR was found to have become negative. There was no statistically significant difference for dogs that had improved compared to those that did not improve in terms of MRI findings  or by clearly elevated IgM titer (two dogs). The latter is suggestive of an immune response to the parasite, while the first demonstrates that the parasite was ingested. As most of our dogs had either an elevated IgM titer (6 of 16) or IgG titer (11 of 16), we concluded that there was an immune response to the parasite in these dogs. The clinical signs observed in the dogs were in accordance with previous studies , 10 and E. cuniculi infection. However, one report in a human case states that both CSF and MRI findings were clearly abnormal (E. cuniculi infection is also clearly abnormal with elevated cell counts as well as protein levels (Interestingly, the MRI scans and CSF analysis were normal in nine of the 16 dogs. There are no detailed reports describing MRI findings and CSF analysis in dogs with n levels ; this waE. cuniculi infection were observed. In rabbits, the diagnosis is confirmed if granulomatous inflammation with spores is found in renal, hepatic, and/or brain tissue at post-mortem (Interestingly five dogs improved after the fenbendazole treatment. Four of these dogs suffered from head tremor, which is also classified as an idiopathic head tremor , and is t-mortem , as alsot-mortem  and Snowt-mortem .E. cuniculi is a true pathogen in dogs. All dogs included into this study were infected with E. cuniculi, but MRI and CSF analysis revealed no abnormalities in nine of these dogs nor in the three necropsied dogs. And there was a lack of response to treatment in 11 dogs. Based on these results, E. cuniculi is most likely of limited clinical significance in young dogs.This study posed the question of whether E. cuniculi in dogs and rabbits in the Netherlands is not studied and therefore unknown. E. cuniculi as a disease in rabbits is frequently observed in the Netherlands but exact morbidity and mortality figures are sadly unknown. Secondly the study population is small. It may be of interested to perform this study together with a prevalence study in other countries as well. And if E. cuniculi was the cause of neurological signs in these examined dogs, the lack of response could be because of our choice of fenbendazole treatment. Rabbits suffering from E. cuniculi can be treated with fenbendazole or albendazole (This study has limitations. First of all, the prevalence of endazole , 14. Howendazole .E. cuniculi was found to be present in 16 dogs presenting various neurological signs. However, MRI and CSF analysis were not found to be abnormal in nine dogs, three dogs were necropsy-negative, and there was a lack of response to treatment in 11 dogs. Based on the current results, E. cuniculi is most likely of limited clinical significance in young dogs.The parasite The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because all dogs were referred cases with neurological deficits. Written informed consent was obtained from the owners for the participation of their animals in this study.TB performed this study as her master thesis. MD co-supervised and reviewed with PM the study. PM set up the study, examined all dogs, supervised, and reviewed the analysis. All authors read and approved the final manuscript.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.


Background: Myasthenia gravis (MG) is an autoimmune disorder of unknown etiology in most patients, in which autoantibodies target components of neuromuscular junctions and impair nerve to muscle transmission.Objective: To provide a synthesis of the evidence examining infectious agents associated with the onset of MG.Hypothesis: We hypothesized that microbes play a pathogenic role in the initiation of MG. For clinical cases, the onset of clinical signs is used as a proxy for the true onset of autoimmunity.Methods: We searched PubMed and Web of Science. Papers captured through database searching (n = 827) were assessed, yielding a total of 42 publications meeting the inclusion and exclusion criteria. An additional 6 papers were retrieved from the reference lists of relevant articles. For each pathogen, an integrated metric of evidence (IME) value, from minus 8 to plus 8, was computed based on study design, quality of data, confidence of infectious disease diagnosis, likelihood of a causal link between the pathogen and MG, confidence of MG diagnosis, and the number of infected patients. Negative IME values corresponded to studies providing evidence against a role for microbes as triggers of MG.Results: One hundred and sixty-nine myasthenic patients infected with 21 different pathogens were documented. Epstein-Barr virus (median = 4.71), human papillomavirus (median = 4.35), and poliovirus (median = 4.29) demonstrated the highest IME values. The total median IME was 2.63 , suggesting a general lack of evidence for a causal link.Conclusions: There was a notable absence of mechanistic studies designed to answer this question directly. The question of the pathogenic contribution of microbes to MG remains open. Myasthenia gravis (MG) is a T cell-dependent, antibody-mediated chronic autoimmune disorder in which autoantibodies attack components of the postsynaptic membrane and impair neuromuscular transmission, resulting in skeletal muscle weakness and fatigue . MG is tde novo. D-penicillamine, a drug used to treat rheumatoid arthritis, is the prototypical offending drug to induce MG (The etiology of MG is largely unknown. Thymic pathologies are frequently associated with MG. The major role of the thymus in the development of MG is supported by the facts that: (1) ~15% of patients with MG have a thymoma; (2) 50% of thymoma patients develop MG; and (3) thymectomy improves the clinical symptoms in some MG patients . Anothernduce MG . There induce MG .Infectious agents have been suspected as a primary external trigger for autoimmune disorders. Multiple studies have reported pathogens associated with MG; however, no study to date has compiled the evidence for infectious agents in the onset of MG in a systematic fashion. Our aim was to compile all the scientific information referring to infectious agents and the onset of MG to interrogate evidence for a causal relationship. All articles that satisfied the inclusion and exclusion criteria were scored using a unique and unbiased equation, yielding integrated metric of evidence (IME) values. Numerical IME values were calculated to assess and categorize the level of evidence supporting the research question.*) AND ], denoted as A1, were manually assessed to determine if they met the inclusion criteria, described in We searched two databases (Web of Science and Medline) for relevant primary research. Articles captured by the search algorithm [(myasthenia gravis) AND (pathogen OR infection = 44) as defined in the inclusion criteria, >1 pathogen associated with MG (n = 7), lack of infection in myasthenic patients (n = 57), failure to describe the specific pathogen associated with MG (n = 3), use of same data as previously published work (n = 2), or full text unavailable (n = 4)  .We developed a unique equation to assess study design (D), the quality of the research paper (Q), the confidence of infectious disease diagnosis (C), the likelihood of a causal link between the infection and MG (L), the confidence of MG diagnosis (I), and, lastly, the number of patients with the given infection (N). For each pathogen identified in a paper, an integrated metric of evidence (IME) was calculated as a sum of normalized scores: IME = 2D + Q + C + 2L + I + N. Each value was weighted according to our assessment of its relevance to evidence rating. The D score determines the accuracy of reported results and conclusions of the paper and L score corresponds directly to the research question. D and L scores were assigned higher weighting in the IME calculation given their relative importance in assessing evidence for a causal relationship between infectious agents and MG. A maximum normalized score of 1 was assigned for each value by dividing the given scores by the highest potential score for the value, yielding a total maximum IME value of 8. A negative score was applied to papers providing evidence against infection as a cause of MG by multiplying the calculated IME value by −1. Individual patients infected with >1 pathogen were not assigned an IME value, and were excluded. The most conservative scores were applied for each criterion to avoid inflation of IME values. Threshold IME values were determined to categorize pathogens as having negligible, low, intermediate, or high evidence for a causal relationship with the onset of MG. The threshold between negligible and low was taken to be a hypothetical retrospective case report, with a Q score of 14, intermediate C, L, and I scores, and 1 positive case (IME = 2.79). The threshold between low and intermediate was taken as a hypothetical cross-sectional study with a Q score of 24, intermediate C, L, and I scores, and 2–5 positive cases (IME = 4.17). Lastly, the threshold between intermediate and high was taken as a hypothetical prospective cohort/case-control study with a Q score of 28, high C score, intermediate L score, high I score , and 2–5 positive cases (IME = 5.58). Further information on the IME value calculation is provided in Ten references were randomly selected from the pool of included articles and independently scored by OAG, VL, and AP. Agreement between reviewers was evaluated using interclass correlation and necessary adjustments were made to the scoring system to avoid misinterpretation. References were re-valued by all reviewers once the necessary changes were made.The diagnosis of MG is heavily dependent on the history and physical examination of the patient. Muscle weakness or fatigue is often the first indication of disease, which is then followed by a blood test to determine the presence of anti-AChR or anti-MuSK antibodies. Positive detection of anti-AChR or anti-MuSK antibodies through radioimmunoassay, enzyme-linked immunoassay (ELISA), and/or cell-based assays (CBA) is considered diagnostic for MG .Elevated concentrations of anti-AChR or anti-MuSK antibodies confirms MG diagnosis; however, a normal titer does not exclude disease. A number of patients demonstrating muscle weakness do not have detectable AChR or MuSK antibodies and are classified as “double seronegative.” Repetitive nerve stimulation studies (RNS) and single-fiber electromyography (SFEMG) compatible with a postsynaptic NMJ disorder is supportive of MG, provided that no other causes of muscle weakness can be identified  14)..14).To ensure that the qualitative assessment of papers was robust and unbiased, 10 references from the pool of included articles were randomly selected using a random number generator. Papers were scored independently by all reviewers. The intraclass correlation coefficient for the dataset of assigned IME values was 0.97, with 1 being perfect concordance between scores. For the majority, the IME values of individual articles assigned by each reviewer fell within 0.5 points of each other, demonstrating excellent reliability of the scoring system .Leptospira interrogans, West Nile virus, Zika virus, hepatitis E virus, Leishmania infantum, Varicella-Zoster virus, hepatitis C virus, human polyomavirus 7, human T lymphotropic virus type III, Clostridium botulinum, Merkel cell polyomavirus, and hepatitis B virus were all documented in associated with MG, but provided low to negligible evidence supporting a causal link between the pathogen and MG  , 38. TheG titers .One study demonstrated the presence of human papillomavirus (HPV) in 11 patients diagnosed with thymoma-associated MG . Thymic Infections are thought to play a major role in the development of autoimmune disease. Microbes can potentially provoke the immune system to react to self-antigens by molecular mimicry (cross-reacting epitope between the foreign antigen and the host), bystander activation (the activation of autoreactive immune cells by antigenic non-specific mechanisms during an infection), epitope spreading, and viral persistence  , 64. It in vitro and in vivo studies have demonstrated that the production of latent EBV proteins stimulates the expression of Bcl-2, an antiapoptotic gene (Bcl-2 hinders B cell tolerance and is suspected to contribute to autoimmunity by inducing clonal expansion of autoreactive B cell populations (There is an overall intermediate level of evidence that Epstein-Barr viral infections, particularly within thymic tissue, is associated with the development of MG , 43, 62.tic gene . Expressulations . The isoulations , 16, 18.in vivo and in vitro studies (The implications of human papillomavirus and poliovirus in the etiology of MG are each supported by a single study. Both studies measure the presence of the pathogen and markers of inflammation , 54. The studies . Chemoki studies . The ove+ T cells, suggesting a correlation between infection, Vβ CD8+ T cells, and MG. While the pathogenic role of CD8+ T cells in human MG has yet to be elucidated, in vivo rat studies have demonstrated their necessity in this rodent model of MG. CD8-depleted rats were remarkably less susceptible to experimental autoimmune MG than normal rats (+ T cells are speculated to play a role in the onset of MG through epitope spreading, in similar fashion to that demonstrated in a humanized model for multiple sclerosis (+ T cells, and the development of MG is lacking.Finally, the association between MG and CMV was documented in two studies, with only one falling within the intermediate level of evidence range , 38. Myamal rats . CD8+ T clerosis , 72. OncOverall, multiple pathogens have been associated with the onset of MG, with Epstein-Barr virus, human papillomavirus, and poliovirus presenting the most compelling evidence for a causal link. However, no pathogen has been proven to cause MG and further studies are required to establish the role of infections in the etiology of MG. Observational studies such as prospective cohort and prospective case-control studies, involving larger sample sizes, multiple clinics and institutions, and clear inclusion and exclusion criteria, with appropriate statistical analysis, must be conducted to establish a stronger correlation between a specific pathogen and MG. Mechanistic studies, which provide the highest level of evidence, will ultimately be required to establish causality.The original contributions generated for the study are included in the article/VL assessed the relevance of all abstracts and full texts, analyzed and interpreted the results, and wrote the first draft of the manuscript. OG and AP analyzed and assessed a subset of articles to ensure concordance of scores. OG and Y-MC developed the scoring system. Y-MC created the figures. OG and JL conceptualized the idea for the manuscript. OG, JL, and Y-MC edited the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Depression remains an important health problem among older adults and it may be correlated with the deterioration of physical fitness, whose chief indicator is hand grip strength (HGS). The aim of the study was to investigate the relationship between depression and HGS among older populations using the available literature. Methods: PubMed, Web of Science and Science Direct databases were searched. The inclusion criteria were as follows: written in English and published after 2009, subject age: ≥60 years, HGS measured using a hand dynamometer, assessment of the depressive symptoms using a validated tool. The following articles were excluded: studies conducted among institutionalized subjects and/or populations with a specific disease. Results: The total combined effect of 33 results presented in 16 studies included in the meta-analysis, converted to the correlation coefficient, was OEr = −0.148 , indicating a weak, negative correlation between HGS and depressive symptoms. Conclusions: The review of the literature and the meta-analysis demonstrated a relationship between low muscle strength and intensified depressive symptoms in older populations. Bearing in mind that depression is often unrecognized or underdiagnosed among older patients, lowered muscle strength should be an important sign for physicians and an incentive to screen them for depression. Depression remains an important health problem among older adults, resulting in lower cognitive ability and quality of life . AccordiAccording to a number of studies, as many as 80% of older people are affected by at least one somatic condition ,4, and 6On the other hand, an equally impressive amount of data demonstrated that higher cardiorespiratory fitness and regular aerobic exercise prevent the development of depression among older individuals . AccordiAccording to the available literature, a relationship between low muscle strength and cognitive function impairment and the risk for developing neurodegenerative diseases such as Alzheimer’s or Parkinson’s disease has been confirmed . FurtherThe impact of depressive symptoms on HGS has been investigated for various age groups. In a systematic review , summariThe aim of the study was to investigate the relationship between depression and HGS among older populations using the available literature.The review of the literature and the meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The proPubMed, Web of Science and Science Direct databases were searched. An algorithm with key words (‘handgrip strength’ AND ‘depression’ AND ‘older’ OR ‘elderly’) was used to identify the publications. Additionally, the reference sections of the included articles were manually inspected to identify additional records. Two authors (EZ and TT) conducted their independent searches between 1 January 2010 and 17 January 2020. Only articles published in English were taken into consideration.The inclusion criteria for the reports were as follows: (a) written in English and published after 2009, (b) subject age: ≥60 years, (c) HGS measured using a hand dynamometer, (d) assessment of the depressive symptoms using a validated tool.The following articles were excluded: studies conducted among (a) institutionalized subjects and/or (b) populations with a specific disease, e.g., malignancy or carpal tunnel syndrome.All articles were independently analyzed by two authors (E.Z. and T.T.) to remove duplicates. The results were reviewed, and full versions were checked for compliance with the inclusion and exclusion criteria. The following data were extracted from each study: first author, year of publication, study population characteristics, study design, inclusion/exclusion criteria, method of assessing HGS and depressive symptoms, assessment of the outcome, and results. Next, methodological quality standards and risk of bias  adapted for cross sectional studies were investigated . NOS assn = 12). The linear regression method allowed to control for the effects of mediator variables such as age, sex, education, and others, and that is why these values represent a partial effect of HGS on the level of depression. We converted these values to r_eq using the formula n = 9) measure. The tables were prepared based on the threshold values for the number of depressive symptoms and according to the generally accepted thresholds for HGS or the thresholds calculated using the Receiver Operating Curve (ROC). We converted these values to r_eq using first the formula n = 4), correlation (n = 2), contingency coefficient , standardized beta value  and d Cohen . In two cases, the identified texts did not report the effect size but only the p-values. Given the sample size and assuming test power of the analyzed studies (1 − β = 0.80), the minimal effect was calculated . The total effect for the relationship between depressive symptoms and HGS was not described in six studies—the results were presented for groups with varying levels of depression and different sex groups, but it did not differentiate the total effect .The collected results had been presented in various ways and had to be converted to the correlation coefficients. The highest number of relationships between depressive symptoms and HGS was expressed as beta coefficients, obtained by the linear regression analysis (p = 0.493).Most studies did not present sex-stratified data as they used statistical measures which allowed to control for sex, but also other variables. Nevertheless, nine results were related to male subjects only, also nine to female subjects only, and eleven to male and female participants. No statistically significant differences in the effect size were found between these groups  = 0.741, p < 0.001) and revealed high heterogeneity of the results. The I2 index was 92.3%, which justifies the use of the random effects model in the meta-analysis.Statistical analysis was conducted using the Jamovi software (2020), Jamovi project, Sydney, Australia, with the Viechtbauer metaphor package . PublicaOut of 473 records identified during the database search and 21 additional records identified after reference list search, a total of 16 entries ,32,33,34The methodological quality of all included studies was sufficient . The higOverall, the results of 19,637 subjects  were presented in the meta-analysis. The GDS-15 scale was the most commonly used tool for evaluating depression in older patients (8 studies) ,32,33,34The total combined effect of 33 results presented in 16 studies  includedp = 0.881) and Kendall’s τ coefficient  showed no publication bias.Potential publication bias was tested via funnel plot . Egger’sThe Fail-Safe N coefficient, according to the Rosenberg algorithm, indicates that a 2932 of texts with null effect would need to be included in the selection for the total score to reach zero. Sequence analysis  of the rThis systematic review and meta-analysis of 16 studies involving 19,637 individuals aged ≥ 60 revealed a weak negative correlation between HGS and depression. The GDS-15 scale was the most commonly used tool for evaluating depression in the analyzed publications. According to Friedman et al.  GDS has In recent years, HGS has been perceived as a reliable indicator of the whole-body muscle strength, physical function, and health status, as well as a predictor of the length of hospitalization and even mortality for older populations, and has been investigated by a number of authors ,42,43. AHGS test is also used to assess physical and functional fitness in older people. Vasconcelos et al.  investigp = 0.021).Chen et al.  investigHGS allows to predict mortality among older populations, especially the ‘oldest’ old ,31. AddiDepression in older people is associated with more functional and cognitive impairment than in younger adults . HolmquiDepression is one of the multiple geriatric syndromes ,45. SeinIn our meta-analysis, we also took into consideration research of Korean authors, who studied a relationship between blood cadmium levels and HGS and depressive symptoms. Higher HGS values were associated with a lower number of depressive symptoms, assessed with the Korean Version of the GDS-short form .Out of the 16 texts which were deemed eligible for the meta-analysis, only two aimed to establish the relationship between HGS and depression ,24. Han The fact that the modified NOS scale was used to analyze the quality of the studies, due to the lack of a more adequate tool to evaluate cross-studies, was a certain limitation of our study.To sum up, the review of the literature and the meta-analysis demonstrated a relationship between low muscle strength measured with the HGS test and intensified depressive symptoms in older population, even though they were merely the additionally analyzed variables in the vast majority of the included texts.Bearing in mind that depression is unrecognized or underdiagnosed in approximately 16% of the older patients , loweredThe mechanism linking HGS with depressive syndromes remain to be fully investigated. Their interdependence is a complex matter, indicating a strong two-way interconnection and the need for further studies to elucidate the matter.