Schistosoma mansoni infections in children aged 9–12 years, each year their village received MDA. Baseline and year 5 assessments of first-year students and adults were also performed. Using Poisson and negative binomial regression with generalized estimating equations, we found similar effects of CWT and SBT MDA treatment strategies in children aged 9–12 years: significant reductions of prevalence of infection in all arms and of heavy-intensity (≥ 400 eggs/gram) infections in most arms but no significant differences between arms. Combined arms of villages that received four rounds of treatment had greater reduction than villages in arms that only received two rounds of treatment. Surprisingly, we also found benefits of SBT for first-year primary students and adults, who never received treatment in those arms. Our data support the use of annual SBT for control programs when coupled with attention to infections in younger children and occasional treatment of adults.We conducted a cluster randomized trial comparing the target population and timing of mass drug administration (MDA) with praziquantel for control of schistosomiasis in villages in western Kenya with high initial prevalence (> 25%) according to a harmonized protocol developed by the Schistosomiasis Consortium for Operational Research and Evaluation. A total of 150 villages were randomized into six treatment arms (25 villages per arm), were assessed at baseline, and received two or four rounds of MDA using community-wide (CWT) or school-based (SBT) treatment over 4 years. In the fifth year, a final evaluation was conducted. The primary outcomes were prevalence and intensity of  By providing regular MDA to at-risk populations, infection levels of these neglected tropical diseases (NTDs) can be reduced to a point where the force of transmission is reduced and morbidity is moderated.3 other programs such as schistosomiasis control still have important operational research questions that require attention. This is in part due to the longer time that donated drugs used for treating lymphatic filariasis  and trachoma (azithromycin) have been available. However, in recent years, generous donations from pharmaceutical companies, governmental bodies, and private foundations have made it possible to begin widespread MDA for schistosomiasis using praziquantel.The programs for different NTDs are at various stages of maturation. Whereas lymphatic filariasis and blinding trachoma have fairly well-defined strategies for where to initiate MDA, how to track progress, and when treatment can be stopped,4 A primary goal of SCORE has been to identify the most effective strategies for reducing prevalence and intensity of schistosome infections in endemic areas with different initial prevalence of Schistosoma mansoni or Schistosoma haematobium through randomized trials to compare MDA frequency and target population. We conducted one of the SCORE studies in 150 villages in western Kenya with high baseline prevalence (> 25%) of S. mansoni. Over a 5-year period, we compared the impact of MDA provided at the community or school level either annually or with intervening years. Assessments of infection prevalence and intensity in children aged 9–12 years were performed at baseline, each year MDA was provided, and a final evaluation was conducted. The studies focused on school-aged children (SAC) because this is the age-group that typically has the highest infection levels. In addition, infection levels in community adults and first-year students were assessed at baseline and the final evaluation to determine what effect MDA may have on infection levels in the larger community.In part to address the unanswered questions about best methods for schistosomiasis control, the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was formed.This study was reviewed and approved by the Scientific and Ethics Review Committees (ERCs) of the Kenya Medical Research Institute ; the Institutional Review Board (IRB) of the CDC (protocol #6016) relied on the KEMRI ERC. Administrative review and approval was also provided by the IRB of the University of Georgia. Written informed consent was obtained each year of the study from participants or guardians of participants younger than 18 years, and assent was obtained from children. The trial was registered with the ISRCTN (#16755535).4 In brief, villages were eligible for inclusion if at least 25% of 50 sampled 13- and 14-year-olds were positive for S. mansoni eggs by the Kato–Katz method in at least one of two fecal smear slides prepared from a single stool sample. The 150 eligible villages were then randomized into one of 6 treatment arms of 25 villages each , each treatment year, and at final evaluation (year 5). Sample collection from children took place at a village’s primary school. If there were more than 100 children eligible for inclusion in a village, enrollment records were used to generate a random list to recruit participants. Children not attending school were also invited to come to schools on sampling and MDA days. However, because primary education is free in Kenya and > 95% of the eligible population attends school, the sample was effectively from all school-aged children.5Participating children were assigned a unique identification number and provided with a corresponding barcoded stool collection cup each morning over 3 consecutive days. Returned stool samples were used to prepare two slides per stool according to the Kato–Katz method. Thus, up to six slides were prepared per student, although not every student was able to produce a stool sample on every day. Trained microscopists enumerated the number of eggs per slide and calculated the eggs per gram feces (EPG). For the estimation of prevalence, a child was considered positive if a schistosome egg was identified on any slide. Infection intensity was the average EPG from all slides examined for a given individual and was categorized as light (< 100 EPG), moderate (100–399 EPG), or heavy (≥ 400 EPG) according to WHO guidelines.In each village, at years 1 and 5, three stool samples were also sought from 100 first-year students as was a single stool sample from 50 adults aged between 20 and 55 years. First-year students were recruited in the same way as 9–12-year-old children and sampled at primary schools. Adults were recruited at their homes with the assistance of community health workers and village elders using a random sample of census data.All treatments were recorded in treatment booklets to determine the reported treatment coverage. Coverage for SBT was estimated by dividing the number of children who received treatment at the school by the total school enrollment, with a target of treating at least 90% of the students. For CWT, the number of people who received treatment was compared with the village census, with a targeted coverage of ≥ 75%.4 In brief, sample size calculation assumed a binomial model with generalized estimating equations (GEEs). A baseline prevalence of 50% was assumed for all arms. For a two-sided test with a 5% level of significance, 25 villages per arm and 100 children per village provide 90% power to detect a difference between a target level of 15% for the most intense treatment arm and an absolute difference of 11.4%. These calculations assumed an over-dispersion parameter of 5.0 and a trivial correlation between observations at years 1 and 5.Sample size calculations are detailed by Ezeamama et al.6 Comparisons between arms were performed with negative binomial regression with GEEs, with an exchangeable correlation structure.7 Results are reported as a prevalence ratio (PR) and 95% CI when analyzing S. mansoni infection prevalence or an arithmetic mean ratio (AMR) and 95% CI when analyzing S. mansoni infection intensity in EPG. Adjusted models controlled for age and gender. Comparisons between individual arms assessed the change from year 1 to year 5 to account for differences at baseline. In the analyses comparing four and two treatments, summary statistics indicated similar prevalence at year 1, thus only year 5 was evaluated. Mixed models were used to calculate interclass correlation coefficients and design effects.9 All results from regression models reported in the text control for age and gender.All analyses were performed at the individual level, used the 5% level of significance, used SAS version 9.3 , and accounted for community-level clustering of infections. Basic summary statistics  accounted for village-level clustering via Taylor series linearization.10 These models were implemented with the same methodology described earlier.Aforementioned models were also fit without villages contained within a hotspot of elevated infection found in spatial analyses of the data.Supplemental Table 1). Overall prevalence and prevalence of heavy- (≥ 400 EPG), moderate- (100–399 EPG), and light-intensity (1–99 EPG) infections were calculated for each year stool data collected . Treatment coverage data are shown in Assessments for inclusion were conducted in 358 villages to identify 150 eligible villages that were randomized into six arms of 25 villages each . Numbersollected . In all P = 0.008).There was a larger than expected within-arm variability among villages in year 5 prevalence  and meanOnly first-year students living in villages in arm 1 would have received MDA in year 4. Nevertheless, at the final evaluation in year 5, the prevalence for all arms and intensity in five of six arms were lower than those at baseline , althougP < 0.0001), and the prevalence of heavy-intensity infections and overall infection intensity were significantly lower in five of six arms at year 5 than those at year 1 (P = 0.92) and adults  and intensity (P ≤ 0.002) of S. mansoni infections in 9–12-year-olds over the time of the study within each arm. There were also significant differences in 5th year prevalence  and overall prevalence reduction from year 1 to year 5  between arms 2  and 4  compared to arms 3, 5, or 6. Furthermore, although there was only roughly a 50% decrease in prevalence from year 1 to year 5 for most arms when all villages were included (P < 0.001) than the change seen in the villages that received only two rounds of treatment . The prevalence and intensity of infection at year 5 was also significantly lower for the combined arms receiving four rounds of MDA than those that had only received two . For all arms, the prevalence of heavy-intensity infections after hotspot village removal was less than 1%, the current WHO target for elimination of schistosomiasis as a public health problem.The high within-arm variability in prevalence  and infeanalysis  resultedincluded , when ho11 However, despite generous donations from pharmaceutical companies, government agencies, and private foundations, the quantity of praziquantel available still falls well short of the global demand, especially for adult populations. The need to use limited resources as efficiently and effectively as possible was part of the stimulus for the SCORE projects comparing different frequencies or recipient populations of praziquantel MDA. We found that both annual or biennial MDA distributed in schools (SBT) or at the community level (CWT) had roughly similar benefits, with significant decreases in overall prevalence and prevalence of heavy-intensity (≥ 400 EPG) infections in school-aged (9–12-year-old) children after two to four rounds of MDA. Although there were no statistically significant differences between individual arms, by analyzing combined data from children aged 9 to 12 years, we found that the arms that received a total of four rounds of MDA had significantly lower prevalence at the final evaluation than the compiled data from arms that only received two rounds of MDA during the study.The distribution of MDA for schistosomiasis has increased substantially since the adoption of World Health Assembly Resolution 54.19 in 2001, with coverage levels for SAC approaching the target goal of 75%.12 and parallel studies in villages with > 25% initial S. mansoni and S. haematobium prevalence conducted in Tanzania and Mozambique, respectively.14 The lack of statistical differences in prevalence in 9–12-year-olds between individual arms may in part reflect a much higher design effect  than anticipated when the study was planned. Although schistosomiasis is known to be a highly focal disease, the very large interclass correlation (40%) observed in this study practically precludes the ability to detect significant differences between individual arms. Thus, should similar studies be performed in the future; it will likely be necessary to have a much higher number of villages per arm, fewer arms, evaluations at the village-level, or a completely different approach.The finding of statistically significant decreases in prevalence over time within arms but no statistical differences between individual arms is similar to the results for SCORE evaluations we performed in Kenyan villages with 10–24% initial prevalenceS. haematobium, and the investigators also attributed it to reduced rates of transmission.14One surprising result from the study was the dramatic reduction in infection prevalence and intensity in the adult population, even in arms in which only SBT was administered. There were also reductions in the infection levels of first-year students at year 5 compared to year 1, although most of these changes were not statistically significant. As with the adults, the reductions were similar for SBT only arms, where these individuals would not have received treatment before their entry in to school, compared with CWT arms. The reduced infections in the non-SAC study participants at year 5, even in SBT arms, may reflect decreases in the force of transmission as a result of lower levels of SAC infection, leading to fewer eggs excreted into the environment and a smaller number of snails becoming infected. This could contribute to fewer infections because of decreased concentrations of cercariae in the waters where individuals are exposed. The SCORE study in Mozambique observed a similar reduction in adult infections with S. mansoni worms are estimated to have a 5.7 to 10.5-year life span.15 Thus, the 60–75% reduction of infection we observed in adults not receiving treatment is greater than would be expected even if transmission rates were drastically reduced. In reinfection studies, older adolescents and adults have changes in their immune responses that confer greater resistance to reinfection than children and early adolescents.18 Although these immune responses have previously been defined in relation to reducing infection with new cercariae, our data suggest they could also affect existing worms. Additional investigations will be needed to confirm or refute this hypothesis. Nevertheless, MDA benefits for non-treated groups in both S. mansoni– and S. haematobium–endemic areas is a welcome finding for schistosomiasis control programs.These data are also consistent with host immune responses contributing to earlier worm death. Adult 20 resulting in better coverage rates in the last 2 years. We were also not always able to recruit the desired sample size to measure infection, especially in the early years of the study and among first-year students as there were fewer potential participants of this age. However, we do not anticipate that this had a large influence on study outcomes given the high degree of correlation within villages that we observed.In addition to the higher than expected design effect, other limitations of our study included the lower than targeted coverage rates, especially among SAC in CWT arms during the first two years. Once we identified these shortfalls, we increased our training of community drug distributors as well as our communication efforts,21 inclusion of adults for 1 or two rounds of treatment followed by SBT (such as employed in arm 2) may be the strategy with the best cost to benefit ratio. However, because preschool-aged children can also have high levels of infection and may be particularly susceptible to harm caused by schistosomiasis, control programs should also include efforts to treat this age-group. Furthermore, in settings where it is appropriate to move from control to elimination of transmission, it will become important to treat all ages to remove any refugia of infection. Finally, for control programs to use MDA as effectively as possible, it is also important to understand the impact of local disease epidemiology, such as the presence of infection hotspots.10This study confirmed the impact of MDA as shown by reduction in prevalence and intensity across all arms and in all age-groups. Although greater within-arm variability than expected limited the ability to see significant differences between arms; the very similar patterns of infection level over time in arms that received four rounds of CWT (arm 1), SBT (arm 4), or a combination of the two (arm 2) suggest that SBT, which typically costs less and is easier to distribute, has comparable benefits as CWT. The surprising finding that SBT also has benefits for non-targeted age-groups reinforces the conclusion that SBT may be adequate for most ongoing control programs. Nevertheless, because all individuals who are infected likely suffer some health detriment,Supplemental materials


Although practice guidelines recommend physical activity and exercise for the management of knee osteoarthritis, pain is a common barrier to participation. Phototherapy has been shown to reduce pain intensity for people with knee osteoarthritis, but it is unclear if it reduces pain during physical activity or contributes to improved rehabilitation outcomes.The aim of this study is to assess the feasibility of performing a fully powered randomized controlled trial (RCT) comparing an active phototherapy intervention versus placebo on pain during physical activity for people with knee osteoarthritis.A pilot RCT was conducted to test the feasibility of a trial comparing 8-sessions (4 weeks) of active phototherapy versus placebo. People were able to participate if they (1) were an English speaking adult (> 18 years of age), (2) had received a diagnosis of knee osteoarthritis from a physician, and (3) self-reported experiencing pain and disability related to their knee osteoarthritis for > 3 months. Primary outcomes were the feasibility of participant recruitment, retention, assessment procedures, and maintaining high treatment fidelity. Secondary outcomes piloted for a full trial included pain during physical activity ; self-reported pain severity, physical function, stiffness, adherence to prescribed exercise, global rating of change, patient satisfaction, and adverse events; 6-min walk test; and pressure pain threshold.Twenty participants  with knee osteoarthritis and a mean age of 63.95 (SD: 9.27) years were recruited over a 3-week period (6.7 participants per week). Fifteen out of 20 (75%) of participants completed the primary outcome assessment at 4 weeks and 19/20 (95%) of participants were retained and completed the final 16-week assessment. Overall, 89% of all assessment items were completed by participants across all time-points. Fifteen out of 20 participants (75%) completed all 8 treatment sessions. Treatment fidelity was 100% for all completed treatment sessions. No adverse events were reported by participants in either group.Results suggest that the trial methodology and intervention are feasible for implementation in a fully powered randomized controlled trial to determine the effectiveness of phototherapy at reducing pain during physical activity for people with knee osteoarthritis.ClinicalTrials.gov, NCT04234685, January 21, 2020–Retrospectively registered. Prior to this research, the feasibility of performing a fully powered randomized controlled trial comparing an active phototherapy intervention versus placebo to determine the effectiveness of phototherapy at reducing pain during physical activity for people with knee osteoarthritis was unknown.Results suggest the trial methodology and intervention are feasible for implementation in a fully powered randomized controlled trial to determine the effectiveness of phototherapy at reducing pain during physical activity for people with knee osteoarthritis.Results have the following implications for a fully powered randomized controlled trial: (1) we will aim to recruit participants from primary care sites where they have the physical space available to complete the 6-min walk test onsite when necessary to overcome geographic barriers to in-person assessments in order to achieve higher rates of completion for the primary outcome; (2) we will follow-up multiple times via email and telephone with participants who are unable to attend in-person assessments to ensure that we still achieve high rates of completion of self-report measures; and (3) we will update our sample size calculation in order to allow for up to 25% dropout from in-person sessions and/or assessments.Musculoskeletal disorders are the leading contributor to years lived with disability worldwide –3. MuscuClinical practice guidelines recommend aerobic and strengthening exercise for people with knee OA –15. ExerEvidence suggests that pain with movement or physical activity may be a distinct construct from pain at rest  includinPhototherapy may help to address the need for effective, non-pharmacological, pain-relieving interventions in people with knee OA –32. AlthPrimary outcomes of this pilot study were feasibility measures including participant recruitment rate, assessment completion rate, retention rate, and treatment fidelity. Secondary outcomes piloted for a full trial included pain during physical activity , pain severity, pressure pain threshold, functional walking performance, and self-reported physical function stiffness, pain, adherence to prescribed exercise, global rating of change, patient satisfaction, and adverse events.The study was designed as a parallel group, pilot randomized controlled trial with 1:1 allocation ratio to active phototherapy intervention or placebo.Participants were recruited from two primary care practices in Kingston, Ontario, Canada. People who called the primary care clinics were asked for their “reason for visit” (as is standard practice). When the reason for visit was knee OA, people were asked by their physician or nurse if they were willing to be contacted by a research assistant to be invited to participate in this research. If they agreed to being invited to participate, they were asked to provide contact information for a research assistant to contact them. The research assistant then called them, screened them for eligibility over the telephone, and invited eligible participants to an initial visit where agreeable participants provided informed consent and completed an initial assessment.Our targeted sample size was 20 participants. As this was a pilot study, a formal sample size calculation was not conducted. A sample of 20 participants was chosen because researchers and clinical partners felt this would be a large enough sample to allow an accurate assessment of the feasibility of recruitment, retention, outcome measure completion, and delivering the phototherapy and exercise interventions. Additionally, this sample size meets the recommendation from Whitehead et al. of a minimum of 10 participants per arm when estimating the variance for a sample size calculation for a future trial designed with 90% power, two-sided 5% significance, and a large (0.8) effect size . EstimatEnglish speaking adults (> 18 years of age) who had been given a diagnosis of knee OA by a physician and had experienced pain and disability related to their knee OA for at least 3 months in duration were able to participate in this research.Participants were excluded if they had a skin condition or other condition for which the application of phototherapy may have been contra-indicated , history of total joint arthroplasty in the affected knee, and “red flags” suggestive of non-musculoskeletal etiology .This study was approved by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board in Kingston, Ontario, Canada (Reference Number: 6022509). All participants provided written informed consent prior to participation in this research.Participants were randomized using a computer-generated block random number generator with random block sizes by a study team member not involved in the assessments, allocation, or interventions. The allocation sequence was recorded on cards and placed in sequentially numbered opaque envelopes that were sealed. Allocation was concealed until after the initial assessment was completed. A research assistant opened the sealed envelope that said either “group A” or “group B” after the initial assessment without knowledge of whether “group A” or “group B” would receive the active or placebo phototherapy.Participants and research assistants were blinded to whether participants received the active phototherapy intervention or placebo. The phototherapy machine was pre-programmed with two dosage settings for “group A” or “group B.” Both settings involved emission of a visible red light. The phototherapy started after a programmed 15-s delay to allow the research assistant to exit the room prior to the treatment starting. This prevented the research assistant from seeing the difference in light intensity between intervention and control groups. Whether the “group A” or “group B” was the active phototherapy or placebo dosage was not revealed to the research assistant or participant at any point during the research study.Participants from both the active phototherapy intervention and placebo groups took part in a standardized education and exercise intervention as suggested by best evidence and clinical practice guidelines for knee OA , 15. TheParticipants received education on evidence-based management of knee OA at the first visit , 15. ThiParticipants were provided with a tailored home walking program , 42. ParParticipants were instructed how to perform a series of six land-based exercises that were consistent with clinical practice guidelines for knee OA , 12, 15,invitalizer 3.0 workstation was used to apply High Intensity Physio Light (HIPL™) therapy . The phototherapy illuminated the affected knee for 20 min. In the case of bilateral knee OA, the treatment was applied to both knees (20 min each). The knee was positioned approximately 2.54–7.62 cm from the phototherapy source with an intensity setting of 50 mW/cm2. The invitalizer 3.0 workstation uses 5 panels of lights with a total emitter array area of 800 cm2. The 5 panels can be easily configured to allow the light source to be positioned consistently 2.54–7.62 cm from the skin over the anterior, medial, and lateral sides of the knee during application regardless of the size or shape of the participant’s knee.The active phototherapy intervention group received phototherapy in addition to the education and exercise intervention twice weekly for 4 weeks. Participants were positioned in a comfortable and relaxed position on a therapy plinth. The ™ therapy was set at 1 mW/cm2 for the placebo group using the invitalizer 3.0 workstation .The control group received the same procedure as the active phototherapy intervention group , with the substitution of 20 min of placebo phototherapy (versus active phototherapy intervention) twice weekly for 4 weeks. The intensity of the HIPLThe feasibility outcomes described below were the primary outcomes of this pilot study. Secondary outcomes included the outcomes planned for the full trial. We determined the feasibility for collecting these outcomes and report them descriptively with no statistical comparisons made between groups.The feasibility of participant recruitment was determined by the overall recruitment rate. A full trial was considered feasible with our current recruitment methods if, during the pilot study, we were able to recruit three participants per week. This recruitment rate would allow us to exceed the estimated 168 participants needed for a fully powered trial in a 56-week recruitment period.Retention was assessed by attrition rate, with < 20% attrition at 3-month follow-up considered indicative of feasibility with our current protocol. We decided a priori that a full trial could be conducted with attrition rates of < 30%, but with additional strategies to increase retention. This is based on evidence that > 20% attrition threatens trial validity .Feasibility of the assessment procedures were measured by completeness of data and duration of completing all outcome measures. As recommended for pilot studies, we set criteria a priori for acceptable completeness  and consTreatment fidelity was encouraged through training the physiotherapists delivering the program and by providing a treatment fidelity checklist to the research assistants/physiotherapists. Fidelity was measured through an audit of the fidelity checklist and reported as a proportion of intervention components  delivered in alignment with the protocol. An a-priori acceptable level of fidelity was considered 80% for each component of the intervention  among participants that attend each visit.The following measures were collected at baseline to describe the study population: age, sex, gender, duration of knee pain, current medications, comorbidities , woPain during physical activity was measured using change in pain throughout a standardized physical activity, a measure called sensitivity to physical activity (SPA) in the literature –53. SPA Pain severity was measured using a Numeric Pain Rating Scale (NPRS) with anchors including no pain (0) to worst imaginable pain (10). Participants were asked to report their pain intensity at rest currently, on average over the last 24 h, at its worst over the last 24 h, and at its least over the last 24 h. The pain severity was calculated as the mean of the four items. This combination of questions has been validated as a symptom severity index in the Brief Pain Inventory .Self-reported physical function was measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) , 56 physThe WOMAC pain subscale (0–20) was collected as a secondary pain intensity measure with higher scores indicating greater pain . The WOMStiffness was reported by participants on the WOMAC stiffness subscale (0–8) with higher scores indicating greater reports of stiffness . The WOMAdherence to prescribed exercise was measured using a self-reported daily log of all exercises prescribed throughout the 4-week treatment period. The log included whether each prescribed exercise was performed, the number of repetitions, and the number of sets of each exercise. The outcome is reported as proportion of prescribed exercises completed for each participant.Global rating of change (GROC) was measured using an 11-point global rating of change scale (GROC) (− 5 to + 5) as has been recommended in the literature for self-reported rating of change , 58.Satisfaction was assessed using an 11-point scale with anchors of very dissatisfied (− 5) and very satisfied (+ 5).Adverse events were recorded using an adverse events questionnaire that was reported consistently with reporting guidelines , 60 and A performance measure of physical function was the 6-min walk test (6MWT) , 62. The2 rubber tip . Pressure was applied to eight test sites in the peripatellar region, and one control site 5 cm distal to the tibial tuberosity, as described by Ardent-Neielson and colleagues [Pressure was applied using a digital handheld pressure algometer with a 1 cmlleagues . Site 1:lleagues . The preParticipant characteristics were collected at baseline. The primary outcome (SPA) was measured before and after phototherapy at baseline, 2 weeks (mid-treatment period), and 4 weeks (end of treatment period). Self-reported secondary outcomes  were assessed at baseline, 2, 4, 8, 12, and 16 weeks . Adherence was measured daily throughout the 4-week treatment period through a patient log with data collected at each visit. Global rating of change and satisfaction were measured at all time points after the baseline assessment. 6MWT was measured before and after treatment at baseline, 2 weeks (mid-treatment), and 4 weeks (end of treatment). Pressure pain threshold was measured prior to phototherapy at baseline and 4 weeks (end of treatment).Current pain intensity and adverse events were also measured immediately prior to phototherapy, immediately after phototherapy (before exercises), and immediately following completion of exercise to determine the immediate effects of the phototherapy and the combined phototherapy and exercise intervention.All baseline characteristics and outcomes were collected using Qualtrics online survey platform . Assessments completed at baseline, 2 weeks, and 4 weeks were completed in-person with a blinded research assistant. Eight-, 12-, and 16-week assessments were completed through the online survey with individual links to the survey sent to participants and phone calls to remind participants to complete the surveys completed by the blinded research assistants. Multiple attempts were made to contact participants by phone or email for any participant who missed an assessment.As recommended for pilot studies , feasibiTwenty adults with knee OA participated in this pilot study. The majority of participants were female 13/20) with a mean age of 63.95 (SD 9.27) years. Participant baseline characteristics are presented in Table 3/20 withTwenty participants were recruited over 3 weeks (6.7 participants/week) from two primary care sites. Recruitment was stopped when the targeted sample of 20 participants was reached.We achieved an attrition rate of 5% at the end of the study with 19/20 participants completing the 12-week follow-up assessment at 16 weeks. The one person that did not complete the assessments at 16 weeks was from the active phototherapy group and was lost to follow-up due to severe illness. The CONSORT flow diagram extension for randomised pilot and feasibility trials is presented in Fig. n = 1), caregiving responsibilities for a hospitalized spouse (n = 1), mental health concerns (n = 1), and surgical complications (n = 1). These concerns were reported to interfere with in person assessments, but all of these four participants completed the final assessment through online data collection or by phone. Of the 19 completed follow-up assessments at 16 weeks, 18 completed them using the unique link provided by email and one requested to complete the assessment by phone.We achieved an 89% assessment completion rate across all time-points . Of the completed assessments, we had an over 99% item completion rate with very few missing items. The completion rate was 100%, 80%, 75%, 95%, 90%, and 95% at the baseline, 2-, 4-, 8-, 12-, and 16-week assessments respectively. Importantly, the 2- and 4-week assessments relied on in-person appointments for completion of performance measures and psychophysical tests, whereas the 8-, 12-, and 16-week assessments were completed online or by phone. In addition to the participant who dropped out due to illness, the reasons reported for not completing the assessments were hospitalization (The mean time to completion for outcome measures was 14.4 min (SD 5.7) at baseline, 5.9 min (SD 3.4 min) at visit 4 assessment, and 5.7 min (SD 4.1) at visit 8 assessment. The mean time to completion at 8-week, 12-week, and 16-week follow-up was difficult to calculate due to delays evident within the survey . Removing any surveys that took over 30 min as outliers, the following mean times to completion were calculated: 10.7 min, 14.25 min, and 21.2 min at 8-, 12-, and 16-week follow-ups respectively.Fifteen of 20 people completed all eight in-person visits (8/10 from the active phototherapy group and 7/10 from the placebo group). One person completed 4 visits, one person completed 3 visits, two people completed 2 visits, and one person completed 1 visit. The audit of the fidelity checklist suggested that the active phototherapy intervention and placebo groups were delivered with 100% consistency with the planned protocol for all visits in which participants attended. Similarly, all participants received education and exercise consistent with the protocol in both groups.We piloted the collection of primary and secondary outcomes for a full trial. Primary and secondary outcomes are reported in aggregate form in Table The results for the piloted primary outcomes for the active phototherapy intervention group are presented for the active phototherapy group in Table The results for adherence to prescribed exercise are presented in Table The results for current pain intensity and adverse events immediately before and after treatment are presented in Table Our results suggest that a future randomized controlled trial evaluating the effectiveness of active phototherapy intervention versus placebo control in a population with knee OA is feasible. We achieved a recruitment rate of 6.7 participants/week over 3 weeks from two primary care sites. At this rate, a fully powered randomized controlled trial with 168 participants could be recruited in approximately 25 weeks, which would provide 90% power to detect a moderate effect size difference between groups with an alpha of 0.05. The retention rate of 95% at the end of study and overall assessment completion rate of 89% also exceeded our a priori target for proceeding with the full trial. Finally, the pilot study demonstrated strong treatment fidelity with 100% of treatment components delivered in alignment with the study protocol across all completed visits.One challenge experienced in this trial was lower assessment completion rates for in-person assessments at 2 and 4 weeks (80% and 75% completion respectively) in comparison to online follow-up assessments in which 90% or greater completion rates were maintained. This is important, especially given that the primary outcome of the future RCT is a measure of pain during a standardized 6MWT, which requires in person testing. The challenges in attending in person assessments was largely due to the medical complexity of the sample participating in the study. One person dropped out of the study prior to the 2-week assessment, reporting a severe illness that was not directly related to their OA. The other four participants who did not complete the 4-week assessment all missed their appointments due to comorbid health conditions affecting them or their partner. The high completion rate of online assessments despite these ongoing challenges for participants was an indicator of commitment of participants to participating in the study. Therefore, we feel confident that the information and consent process effectively informed participants and that changing the information and consent process would not improve the in-person completion rate. We also discussed how changes to the inclusion or exclusion criteria may have helped to identify participants with multiple comorbidities more likely to experience health complications that could interfere with participation. However, all investigators agreed that the strength of this study was the recruitment of participants through primary care settings to best represent the population of people with OA seeking care, who often experience multiple comorbidities –70.The finding of lower rates of assessment completion at in-person visits will inform the fully powered trial in three ways. (1) We will aim to recruit from primary care sites where they have the physical space available to complete the 6MWT onsite. By offering participants with barriers to attending in person at the university lab the opportunity to complete the assessment in conjunction with another healthcare appointment at their primary care site, we may be able to help participants overcome geographic barriers to participation which may increase our rate of competition of the primary outcome. This is a strategy the research team has implemented successfully in other trials. (2) We will follow-up multiple times via email and telephone with participants who are unable to attend in-person assessments to ensure that we still achieve high rates of completion of self-report measures at those time-points, even if we are not able to capture the performance measures. 3) We will update our sample size calculation in order to allow for up to 25% dropout. These strategies will be implemented for a fully powered trial to address the challenges of achieving high assessment completion rate for the in-person assessments, while maintaining the strength of the study in representing the population of people with OA who are seeking care to facilitate generalizability of the results.This study has important limitations that must be acknowledged. First, although our primary outcome piloted for a future trial (SPA) has demonstrated to be cross-sectionally related to disability in adults with knee OA , the SPAThe results of this pilot study suggest that it is feasible to implement a fully powered randomized controlled trial to evaluate the effectiveness of an active phototherapy intervention versus placebo at reducing pain during movement in a population with knee OA.


Small island states receive unprecedented amounts of the world’s plastic waste. In March 2019, we removed as much plastic litter as possible from Aldabra Atoll, a remote UNESCO World Heritage Site, and estimated the money and effort required to remove the remaining debris. We removed 25 tonnes at a cost of $224,537, which equates to around $10,000 per day of clean-up operations or $8,900 per tonne of litter. We estimate that 513 tonnes (95% CI 212–814) remains on Aldabra, the largest accumulation reported for any single island. We calculate that removing it will cost approximately $4.68 million and require 18,000 person-hours of labour. By weight, the composition is dominated by litter from the regional fishing industry (83%) and flip-flops from further afield (7%). Given the serious detrimental effects of plastic litter on marine ecosystems, we conclude that clean-up efforts are a vital management action for islands like Aldabra, despite the high financial cost and should be integrated alongside policies directed at ‘turning off the tap’. We recommend that international funding be made available for such efforts, especially considering the transboundary nature of both the marine plastic litter problem and the ecosystem services provided by biodiversity-rich islands. Approximately 6,300 million metric tonnes of plastic waste has now been generated worldwide, and because collection and recycling facilities are unavailable or inadequate in most countries, up to 12.7 million tonnes is estimated to enter the oceans annually2. This figure is likely to remain high for the foreseeable future, despite global efforts to reduce single-use plastics7. Although these numbers provide an overview of the global problem, they do not reveal the full environmental and financial impact on countries that unwillingly import this waste, which arrives on their shores every day. While source interventions are being discussed and slowly implemented8, the down-stream accumulation is taking its toll at both local and national level and cannot be ignored, especially in light of the accumulating evidence of the detrimental effects of plastic, microplastics and plastic leachate on species and ecosystems15.In the last decade the world has woken up to the extent and impact of plastic pollution in the oceans2 of the Southwest Indian Ocean and home to only 98,000 people16. One of the largest and most remote marine protected areas within Seychelles is Aldabra Atoll, among the largest raised coral atolls in the world and a UNESCO World Heritage Site. Aldabra is an iconic site, both within Seychelles and globally; heavily protected, it acts as an important benchmark for the impacts of global environmental change. It is home to the last remaining population of Indian Ocean giant tortoises17 (Aldabrachelys gigantea) and provides one of the largest nesting sites for endangered green turtles (Chelonia mydas)18 in the western Indian Ocean. The atoll supports large colonies of seabirds19, 11 endemic land-bird species/sub-species20 and the biomass of fish and sharks in its extensive coral reef and mangrove ecosystems is among the highest in the Indian Ocean21. The ecosystem services that Aldabra and other Seychelles island ecosystems provide are vital to human health and prosperity in the Seychelles and across the wider region but have already been subject to intense pressure from invasive alien species23, habitat loss24and climate change25. To maximise the resilience of these ecosystems to climate change, especially in the marine ecosystems adjacent to islands, governments and managers must ensure the ecosystems are as healthy as possible. The arrival and accumulation of marine plastic litter is both an un-quantified threat to these ecosystems and yet another burden to the organisations and government departments tasked with managing and conserving sites and species26.The Republic of Seychelles is one such nation: a small island state, with 155 islands stretching over 1.4 million km29, these expeditions have never made a serious attempt to remove it, nor have they documented the associated costs. Quantifying the resources needed for removal efforts is critical to estimate the financial burden on small island states like Seychelles to manage marine plastic litter, and to allow such nations to adapt and plan accordingly.The increasing accumulations of marine plastic litter along Aldabra’s coastlines together with direct entanglement, ingestion and injuries to a wide range of species in discarded fishing gear Fig.  is unaccWith long-term management in mind, we estimated the total amounts and types of marine plastic litter found on Aldabra to quantify the source of the problem and to estimate the cost of a clean-up effort for the entire atoll. To do this we recorded all costs associated with the clean-up, and the effort required to do so, by timing clean-up sessions and estimating the amount of litter collected per person per unit time. The waste collected was weighed and categorised and additional surveys were conducted in each coastal habitat type to estimate the total remaining marine plastic litter on Aldabra and its composition. The composition data was used to determine the main sources of litter arriving on Aldabra.3) could be removed from the shore to the cargo vessel and transported back to Mahé. The remaining 0.7 tonnes had to be left on Aldabra due to unsafe sea conditions that made removal from one of the smaller collection points (Cinq Cases) impossible.During the clean-up a total of 26.4 tonnes of marine plastic litter was collected from the coastal areas of Grande Terre, but only 25.7 tonnes  which collectively made up 60% (15.8 tonnes) of the total, followed by plastic shoes (mostly flip-flops), which made up 24% (6 tonnes) of the total Figure . During 10,285 = 14.96; P < 0.001): the proportion of heavy fishing ropes was highest on the limestone karst, while PET bottles and other light consumer items were collected in greater quantities on the beach and vegetation terrain. Based on the raw data, we estimate the total amount of accumulated litter on Grande Terre to be 513.4 (95% CI 212–814) tonnes. The estimated composition of this litter by weight is 83% (426 tonnes) fishing related, 7% (36 tonnes) footwear, 4% (20.5 tonnes) fragments, 3% (15.4 tonnes) packaging, 2% (10 tonnes) other types of litter and 1% (5 tonnes) consumer items  per hour per person, meaning that it requires 35.7 person-hours to remove 1 tonne of litter. We therefore estimate that it would take a team of 12 people approximately 191 (73 to 303) days (assuming two four-hour sessions per day) to collect the remaining 513 tonnes of marine plastic litter from the largest island of Grande Terre. It took four days to move 26 tonnes of waste from shore to ship, so we estimate that 82 days would be necessary to move all the remaining waste from shore to ship. As the total cost of the five-week clean-up was $224, 537, we estimate that a full clean-up would cost approximately $4.68 million (95% CI: $1.95 million – $7.28 million)  and 52% were unidentifiable. Of the 470 sampled bottles, 45 had intact labels where the manufacturing country was identified Fig. . Of thesn = 50) had ‘Made in Taiwan’ inscribed on them. The remaining floats were branded  but had no clear origin. Of the fish-aggregation devices or FADs (n = 13), seven had clearly decipherable identification codes and all came from purse-seine vessels registered to fish in the Seychelles Exclusive Economic Zone; five were from Seychellois vessels; one was Spanish and one French.Of the fishing floats sampled, 28% . In comparison, the estimate for Henderson Island, another World Heritage Site, is 18 tonnes (ca. 0.18 kg per m2)27, and 238 tonnes on the Cocos Island group (ca. 0.41 kg per m2)28 using a similar methodology, although these studies also include micro-debris (2–5 mm) and buried debris (to 10 cm depth). The amount of plastic litter accumulating on Aldabra seems to be typical of the situation on a number of other Seychelles islands30, although no estimates of total waste accumulation have been made. All such islands have high conservation value due to the marine ecosystems they support21.Our estimate of ~ 500 tonnes 33, on islands in the Atlantic Ocean (> 40%)34, on Australia’s northern shores (63%)35 and across the five sub-tropical gyres (58.3%)36. Elsewhere in the Indian Ocean, the proportion of litter from the fishing industry is much lower; for example, it constitutes 7.7% of the litter on Henderson Island, 1.5% of the litter on Cocos Keeling islands28 and just 2% of that on nearby Alphonse island29. These large differences in the proportion of fishing gear at sites within the region and the high proportion of fishing gear retrieved during this clean-up suggest that Aldabra is a hotspot for accumulation. The arrival of particular types of waste may be heavily influenced by proximity to sources of litter, and/or by the location of islands in particular ocean currents, so will inevitably differ from place to place.Understanding where this waste originated is a vital step in allocating accountability, to galvanise reduction at the source and potentially pinpoint where clean-up costs could be generated. It has been widely reported that approximately 80% of marine plastic litter originates on land, while the remaining 20% derives from marine sourcesThunnus albacares), skipjack (Katsuwonus pelamis) and bigeye tuna (Thunnus obesus) – is one of the most important sources of foreign currency earnings37. The industrial fishery that operates within the Seychelles Exclusive Economic Zone (EEZ) is composed of licensed vessels, both Seychelles and foreign registered, that fall under two main categories: purse-seiners (mainly EU owned vessels) and longliners (mainly Taiwanese and Chinese vessels). Since the early 1990′s, purse-seiners have been mainly operating using fish aggregative devices (FADs). The number of FADs that each ship can maintain is restricted, but because they float freely, they can enter marine protected areas, where the boats are not permitted to follow them. In an assessment of drifting FADs within the Indian Ocean, 9.9% of deployments by purse-seine fisheries were estimated to end with a beaching event, suggesting that 1,500–2,000 may be lost onshore each year in places like Maldives, the Chagos Archipelago, and Seychelles38. Of the 13 FADs collected during the clean-up expedition, we were able to trace the origin of seven, all to purse-seiners that are authorised to fish in the Seychelles EEZ. A recent report for the Indian Ocean Tuna Commission investigated 214 individual FADs that had arrived on or entered into near-shore waters of a number of islands in Seychelles: 76% of the FADs were from Spanish owned or flagged vessels, licensed to fish in Seychelles39. These results are alarming: first because it shows that waste generated by the fishing industry within Seychelles is polluting island ecosystems within the same nation state; second, if the fishing industry is the major contributor to marine plastic litter in the region, then it is almost certainly having indirect negative impacts on the fish communities it needs to sustain9. Our results also indicate that the amount of litter estimated to be circulating in the region is greatly underestimated and highlights the flaws of using sweeping global estimates within a local context. In 1990 the Seychelles acceded to the MARPOL convention and its mandatory Annexes I (Prevention of Pollution by Oil) and II (Control of Pollution by Noxious Liquid Substances in Bulk). Largely in response to this clean-up and other similar efforts by local conservation organisations, which have already received widespread local publicity, the Seychelles Government decided to accede to the remaining MARPOL annexes in 2019; most importantly it acceded to Annex V- Prevention of Pollution by Garbage from Ships, demonstrating that highlighting the problem can lead to political action by concerned governments.The economy of Seychelles is highly dependent on fishing, which directly and indirectly employs around 10% of the population. Industrial tuna fishing – mostly based on yellowfin  and 13% originated in East Asia (mainly China)29. In both cases, the original studies suggested that the intact labels might indicate the source of the bottles was dumping from ships. Only a small proportion of bottles found on Aldabra had intact labels, so we suggest that this hypothesis does not hold for Aldabra. Those found with labels clearly indicate their origin and these data corroborate findings from previous studies showing that globally, the largest input of land-based marine plastic pollution is countries in Asia43.While we were unable to determine the source of individual flip-flops, as most were either too degraded or non-branded, we recorded the country of origin of a sample of PET drink bottles. Perhaps unsurprisingly, given its size and population density, 47% of plastic bottles found on Aldabra with intact labels were from China. This is similar to findings from islands in the Southern Atlantic Ocean44, which are then exported for recycling. At present, there are no in-country recycling options for any plastics45 and marine-degraded plastic requires specialist recycling. The relatively small amount of waste we returned to Mahé spent six months in a holding site while we attempted to find local re-use and re-purposing solutions. In total, 9.2% of the litter was re-used by conservation organisations, local schools and artists, but these are not long-term pipelines for waste. Recycling solutions exist elsewhere in the world to enable a circular economy for the majority of plastic types ; (2) plastic packaging material ; (3) fishing-related items  and ropes); (4) plastic footwear (mostly flip-flops); (5) unidentified plastic fragments > 1 cm in diameter; (6) other materials (e.g. glass). These categories were defined based upon those outlined in the Tangaroa Blue Foundation Marine Debris Identification Manual , although we grouped all non-plastic items into the ‘Other’ category and segregated footwear into its own category due to the visible dominance of this type of debris. The full sacks and slings were left above the high-tide line at designated collection points.A team of 12 volunteers comprised the clean-up work-force. The team spent three weeks stationed at three field camps. The camps are situated at the only locations along the coast where a boat can land safely from the ocean side: Dune d’Messe (DdM), Dune Jean-Louis (DJL) and Cinq Cases (CC) . The data were highly over-dispersed, so we modelled Log(litter mass + 1) which corrected the problem. To scale up from transects to the total litter on Grande Terre island we used the raw data, rather than estimates from the model, which we considered to be a conservative approach (variation associated with location and transect variability is then included in the standard errors of the estimates). The estimate for each litter category in each habitat type was then combined with estimates of the total area of each habitat on Grande Terre  sandy beach above the high-tide line (where green turtles nest); (2) coastal limestone karst; and 3) coastal vegetation, within 5 m of the beach or karst, as the amount of marine plastic litter declines with distance away from the coast. There were a small number of places with extreme accumulations, like blowholes Fig. , that we coastal re Table , taken fIn addition to the transects, we recorded the total amount of litter collected in each of the 40 clean-up sessions, together with the length of the session and the number of people working in it. These numbers were used to estimate the amount of litter collected per person per hour. Once we had estimated the total amount of litter present on Grande Terre, we then estimated the total effort and costs needed to remove all the accumulated litter from Grande Terre, assuming that future teams could work at a similar rate.We provide a breakdown of costs for the clean-up operation and use these to estimate the costs per day of clean-up (our costs divided by the number of clean-up days) and costs per tonne (our costs divided by the number of tonnes) and the projected costs of a full-island clean-up , Table . The mai51. Using the identification codes we could attempt to track their origins .All the plastic litter was moved from Aldabra to a storage facility in Mahé. Once there, we estimated the total volume of plastic and sampled six haphazardly-selected sacks of PET bottles  to record the type and origin of all the bottles on which labels remained. For the fishing buoys we recorded the brand and/or origin of 50 buoys, also selected haphazardly. We also recorded the identification codes on each fish aggregation device (FAD); a free-floating human-made raft equipped with floats to ensure buoyancy and a sea anchor mostly built from old fishing net that are deployed to attract schools of fish in purse-seine fisheries, they are remotely monitored with a GPS-tracked buoy that includes an echo sounder unitThe consent of all persons in photographs for figures was obtained for publication of identifying information/images in an online open-access publication.Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.


This study describes self-reported physical activity (PA), motivation to exercise, physical and mental health and feelings towards PA during the March-May 2020 COVID-19 lockdown in New Zealand. Adults over the age of 18 years  completed the International Physical Activity Questionnaire (IPAQ), the Behavioural Regulation in Exercise Questionnaire 3, the Short Form-36 and open-ended questions about PA through an anonymous online survey. Regular exercise was undertaken by 85% of respondents prior to lockdown, but only 49.8% were able to maintain their usual level of PA. Although respondents were considered sufficiently physically active from the IPAQ, 51.5% reported not being able to maintain their usual level of PA primarily due to the closure of their gym facilities. Sixty percent of respondents reported that PA had a positive effect on their overall wellbeing. When asked to specify which aspects of wellbeing were affected, the effect on mental health was reported the most while the effect on body image or fitness was reported the least. Strategies to increase or maintain engagement in physical activity during lockdowns should be encouraged to promote positive mental health during the COVID-19 pandemic. Substantial evidence exists to support the benefit of regular exercise and physical activity (PA) on all aspects of physical and mental health ,2. The cCoronavirus disease COVID-19) is an infectious disease caused by a newly discovered coronavirus  is an in,24,25,26On the 25 March 2020, New Zealand moved into their highest COVID-19 alert level . People The levels and underlying reasons for those levels of exercise or physical activity during the March-May COVID-19 lockdown of 2020 in New Zealand are unknown. The aim of this study was to describe the self-reported physical activity levels, motivation to exercise and physical and mental health of New Zealanders and to obtain qualitative information on the feelings towards physical activity and exercise during lockdown.This was a cross-sectional study design in which an anonymous survey was distributed to adults over the age of 18 years in the general adult NZ population. This age group and population was chosen as no research has yet been undertaken regarding the impact of COVID-19 on health outcomes in New Zealand.Invitation messages were posted on open community and neighbourhood social media, as well as on online community notices from April 2020 until June 2020. Participants were invited to access the survey information and consent was assumed if the participant completed and submitted the survey. The survey  consisted of demographic questions of the participant as well as questions on the individual’s living situation under the strictest lockdown levels during the COVID-19 pandemic restrictions in New Zealand. Participants also completed a series of questionnaires that collected information on self-reported physical activity, motivation to exercise and quality of life. Responses were recorded anonymously. The study was approved by the University of Auckland Human Participants Research Ethics Committee .All questionnaires were modified to refer to the respondents’ experience during the 7-week lockdown. A modified form of the International Physical Activity Questionnaire (IPAQ) was used to collect information on domain-specific physical activity and sedentary behaviour over the last seven days . The modThe Behavioural Regulation in Exercise Questionnaire (BREQ-3) is based on self-determination theory  and was The short-form 36 (SF-36) was used to measure overall quality of life during lockdown across eight domains including physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue and general health perceptions ,38. The Finally, open-ended questions were also included in the survey to obtain demographic information such as age, gender, ethnicity and work status, and qualitative data on respondents’ feelings towards their physical activity engagement or lack thereof during lockdown. These questions asked whether participants believed their activity levels had changed during compared to before the imposed lockdown and asked for reasons why that may or may not have been the case.Data were summarised and are presented descriptively. Analysis of the main outcome variables of physical activity, motivation and quality of life was conducted using age group, living arrangement, sex and whether the individual had carer responsibility for children under the age of 18 years as factors. A one-way ANOVA with Bonferroni post-hoc analysis was used to analyse three or more groups (age and living arrangement groups). A Kruskal-Wallis test with Dunn’s post-hoc test was used to determine group effects for three or more groups for motivation and quality of life scores as a non-parametric test. An unpaired t-test was used to analyse the difference between two groups (between sexes or between those having to or not having to care for children under the age of 18). For non-parametric data, a Mann-Whitney U test was used to compare differences between 2 group (sex and caring for children <18 years). Finally, the answers to open-ended questions were analysed descriptively. Data were analysed using StataIC .www.ipaq.ki.se, accessed on 19 November 2020), we obtained 196 complete responses on self-reported physical activity levels. The demographics of the 196 survey respondents is shown on Of the 263 respondents who started the survey, 248 completed  the survey. After scoring and cleaning the data obtained from the IPAQ according to standard protocols (From the cohort (n = 195), respondents reported spending a mean (SD) time of 62.4 (43.0) min walking, 125.6 (64.9) min in moderate intensity exercise and 34.3 (43.0) min in vigorous intensity activity per day in an average week during lockdown. Males reportedly spent approximately 16 min more time in vigorous physical activity per day during lockdown than females.The scores from the six styles of motivation calculated from the BREQ-3 questionnaire are presented in Overall, the physical health score (SF-36) of respondents was 56.5 (50.1–61.5) and the mental health score was 38.5 (21.1–50.5) (median IQR) .Respondents were asked to answer questions related to their experience of physical activity and exercise during the lockdown period. We obtained complete data from 238 respondents. 81.9% of respondents rated their overall well-being during the COVID-19 lockdown period as being either excellent or good. Over half of the respondents (54.9%) reported that they had started a new exercise regime during lockdown.Eighty-five percent of respondents reported that they took part in regular exercise or physical activity prior to lockdown. When these respondents were asked if they had been able to maintain their level of physical activity during lockdown, 48.5% said they were, while 51.5% said they were unable to maintain or increase their PA level during this period. The most reported reason given for being able to increase or maintain level of PA during lockdown, was more time was available from not having to commute into work. Other responses provided were that some people felt they were able to adapt their type of exercise to outdoor activity. Others felt that lockdown had motivated them to do some type of activity/made a conscious effort to get outside and do some physical activity or exercise. From those (51.5%) who reported not being able to maintain their PA during compared to before lockdown, the most reported reason given was that gym facilities were closed . Other rOf the respondents who reported regularly taking part in exercise or physical activity, 90.1% reported that their engagement in PA and exercise affected their overall wellbeing during lockdown. These respondents qualified how their engagement in PA affected their overall wellbeing. The qualitative response provided was classified as PA having a positive effect on wellbeing, a negative effect on wellbeing, or no response was provided. Positive effects were responses such as, “it gave me a break from being inside all the time” or “it was good to get some time away from my family!”. While negative effects were responses such as, “No teams sports” or “Elite level swimmer with 20 + hrs of training a week normally but as soon as lockdown started we could no longer swim and was only a few weeks out from Olympic trials so a lot of hard work to not be able to show for it”. Positive effects of PA and exercise on well-being were reported by 57.6% of respondents, while 17.2% reported that their engagement with PA or lack thereof, during lockdown, had a negative effect on their wellbeing. 25% did not elaborate on their answer. Positive effects on wellbeing were further sub-classified into an impact on one of three domains: (1) body image or fitness, (2) mental wellbeing or (3) other. More than half of respondents (54.7%) who reported PA impacting positively on their wellbeing commented on their mental health or mental wellbeing.Of the remaining 36 respondents who reported not engaging in regular PA or exercise prior to lockdown, half (50.0%) reported that regular PA had a positive impact on their wellbeing during lockdown mainly because they had started doing more physical activity such as walking during this time.The aim of the present study was to describe self-reported physical activity, motivation to exercise and physical and mental health of New Zealanders during the March-May 2020 COVID-19 lockdown. This study also aimed to explore some of the feelings towards physical activity during this lockdown period. Our study findings indicated that the majority of respondents took part in regular physical activity prior to the lockdown period, and that only half of those were able to maintain their current level of activity during the lockdown period. These individuals reported that the main barrier to PA was that their exercise facilities  were closed, followed by being afraid to go out and being unable to exercise in a social group or with their friends. Previous studies have reported that a lack of time, cost, and a lack of knowing what to do are common barriers that prevent people from engaging in physical activity ,39,40. SThe reduction in PA reported in our study is similar to findings observed in other international studies during lockdowns or movement restrictions ,18,19,20Respondents in our survey would be considered as being sufficiently physically active according to the current World Health Organisation (WHO) physical activity guidelines for adults . In a siThe COVID-19 lockdown has also impacted people’s mental health worldwide ,16,18. IThe qualitative analysis of the impact of lockdown on mental health was reflected quantitatively in the mental health scores from the SF-36 reported in our study. The scores indicated that respondents had a poor self-perception of mental health during lockdown while they reported an average self-perception of physical health. This finding aligns with several other studies that have indicated increased symptoms of anxiety and depression, and reduced perception of quality of life during nation-wide COVID-19 lockdowns in adults and older adults ,16,21,31Due to the nature of this study being an online survey, selection biases are a limitation as the participants who volunteered to complete this survey may not be an accurate representation of the New Zealand population. A lack of ethnic diversity also suggests limitations in sampling, as the Auckland region has higher proportions of Asian, Māori, and pacific ethnicities, which were not proportionately represented in this study. Self-reported measures are also a limitation of the present study due to the tendency for participants who are already sufficiently physically active to respond to a survey regarding physical activity. A third limitation of the study was the reliance on participants to recalling previous activities, such as physical activity levels prior to lockdown.Overall, the movement restrictions put in place in New Zealand due to the global COVID-19 pandemic impacted the level of PA which may then have had effects on physical and mental health. A contributing factor to the ability to maintain engagement in PA could also have been the type of messaging that was delivered whereby by people were actively encouraged to engage in some exercise but within a certain distance of their home. This may explain why most respondents in the survey rated their overall wellbeing as excellent or good. However, there was a certain proportion of respondents who were unable to engage in activity due to closure of exercise and sporting facilities. Further questions remain as to whether there may be lingering anxiety in people wishing to take up exercise especially those who fall within the vulnerable category and what considerations may be required for additional support for people who may continue to not engage in physical activity during the lockdown period of the COVID-19 pandemic.


Small subtype of the gastrointestinal stromal tumor  is usually asymptomatic and is frequently found incidentally in association with gastric adenocarcinoma (GAC). The background of this coincidence is still an open question. This study comprehensively characterized nine MGs and GACs present in the same surgical specimen by cross-testing the markers of the major pathogenetic pathways of both tumor types. All of the MGs were immunohistochemically positive for CD117/KIT, CD34, and DOG1. DOG1 was also detected in four GACs. Four MGs carried mutations in c-KIT  and two cases in PDGFRα (exon 18). None of the GACs carried activating mutations in c-KIT or PDGFRα. MMR immunopanel identified one GAC as microsatellite unstable tumor. No EBV-positive tumor was found. According to the TCGA molecular classification, one GAC was categorized in the MSI subgroup, three GACs in the genomically stable subgroup, and the rest into the chromosomal instability subgroup. Although a common carcinogenic effect cannot be ruled out, our data suggest a distinct molecular background in the evolvement of the synchronous MGs and GACs. The presence of a MG in gastric resection specimens may be indicative of the development of synchronous malignant tumors in or outside the stomach. Whilst small, indolent variant of GIST  was commonly found to be up to 10 mm in size4, others defined it as small GISTs with a maximum diameter of 20 mm5. These macroscopically well-circumscribed lesions more frequently show spindle-cell morphology with a lower number of mitotic cells than the larger variants6. MGs are frequently found incidentally in the wall of the stomach during surgery or pathological examination of gastric resection specimens8.Gastrointestinal stromal tumors (GISTs) arise from the interstitial cells of Cajal and can show either benign or malignant biological behavior10. In the Central European region, however, the general incidence of MGs in gastric resection specimens is less known.Many case series were published in the last years, mostly from geographic areas having a high prevalence of gastric cancer11. Interestingly, in other published MG case series, these mutations were present in the early-stage/low-risk tumors, supporting these as early events in the tumorigenesis6.Major part of GISTs are arising from mutations in the proto-oncogenic c-KIT receptor tyrosine kinase or intragenic activation mutation in the receptor tyrosine kinase domain of the platelet-derived growth factor receptor α (PDGFRα)12. The identified molecular subtypes are mutually exclusive and reveal the carcinogenetic pathway of the analyzed gastric cancer.In 2014, The Cancer Genome Atlas (TCGA) project provided a novel molecular classification of gastric cancer by introducing subgroups of carrying Epstein–Barr-Virus (EBV)-positivity, microsatellite instability (MSI), genomical stablity (GS) and chromosomal instability (CIN)16. In order to explore this phenomenon, we comprehensively characterized gastric adenocarcinomas with coincidental MGs from the epidemiology of its synchronous presence to the analysis of the major molecular pathways of both tumors. To identify or exclude possible common molecular mechanisms in these neoplasms, known factors of tumor development of both the GISTs and adenocarcinomas  were cross-tested on both tumor types.Since GISTs were identified as a separate entity in the ’80s, several issues have remained unanswered. The rising number of diagnosed MGs has drawn the attention to its synchronous presentation with other gastrointestinal malignancies, especially with gastric adenocarcinomasThe study enrolled 1027 patients that underwent surgical resection of the stomach between 2002 and 2018. In this period, 665 gastric adenocarcinomas were diagnosed, including 10 cases with additional MG. In the case of one patient, the available FFPE material was insufficient for further investigations therefore the present molecular analysis was conducted only on 9 cases having gastric adenocarcinoma and MG synchronously. The selection of the patients is shown in Supplementary Fig. The general rate of MGs in patients operated due to gastric adenocarcinoma was 1.5% (10 out of 665 cases). In 50% of these patients, the small mesenchymal tumor was recognized during the surgery. In two of these five cases, the MG was located in the proximal area of the duodenum and not in the stomach. In the rest of the cases, MG was diagnosed only during the histopathological examination of the surgical specimens. Accordingly, prevalence of the incidental MGs was found to be low  in our study.The mean age of the patients was 72 years (ranging from 61 to 83 years). Gender distribution was unbalanced in the study cohort . The mean diameter of the MGs was 0.77 cm. According to the NIH (Fletcher) prognostic classification, all MGs belonged to the very low-risk group. Two of the nine patients had a history of a prior malignant tumor in their anamnestic data. The entire workflow is summarized in Fig. All of the MGs displayed spindle cell morphology and showed positive immunostaining with CD117, CD34, and DOG1 Fig. .Figure 2All adenocarcinomas were negative for CD117 and CD34, whereas positive DOG1 immunostaining was detected in four cases. C-KIT mutation was found in four GISTs, but no mutation was present in the synchronous adenocarcinomas. Two of the MGs carried mutation in exon 18 of the PDGFRα and one additional case had a benign single nucleotid variant in the PDGFRα exon 18 V824V). This silent mutation was present in the corresponding adenocarcinoma sample too but none of the adenocarcinomas carried gain-of-function mutations in the investigated PDGFRα exons. Detailed results are shown in Table 4V. This In the muscular wall of the stomach, we have observed an ETV1 staining pattern identical with the localization of the KIT-positive interstitial cells of Cajal (ICCs) which served as internal positive control In the nine synchronous MGs; however, the PCR-based analysis of the EBV positivity and immunohistochemical analysis of the MMR proteins provided negative results in all cases.Details are shown in Table The background of the frequently occurred incidental MGs next to gastric adenocarcinomas is still an open question. This study comprehensively characterized 9 MGs and adenocarcinomas present in the same surgical resection specimen by analyzing the c-KIT/PDGFRα status and EBV/MSI status on both tumor types.18. Epidemiological data are largely limited to large-size, mostly malignant subtypes of GISTs while the small, indolent MGs are usually not included in the cancer registries. Nevertheless, the general occurrence of MG in gastric resection specimens varies between 0.5 and 35%, which is markedly higher in the studies focused on its incidence next to gastric adenocarcinomas19 compared to that in patients without upper gastrointestinal neoplasms20. In contrast, our study revealed a relatively low prevalence of incidental MGs  in Central Europe.GISTs are rare tumors located throughout the gastrointestinal tract with an estimated incidence of 10–15 per million people per year21. This could partly be explained by the phenomenon that higher male predominance is a characteristic feature of gastric adenocarcinoma as compared to GIST alone22. No gastric adenocarcinoma with distant metastasis was found in the present study cohort, corresponding to the results of a published case series10.An outstanding gender imbalance was present in the study cohort with male predominance , similarly to other studies23 and in line with this, these tumors were the largest ones  in our series. All MGs displayed spindle cell morphology and were categorized as very low-risk tumors, similarly to other case series10.There is a predilection site for MGs in the upper region of the stomach (fundus and body). Concordantly with the literature, 7 MGs of our cohort  were present in the gastric body and two further tumors were located in the proximal area of the duodenum. Small intestinal localization of GISTs was described to be associated with bad prognosis10. In other studies investigating synchronous and solitary GISTs, however, Liu et al. found a lower frequency of DOG1 immunopositivity, whereas Lin et al. observed lower CD117 and CD34 positivity rates in the synchronous tumors24. When performing the same analyses on the synchronous adenocarcinomas, all cases proved to be negative for CD117 and CD34. However, four adenocarcinomas showed weak to focally strong DOG1 expression. As a transmembrane protein, DOG1 forms a Ca2+-mediated chloride channel and it is present in normal tissues of several organs due to its important role in secretory, sensory and contractile functions25. Several studies have examined DOG1 positivity in non-GIST tumors31. To the best of our knowledge; however, DOG1 expression of gastric adenocarcinomas was only investigated in one publication, a case series with immunohistochemistry, where a positivity rate of 27.6% (8/29) was found in intestinal-type carcinomas and 23.1% (3/13) in diffuse-type gastric cancers31. Our results are in line with this as two intestinal-type and two diffuse-type gastric adenocarcinomas expressed the DOG1 in our cohort.By immunohistochemical analysis, all MGs showed diffuse positivity for the GIST markers CD117, CD34, and DOG1, in various degrees. In their analogous study, Luo et al. found similar results32. However, the ETV1 is not universally expressed in the GISTs but was more frequently found in the early, small tumors (over 60%)34. Interestingly, we found similar rate of positivity (6/9) among our cases but with very low ETV1 expression level in all the positive tumors which is a peculiarity among the small indolent GISTs. On the other hand, ETV1 overexpression was shown to contribute to the epithelial to mesenchymal transition (EMT) by the upregulation of Snail expression and to be associated with higher tumor grade and stage in gastric adenocarcinomas35. The number of the patients in our case series is unfortunately too small to draw similar conclusions. Even so, we have carefully examined the adenocarcinomas in order to reveal any tumor budding-related special ETV1 expression pattern as the EMT is a key feature of the tumor budding36. Accordingly, one can speculate that the ETV1 expression level should be lower in the budding tumor cells of the invasion front. However, in our ETV1 positive gastric adenocarcinomas, no difference was apparent in the ETV1 expression pattern between the invasion front and the more central tumor areas. Another possible mechanism that a gastric adenocarcinoma might trigger the proliferation of the ICCs by inducing an elevated ETV1 expression and hereby contribute to the development of a GIST. But we found a significantly reduced ETV1 expression in the tumor cells of synchronous GISTs in comparison with the ICCs of the adjacent gastric wall. This suggests an ETV1-independent tumorigenesis or subsequent activation of antagonistic processes such as the degradation of ETV1 by the tumor suppressor COP137. A further notable finding that all the three ETV1-negative GISTs were associated with ETV1 negativity of the synchronous adenocarcinoma as well . However, we used another ETV1 primary antibody than in most of the previous studies since that one is not available anymore. This might be a considerable limitation from the aspect of comparability since instead of the previously described nuclear positivity we observed a different subcellular localization pattern with nuclear/cytoplasmic positivity of the ICCs and prevalent cytoplasmic and scattered nuclear/cytoplasmic positivity in both the GISTs and adenocarcinomas.We have also investigated the immunohistochemical expression of the ETV1 in the synchronous GISTs and adenocarcinomas since it was described as a transcription factor responsible for the differentiation of the interstitial cells of Cajal and to cooperate with KIT to promote GIST tumorigenesis10, their prevalence is generally lower in MGs as compared to larger GISTs39. Luo and his colleagues published a lower mutation rate in synchronous cases in comparison to solitary GISTs10. Our results provide further support to this, since only six of our cases carried mutations in c-KIT or PDGFRα, whereas the rest three cases proved to be negative for all of the investigated exons. The most frequently mutated exon was the c-KIT exon 11, concordantly with other studies13. One mutation in the exon 18 of the PDGFRα (D842V) is reported to be associated with resistance to imatinib40. Furthermore, mutated c-KIT and PDGFRα have been suggested to be involved in the pathogenesis of certain non-GIST tumors as well42. However, our gastric adenocarcinomas turned out to be negative for gain-of-function mutations in all of these mutational analyses.Although c-KIT or PDGFRα mutations are frequently present in the early GISTs as well12. The EBV-positive and MSI subtypes were underrepresented in our case series as none of our cases were positive for EBV infection (vs. the 8.8% rate in the previous TCGA study) and only one (11.1%) dMMR positive adenocarcinoma was found (vs. 21.7% rate for MSI subtype in the previous TCGA study). On the one hand, however, the low number of cases in our study (9 vs. 295 cases of the previous TCGA study) and the consequently high variability of the proportional frequency between the subgroups can explain these discrepancies. On the other hand, limitations of the used approximation approach for the TCGA subtyping might contribute to the observed slight differences as well. Regardless of the possible inaccuracy, our analysis clearly showed that there is no significant correlation between the TCGA subgroups and the presence of adjacent synchronous MG.Our approximated TCGA subtyping of adenocarcinomas showed slight differences in the proportional frequency of the four subgroups when being compared to the previous TCGA study49. Even though we used precise and sensitive diagnostic tools, lower number of cases of these better-prognosis subtypes were detected in our study, which suggests that adenocarcinomas with synchronous tumor have usually worse overall survival than the expected average prognosis of gastric cancers. Accordingly, as the immune-checkpoint inhibitor therapies are becoming more and more widely available, underrepresentation of the immunogenic EBV-positive and MSI subtypes will further widen the prognostic gap between the adenocarcinomas with and without synchronous MG.The EBV-positive and MSI gastric adenocarcinomas were reported to be associated with better prognosis in several studies and these tumors showed a higher response rate to immune-checkpoint inhibitors in a clinical trialRegarding the concomitant MGs, all cases were microsatellite stable and negative for EBV infection. This together with the absence of c-KIT and PDGFRα mutations in the adenocarcinomas confirm that the major molecular pathways of tumor development are different in gastric adenocarcinomas and adjacent MGs. This is important for a better understanding of the pathogenetic background of synchronous occurrence of GISTs and malignant tumors, which seems to be a relatively frequent event.50. In the case of adjacent synchronous tumors, we speculate that the gastrointestinal adenocarcinoma provides a growth factor-rich microenvironment, which induces the development of GIST from the nearby Cajal cells. In the majority of the cases with high-risk GISTs; however, the synchronous malignancy was reported to be present in extra-gastric localization51. This indicates that non-gastrointestinal cancers and GISTs either have common carcinogenic induction or the occurrence of one of the tumor types facilitates the development of the other tumor in a way of “action at a distance” .Several studies reported high sporadic coincidence of GISTs and other neoplasms and described GISTs as “sentinel tumors”10, or only a few millimeters larger in size51. Our results provide further support to this as the average diameter of the synchronous GISTs was 7.67 mm (2–20 mm), indicating that all of them are MGs, indeed. Interestingly, the average diameter of the MGs located more distant from the synchronous gastric adenocarcinoma  draws the attention to the prognostic role of synchronous MGs in view of developing further malignancies as well.Moreover, there is an interesting finding indicating a further relationship between synchronous tumors. Even though the prevalence of GISTs is higher when gastric cancer is present, it seems that the average size of the GIST is smaller than that of the solitary form. In the case series published previously, all of the synchronously occurred GISTs are categorized as MGs with a maximum diameter of ≤ 20 mmTo the best of our knowledge, our study characterized one of the largest case series of gastric adenocarcinomas with synchronous MGs and it is the only one which analyzed the background of this simultaneous appearance by taking the pathomechanism of both tumor types into consideration. Notwithstanding, the number of cases and the considered immunohistochemical and molecular markers may be less than to be able to draw more precise conclusions about the potential common tumorigenesis. Furthermore, the retrospective character of the study limited to examine the resection specimens in higher detail than the routine grossing process and to analyze more clinicopathological conditions. Therefore, more precise identification of the groups of patients with higher risk to develop synchronous tumors was not possible.To conclude, our data further support that distinct mechanisms play roles in the development of synchronous GISTs and gastric adenocarcinomas, although a common carcinogenic effect cannot be ruled out. In light of our study, it is important to systematically look for associated MGs during a gastrectomy due to gastric cancer and during the grossing of its resection specimen. Regarding the possible “sentinel” role of the GISTs, however, it is also worth keeping in mind that malignant tumors of other primary sites can be associated with these mesenchymal tumors as well.During the study period (2002–2018), gastrectomy specimens containing gastric adenocarcinoma and synchronous MG were selected from the institutional archives of the 2nd Department of Pathology for this retrospective cross-sectional study. Detailed clinical data of the patients were collected from the electronic patient register of Semmelweis University. All cases with sufficient tumor content in the available formalin-fixed, paraffin-embedded (FFPE) tissue block(s) were included in the study (n = 9). The detailed case selection procedure is shown in Supplementary Fig. The study protocol was following the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Ethical Committee of the Semmelweis University, Budapest (#22/2019). Based on the current Hungarian law for the scientific research, contacting the patients in order to have their informed consent is basically not requested for the retrospective studies. According to this, the Ethical Committee of the Semmelweis University, Budapest has waived the informed consent procedure for the study.52. For prognostic stratification of GIST tumors, the NIH standard was used proposed by Fletcher et al. in 200253. GISTs up to 20 mm were considered as MG in this study, based on the definition by Anderson et al.5.Diagnostic work-up of gastrectomy specimens was performed according to a standardized protocol. Tissue samples were fixed with formalin and embedded in paraffin (FFPE). Tissue sections of 3 μm thickness were cut from the FFPE tissue blocks and stained with hematoxylin and eosin. For the routine diagnostic purpose of gastric adenocarcinomas and GISTs, immunohistochemical stainings were performed in the representative areas of the resection specimens when it was necessary for the diagnosis. The cases containing both tumor types synchronously were re-analyzed by an experienced histopathologist (GL) and detailed histologic features were recorded (see results). Stages of both tumors were classified according to the eighth edition of the UICC TNM classification of malignant tumorsThe histological subtype of gastric adenocarcinomas was classified according to the Lauren classification.For the analyses, patients were randomly numbered from 1 to 9 and the two distinct tumors were labeled as 1GAC (gastric adenocarcinoma of Patient 1) and 1MG (micro-GIST of Patient 1). All analyses were performed on both the GAC and the MG components of resection specimens. For the immunohistochemical (IH) analyses, 4 µm thick tissue sections were cut from the FFPE tissue blocks and mounted on a coated glass slide. Stainings were performed on a Ventana Benchmark Ultra automated IH staining system using standard protocol including steps of heat pretreatment with pH = 9 Cell Conditioning 1 and signal development with UltraView Universal DAB Detection Kit . Hematoxylin was used for counterstaining.Both tumor types were tested with GIST immunomarkers, including anti-CD117/c-KT , anti-CD34  and anti-DOG1  as well as by anti-ETV1  primary antibody. The intensity of these IH stainings was ranked as follows: − (negative), + /− , + (weak), ++ (moderate), and +++ (strong).For detection of Mismatch Repair (MMR) protein status, a panel of four ready-to-use (RTU) primary antibodies was used: anti-MLH1 , anti-MSH2 , MSH6  and PMS2  . Epithelial cells of the intestinal crypts were used as positive controls. When a loss of any of these proteins was detected (corresponding to the significant reduction in IH staining intensity of the specific nuclear positivity), the tumor was referred to as mismatch repair deficient (dMMR) and classified into the MSI subgroup. The primarily affected protein of the heterodimer pairs was determined by the following scheme: MLH1-/PMS2- → MLH1; MLH1 + /PMS2- → PMS2; MSH2-/MSH6- → MSH2; MSH2 + /MSH6- → MSH6.From FFPE tissue blocks, three sections of 10 μm were cut and areas containing at least 80% of the tumor cells were manually macrodissected using a marked hematoxylin-eosin-stained slide from the corresponding tissue block as a guide. To reduce cross-contamination between the cases, the microtome was cleaned with non-denaturated absolute ethanol in-between each tissue-block sectioning. Following deparaffinization, DNA extraction was performed using the Roche High Pure FFPET DNA Isolation Kit  following the manufacturer’s instructions. The quantity of the extracted DNA was measured by NanoDrop 1000 Spectrophotometer .http://www.ncbi.nlm.nih.gov.Exons 9, 11, 13, 14 and 17 of c-KIT and exons 10, 12, 14, and 18 of PDGFRα were screened for mutations using amplification of genomic DNA by polymerase chain reaction (PCR) followed by direct sequencing of PCR products. Supplementary Table Detection of EBV DNA by PCR analysis was carried out under standard conditions. The sequences of the applied primers are listed in Supplementary Table 12, we characterized our cases according to this classification. We used a simplified, dichotomous algorithm described in recent publications43. Based on a recently published study from Yoon and his colleagues17, an approximated reproduction of the TCGA classification is achievable by an algorithm starting with the analysis of the EBV positivity, following by the investigation of the MSI status. Finally, the GS and CIN tumors are separated by the histological subtypes according to the Lauren classification .Since TCGA classifies gastric cancers into molecular subtypes based on major pathogenetic pathways Supplementary Table S1.Supplementary Figure S1.Supplementary Figure S2.