CSF1R gene are the most common cause of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP), a neurodegenerative disease with rapid progression and ominous prognosis. Hematopoietic stem cell transplantation (HSCT) has been increasingly offered to patients with CSF1R-ALSP. However, different therapy results were observed, and it was not elucidated which patient should be referred for HSCT. This study aimed to determine predictors of good and bad HSCT outcomes in CSF1R-ALSP. We retrospectively analyzed 15 patients, 14 symptomatic and 1 asymptomatic, with CSF1R-ALSP that underwent HSCT. Median age of onset was 39 years, and the median age of HSCT was 43 years. Cognitive impairment was the most frequent initial manifestation (43%), followed by gait problems (21%) and neuropsychiatric symptoms (21%). Median post-HSCT follow-up was 26 months. Good outcomes were associated with gait problems as initial (p = 0.041) and predominant (p = 0.017) manifestation and younger age at HSCT (p = 0.044). Cognitive impairment as first manifestation was a predictor of a bad outcome (p = 0.016) and worsening of cognition post-HSCT (p = 0.025). In conclusion, gait problems indicated a milder phenotype with better response to HSCT and good therapy outcomes. In contrast, patients with a higher burden of cognitive symptoms were most likely not to benefit from HSCT.Mutations in the  Colony Stimulating Factor 1 Receptor (CSF1R) gene are the most common cause of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) [Mutations in the a (ALSP) . The disa (ALSP) . Some paa (ALSP) . The proa (ALSP) .CSF1R-ALSP have uncovered pathophysiological mechanisms and opened new treatment perspectives for the previously untreatable disease [CSF1R mutations lead to haploinsufficiency, but the remaining microglia are sufficient to compensate during the first few decades of life. However, with aging, there is a growing accumulation of damage to white matter, and once the compensation abilities are overwhelmed, the symptomatic disease ensues [CSF1R-ALSP by Eichler and colleagues in 2016 [CSF1R-ALSP.In recent years, advances in research on  disease ,3,4. The disease . CSF1R me ensues . Since tCSF1R-ALSP and found data on 13 patients treated with HSCT [CSF1R-ALSP treated with HSCT were included in the study. Data extraction and retrospective analysis were performed in a structured manner.We searched the medical literature databases until 16 September 2022, for all manuscripts reporting HSCT applications in ith HSCT ,9,10,11.Information was collected regarding demographics , initial symptoms, pre-HSCT predominant symptomatology, pre-HSCT activities of daily living (ADLs), pre-HSCT professional activity, pre-HSCT clinical symptoms , clinical asymmetry, pre-HSCT brain magnetic resonance imaging (MRI) characteristics (white matter lesions (WMLs), cerebral atrophy, corpus callosum involvement, asymmetry), post-HSCT ADLs, post-HSCT professional activity, post-HSCT clinical outcomes , and post-HSCT radiological outcomes. Additionally, we calculated two combined measures of the post-HSCT outcome as follows. First, as a dichotomous combined outcome measure, the outcome was considered to be “good” if the patient was assessed as having either no change or improvement for each of the six symptom-related outcomes  or independent for ADLs or active for professional activity; all other patients were considered to have a “bad” outcome. Second, we calculated a score for each patient by summing the values for the individual post-HSCT outcomes , where missing data for a post-HSCT outcome was imputed by using the mean value of the patients who did have data for the given outcome in order to avoid scores that are biased too low due to the presence of missing data. Therefore, a higher score indicates better post-HSCT outcomes.p-values < 0.05 were considered as statistically significant. All statistical tests were two-sided. Statistical analyses were performed using SAS .Continuous variables were summarized with the sample median and range. Categorical variables were summarized with numbers and percentages. Comparisons of demographics and pre-HSCT characteristics according to outcomes were made using a van Elteren stratified Wilcoxon rank sum test (continuous variables), or a Cochran-Mantel-Haenszel exact test , where the tests were stratified by median follow-up length after HSCT (≤26 months or >26 months). For outcomes that were measured as three-level categorical variables of either deterioration, no change, or improvement, the no change and improvement categories were combined and compared vs. the deterioration category in statistical analysis. Only outcomes that had a minimum of five patients in both categories were examined in statistical comparisons, and only demographics and pre-HSCT characteristics that were measured in at least 10 of the 15 patients were included in these comparisons. Associations of demographics and pre-HSCT characteristics with the combined outcome score were assessed using linear regression models that were adjusted for follow-up length after HSCT as a continuous variable. No adjustment for multiple testing was made in these exploratory analyses, and CSF1R-ALSP treated with HSCT were included in the study. All 15 patients harbored different CSF1R mutations  and were more likely to have gait problems as their predominant symptom  compared to patients with deterioration on cognition  findings were observed , more often had an initial symptom of gait problems , had a younger age at HSCT , and more often had a predominant symptom of gait problems . Regarding the combined outcome score, this was higher (indicating better outcomes) for patients with an initial symptom of gait problems (p = 0.009) and for patients whose predominant symptom was gait problems (p = 0.001).Associations of demographics and pre-HSCT symptoms with combined outcome measures are displayed in We found that gait problems as the initial and predominant manifestation of the disease were the most consistent predictors of good treatment outcomes. Moreover, younger age and an absence of pyramidal signs before HSCT increased the likelihood of good outcomes. There was also a suggestive association between disease duration before HSCT and treatment outcomes, with the shorter duration having better post-HSCT results, but it did not reach statistical significance. Conversely, prominent cognitive dysfunction was the most consistent predictor of bad outcomes following HSCT. The strongest link was observed for cognitive impairment as the first manifestation; however, there was also a suggestive association with cognitive impairment as the predominant symptom.CSF1R-ALSP; however, in other neurodegenerative diseases, cognition was shown to be one of the most important determinants of the QoL of patients and their caregivers [We found a significant link between the initial presentation with cognitive symptoms and the worsening thereof after HSCT. There was also a suggestive association between cognitive decline as a predominant symptom before HSCT and deterioration thereof after the treatment. There are no studies on quality of life (QoL) in regivers ,13,14. TCSF1R-ALSP to compare the results. It may be the case that the HSCT group had a more aggressive form of the disease with a worse prognosis than other CSF1R-ALSP patients. This may be supported by the lower mean age of onset in our cohort (39.5 years) than the previously estimated (43 years) in the group of 122 patients with CSF1R-ALSP [CSF1R-ALSP patients [CSF1R-ALSP and could be considered a representative sample.The higher-than-expected rate of bad outcomes (60%) in the present study is disconcerting. However, there are no previous studies systemically analyzing the HSCT outcomes in F1R-ALSP . ContrarF1R-ALSP . The preF1R-ALSP . CompariF1R-ALSP . Parkinspatients . In our patients . As gaitpatients . Thus, oOn the other hand, the bad outcome in most patients in the present study may be attributed to applying very strict criteria for good outcomes following HSCT. The reported pre-HSCT high rate of ADLs dependence and low rate of professional activity , that only slightly deteriorated during post-HSCT follow-up , together with observed in most patients no change or improvement in clinical symptoms post-HSCT, suggest at least stabilization of the disease in the majority of patients. Furthermore, given the aggressive natural course of the disease leading inevitably to death within few years from the onset, we think most patients actually benefited from the treatment.CSF1R-ALSP, a milder one manifesting primarily with motor phenotype and another more severe with predominant cognitive dysfunction. These subtypes not only differ by clinical manifestations but, most importantly, respond differently to HSCT and thus have distinct prognoses. As the treated group was small, it was impossible to investigate the two subtypes in more detail. The previous studies did not identify genotype-phenotype correlations [CSF1R-ALSP subtypes per se and their radiopathological characteristics were not elucidated.This study also provides evidence of at least two different subtypes of elations . Neuroimelations . Anotherelations ,18. HoweCSF1R-ALSP is challenging yet warrants further investigation. CSF1R-ALSP is a very rare disease, with approximately 300 cases reported worldwide. To further confound the picture, cognitive dysfunction and gait disturbances are both heterogenous groups of disorders with various pathological underpinnings. Lastly, the basis of these symptoms is not fully understood even in other, more common disorders, like multiple system atrophy, pseudotumor cerebri, or stroke [Understanding the molecular and pathological basis underlying phenotypic dichotomy in r stroke ,20,21. Ir stroke . Thus, dp-value in this study. The limited sample size also prevents a rigorous multivariable analysis assessing independent predictors of outcome following HSCT, or development of an algorithm or scoring system that can be used to predict outcome. With more patients undergoing HSCT in the future, it might be possible to compare the two distinct phenotypes regarding the age of disease onset, gender, and other important clinical variables to further clarify our observations.The main limitation of this study is the small sample size, which results in a lack of power to detect associations with outcomes. Therefore, the possibility of a type II error  is important to consider, and we cannot conclude that no true association exists simply due to the occurrence of a non-significant CSF1R-ALSP with different clinical presentations and responses to HSCT were recognized. Gait problems as initial manifestation and predominant symptomatology before HSCT indicated a milder disease phenotype with better response to HSCT and good therapy outcomes. On the opposite end were the patients who developed cognitive symptoms first, as they were the least likely to benefit from HSCT.Two distinct phenotypes of


Mammary Paget’s disease of the breast is an uncommon and often misdiagnosed breast malignancy. The review discusses the diagnosis, work-up, treatment, and prognosis of mammary Paget’s disease.Mammary Paget’s Disease is a non-invasive cutaneous malignancy of the breast involving the nipple-areolar complex that is commonly mistaken for benign breast conditions, leading to delay in diagnosis. This review article discusses Paget’s disease etiology, clinical presentation, differential diagnosis, diagnostic work-up, natural history and prognosis. This article also discusses evolving strategies for the surgical and non-surgical management of Paget’s disease. HER2 oncogene positivity, but estrogen and progesterone antigens are frequently negative  . In the Whether or not underlying malignancy is identified, patients presenting with a persistent nipple-areolar rash and suspected MPD should undergo a full-thickness biopsy of the nipple or areolar using a 2–4 mm diameter punch biopsy tool or a full-thickness incisional biopsy [There are no category 1 data that specifically address the local management of MPD according to the 3.2022 version of the National Comprehensive Cancer Network guidelines (accessed on 23 March 2022). Therefore, surgical management remains the main intervention for MPD based on the management of non-MPD-associated breast cancer. Total or skin-sparing mastectomy with surgical axillary staging with or without breast reconstruction is frequently performed for the treatment of MPD due to the frequency of multicentric or multifocal disease . HoweverNon-surgical or limited surgical approaches have also been utilized to manage MPD. In cases without evidence of underlying disease, non-operative management can offer an effective alternative therapy to traditional breast-conserving therapy. In a study by Bulens, et al., 13 patients with MPD confined to the nipple or surrounding skin without signs of an underlying tumor were treated with radiotherapy alone without surgical resection, with no recurrences detected after 58.6 months of mean follow-up . AlternaNearly all patients diagnosed with MPD have either underlying invasive or intraductal carcinoma . In patiThe study by Kothari, et al.  of 70 paIn a retrospective study of 200 women with MPD followed for 25 years, Dalberg, et al. studied the effects of various treatments on survival and recurrence . Twenty Another prospective study observing local recurrence following breast-conserving therapy and radiotherapy included 61 patients with MPD without underlying invasive carcinoma . Of patiIn a study by Dubar, et al., 36 patients with MPD and no underlying palpable mass or mammographic anomaly underwent complete or partial resection of the areola and radiotherapy, of which 11% developed a local recurrence at a median follow-up of 112 months [Additionally, a 2003 report by Marshall, et al. for the American Cancer Society studied 38 cases of biopsy-proven MPD from 7 institutions between 1980 and 2000 treated with BCS and radiotherapy with a median follow-up of 113 months . At the Without treatment, the skin lesions and underlying disease will progress to the development of invasive breast cancer, potentially followed by lymph node and visceral metastasis. The presence of a palpable breast tumor, lymph node enlargement, high nuclear grade, and age below 60 years are unfavorable prognostic factors that correlate with a high risk of invasive carcinoma and a high rate of lymph node metastasis .Many studies have found that MPD negatively influences breast cancer survival, consistent with its tendency to develop in association with higher-stage disease. Ordz-Pagan conducted a study comparing MPD and non-MPD groups and found that the non-MPD group had an overall 5-year survival rate of 93.8% compared to 81.2% for MPD; however, there was no difference in disease-free survival (DFS) . HoweverLymph node status correlates with overall survival with 75–95% 5-year overall survival in patients with negative lymph nodes compared to only 20–25% in patients with positive lymph nodes . There i


To measure trends in the supply of DMPA-SC in public and private health facilities and compare with other prominent modern methods.We used repeated cross-sectional data from service-delivery-point surveys in six settings: Burkina Faso, Democratic Republic of Congo , Nigeria (Kano and Lagos), and Uganda, each with 3-5 rounds of data collected between 2016 and 2020. We analyzed trends in DMPA-SC availability using percent of service delivery points offering the method and percent experiencing stockouts; trends were compared with those for DMPA-IM, IUD, implants, and other short-acting methods, by facility type.All settings showed increased offering of DMPA-SC over time for both private and public facilities. Larger proportions of public facilities provided DMPA-SC compared to private facilities (66%–97% vs 16%–50% by 2019–2020). DMPA-SC was provided by fewer facilities than DMPA-IM , but comparable to implants  and IUDs . Trends of DMPA-SC stock varied by setting, with more consistent stock available in private facilities in the DRC and in public facilities in Burkina Faso and Nigeria. Uganda showed decreasing stock in public facilities but increasing stock in private facilities.DMPA-SC availability has been increasing since its introduction in sub-Saharan Africa, yet significant gaps in stock exist. Countries should consider alternative distribution models to address these issues.Our findings may help inform countries about the need to monitor DMPA-SC availability and to consider solutions that ensure contraceptive options are available to women who need them and disruptions to contraceptive use are minimized. Its benefits include a delivery design that combines the drug and needle in a prefilled system, making it simple to administer and suitable for self-injection  been out of stock at any time in the last 3 months?” Combining data from these 2 questions, stock status for each method was analyzed using 3, mutually exclusive categories: “currently in-stock,” if they had stock at the time of the survey and had not experienced a stockout over the previous 3 months; “currently in-stock but had a recent stockout” if they had stock at the time of the survey, but experienced a recent stockout; or “currently out-of-stock” if they did not have stock at the time of the survey.DMPA-SC trends were compared to other modern methods, namely DMPA-IM, intrauterine devices (IUD), implants, and other short-acting methods . Service delivery points were coded as providing other short-acting methods if they reported providing at least one of the included methods and coded as in stock if they had any in stock. Analyses were stratified by public and private managing authority. Number of service delivery points per facility type, by round of data collection and setting are outlined in 2.5For each setting, we tabulated the percentage of service delivery points that provided DMPA-SC over the period from 2016 to 2020 by facility type, and then compared this to provision trends observed for other modern methods over the same period by facility type. Next, within each setting, we presented trends of DMPA-SC stock status by facility type, limiting our analysis to service delivery points that reported providing DMPA-SC. All analyses were conducted using Stata 16.1.33.1All settings generally showed increasing provision of DMPA-SC for both private and public facilities . More puMost settings saw steady increases in DMPA-SC provision over time; however, in Kano and Lagos, provision remained low in both public and private facilities until 2020, when we see a sharp increase in public facility provision . Similar increases were not observed in private facilities, where provision remained low .Burkina Faso showed consistently high DMPA-SC provision in public facilities, increasing from 80% in 2016 to 100% by 2018 and remaining around this level until 2020. While Uganda's public provision reached 84% in 2019, this increase was gradual. Comparatively, private facility provision was approximately 30% in both settings.In the DRC, DMPA-SC provision increased steadily over time in Kongo Central for both private and public facilities; however, by 2020, only 27% of private facilities and 66% of public facilities provided the method. These levels were lower than those observed in Kinshasa, where 50% of private facilities and 90% of public facilities provided DMPA-SC by 2020.3.23.2.1Similar to DMPA-SC, provision of DMPA-IM was higher in public facilities than private facilities across all settings . DMPA-IM3.2.2Other short-acting methods were provided by almost all public and private facilities, except in Burkina Faso . Public facilities showed a decrease in DMPA-SC availability between 2016and 2017, but rebounded thereafter. By 2020 availability of DMPA-SC in public facilities was slightly higher than in private facilities, with 32% to 40% of private facilities experiencing a recent or current stockout.In Kano, stock was 100% available in the 3 public and private facilities that offered DMPA-SC. By 2020, availability maintained at 84% in public facilities; however, the 2 private facilities experienced a recent or current stockout. Similar stock trends were not viewed in Lagos. The few public and private facilities that offered DMPA-SC in 2017 and 2018 almost always experienced a recent or current stockout. By 2020, availability increased to 96% in public facilities and 66% in private facilities.In Uganda, DMPA-SC stock availability decreased over time in both public and private facilities. In public facilities, current stockouts increased from 26% in 2017 to 39% in 2019; whereas in private facilities, recent stockouts increased from 10% to 29%, while current stockouts were cut by more than half from 2018 to 2019.4This is the first study to describe trends of DMPA-SC provision and stock availability and compare with other contraceptive products at public and private facilities across multiple country settings. Specifically, we examined DMPA-SC supply side trends, using data from 6 settings. Results showed that an increasing number of facilities provided DMPA-SC over time in both the public and private sectors, and across all settings. More public facilities provided the method than private, but this difference was not unique to DMPA-SC. This pattern was also observed for DMPA-IM and long-acting methods.A strength of this study is its use of facility data at multiple time points and settings. The DHS Service Provision Assessments (SPA) only provide a snapshot of contraceptive supply and availability at irregular intervals and for a limited number of countries Our study observed supply side trends that are consistent with increasing DMPA-SC prevalence across SSA Despite its relatively recent introduction, DMPA-SC provision has reached the same degree of availability as implants and IUDs. It can potentially surpass them to reach the same level as DMPA-IM, as previous studies have described how short-acting reversible methods, including injectables, are more available than long-acting ones, such as implants and IUDs ,17,19. SThis research is not without limitations. Given annual data collection, we could not detect potential changes in stock patterns at shorter time intervals. Previous work found variation in contraceptive availability in 4 African countries using data collected quarterly in only 2 years Overall, despite the increasing availability of DMPA-SC, availability varies by facility type and across settings. Persistent stockouts and limited method options can disrupt contraceptive use and increase discontinuation


Background: Diagnosis of co-infections with multiple pathogens among hospitalized coronavirus disease 2019 (COVID-19) patients can be jointly challenging and essential for appropriate treatment, shortening hospital stays and preventing antimicrobial resistance. This study proposes to investigate the burden of bacterial and fungal co-infections outcomes on COVID-19 patients. It is a single center cross-sectional study of hospitalized COVID-19 patients at Beit-Jala hospital in Palestine.Methods: The study included 321 hospitalized patients admitted to the ICU between June 2020 and March 2021 aged ≥20 years, with a confirmed diagnosis of COVID-19 via reverse transcriptase-polymerase chain reaction assay conducted on a nasopharyngeal swab. The patient's information was gathered using graded data forms from electronic medical reports.Results: The diagnosis of bacterial and fungal infection was proved through the patient’s clinical presentation and positive blood or sputum culture results. All cases had received empirical antimicrobial therapy before the intensive care unit (ICU) admission, and different regimens during the ICU stay. The rate of bacterial co-infection was 51.1%, mainly from gram-negative isolates (Enterobacter species andK.pneumoniae). The rate of fungal co-infection caused byA.fumigatus was 48.9%, and the mortality rate was 8.1%. However, it is unclear if it had been attributed to SARS-CoV-2 or coincidental.Conclusions: Bacterial and fungal co-infection is common among COVID-19 patients at the ICU in Palestine, but it is not obvious if these cases are attributed to SARS-CoV-2 or coincidental, because little data is available to compare it with the rates of secondary infection in local ICU departments before the pandemic. Comprehensively, those conclusions present data supporting a conservative antibiotic administration for severely unwell COVID-19 infected patients. Our examination regarding the impacts of employing antifungals to manage COVID-19 patients can work as a successful reference for future COVID-19 therapy. Additionally, it causes multi-organ failure that involves sepsis and thromboembolic complications, which progresses into an acute kidney and cardiac injury. On March 11th, 2020, the World Health Organization (WHO) deemed coronavirus disease 2019 (COVID-19) a pandemic disease due to its unusual transmission speed and the wide scale of infection.Severe Acute Respiratory Syndrome Coronavirus 2 (SAR-CoV-2) is a highly contagious novel viral pathogen that provokes an immediate spread among hospitalized patients with Community-Acquired Pneumonia (CAP) The possibility of co-infections raises concerns as it hinders COVID-19 management, worsens prognosis, and might increase the fatality rate. The reported prevalence of bacterial co-infection varies between studies. Previous studies showed a low prevalence of early bacterial coinfection., On the other hand, data from France pointed to a high prevalence of early bacterial coinfection during severe COVID-19 pneumonia.The bacterial and fungal co-infections are frequently recurring due to respiratory viral diseases. For example, most deaths in the Spanish flu pandemic in 1918 were due to subsequent bacterial infection.S. aureus, S. epidermidis, H. influenzae, Streptococcus spp.,E. coli, K. pneumoniae, and P. aeruginosa. Therefore, many COVID-19 treatment protocols include empirical antibiotic therapy to cover suspected organisms. Thirty studies were summarized in a systematic review, including 3834 COVID-19 patients. Overall, only 7% of the hospitalized patients were confirmed to have bacterial co-infection with one or more pathogens, primarily in seriously ill patients. On the contrary, diagnosis and/or treatment of fungus infections in COVID-19 patients are neglected or delayed, and the actual prevalence of fungal co-infection is yet to be established. Few studies addressed this issue; one systematic review meta-analysis research was carried out in China on 2780 confirmed SAR-CoV-2 participants from nine relevant articles. After fungal culturing at admission, 0.12%-0.15% of the cases were positive for fungal infection, and Asian patients were more likely to acquire fungal co-infection than the patients in the studies from the U.K. The infecting fungi includeAspergillus, Candida, Cryptococcus neoformans, andPneumocystis.Throughout the pandemic, evaluation of gathered specimens from hospitalized COVID-19 patients reported the following as the most prevalent organisms that induce co-bacterial infection: In addition, it debilitates the body's defense and induces cellular dysfunction and death.The exact mechanism of microbial co-infection is inadequately understood. Virologists assumed that the viruses attach and penetrate the host's airway epithelial cells creating an inflammatory response, desensitizing Toll-like receptors, and leading to cellular apoptosis in numerous mechanisms. Furthermore, various researchers, highlighted the synergy regulations among viruses and bacteria; both are jointly advantageous, aggravating clinical outcomes. If this cooperation is confirmed, the management of some viral infections with antibiotics becomes further necessary.Viruses aid in proliferation, colonization, and invasive infection of opportunistic nosocomial pathogens or normal respiratory tract flora, hindering the innate immune response, compressing airway mucus, and disrupting the cilia allowing the virus to spread and adhere to more sites. However, according to current studies, most COVID-19 patients did not have bacterial or fungal co-infections upon admission or through the hospital stay, even though they received antibiotics upon admission or before diagnosis. Furthermore, many factors advocated escalation of antimicrobial consumption during the pandemic: lack of specific antiviral agents, the overload of the health services’ capacities, saturated laboratories, and diagnosis uncertainty. As a result, clinicians are obliged to prescribe broad-spectrum multi-antibiotic regimens to treat all the possible infected pathogens. Therefore, this study aimed to investigate and evaluate bacterial and fungal co-infection burden and prevalence among COVID-19 patients admitted to a treatment facility at Beit-Jala hospital in Palestine. In addition, it reveals the etiology of the infection, provides the antimicrobial stewardship that was used in the hospital and provides insight into the association of clinical outcomes with several factors and comorbidities.COVID-19 has been chiefly linked to high levels of inflammatory markers, such as elevated levels of C-reactive protein and procalcitonin. Accordingly, the similarity between Sar-CoV-2 and bacterial infections in radiological infiltrates and laboratory findings makes it challenging to provide a precise diagnosis in daily medical practice.The current research is based on data extraction from electronic medical reports, and as such, it is not considered human subject research. Neither patients nor the public was involved in this research’s design, conduct, or reporting. The research was done retrospectively and without patient involvement. The study was approved by the Scientific Research Ethics Committee of Birzeit University on 27-2-2021 and by Beit-Jala hospital on 10-3-2021. The permission to use the generated data was obtained from the Beit Jala Governmental Hospital laboratory administration.This single-center cross-sectional study was conducted at Beit-Jala hospital, one of the central institutes for treating SAR-CoV-2 patients in Palestine. Patients included in this study were aged 20 years and older as patients under 20 are not admitted to this hospital. The records were for critically ill patients admitted to the ICU between June 2020 and March 2021. All patients were diagnosed with COVID-19 via reverse transcriptase-polymerase chain reaction assay (RT-PCR) conducted on nasopharyngeal swab specimens. A total of 458 records of moderate-severe COVID-19 ill patients were screened and evaluated. 321 patients who had positive cultures for bacteria or fungi within 48 hours of hospital admission were included in the study, and patients with negative cultures were excluded.th-29th of March 2021 and verified by a second researcher, using graded data forms from electronic medical reports. The obtained data were socio-demographics, chronic comorbidities, laboratory findings , duration of the ICU stay, and if they had taken an iron supplement. The bacterial or fungal co-infection was proved through clinical presentation and positive blood or sputum testing via Laboratory Information System. Before and during the ICU admission, antimicrobial utilization was recorded, and the reports were double-checked for accuracy and completeness.Data extraction was done manually by one researcher between the 15Data were analyzed, socio-demographic and clinical characteristics were summarized using relevant descriptive statistics, and categorical variables as percentages and frequencies. Pearson’s Chi-square test was performed to determine the association between the main parameters: the ICU residency duration and the other factors such as age, gender, iron supplements, antibiotics administration before and during the ICU admission, smoking habits, and comorbidities. Data was analyzed and presented using SPSS version 22.0.2), Leukocyte numbers, and body temperature. Patients were immediately admitted to the ICU if two or more of the above matched positive isolates test and their CT scan showed pneumonia.Co-infection is a sequela that occurs during or after the primary causative pathogen or treatment. The isolated bacteria or fungi obtained from COVID-19 patients should be clinically relevant, not microbiota or contaminants. All the microbiological samplings were conducted upon the hospital’s entry and before the ICU admittance, and only patients holding positive bacterial or fungal outcomes were admitted into the unit. In combination with decision-making, a scope of tests should be met to provide permission on who necessitates access, including computerized tomography (CT) scans to reveal ground-glass opacification, which correlated with pneumonia. In addition, supplementary laboratory outcomes were crucial in making the diagnosis, such as C-reactive protein (CRP) level, Oxygen saturation  andEnterobacter 24.9% (80), as shown inThe overall mortality rate in this study was (26/321*100% = 8.1% (26)), while 72.9% (234) of the patients remained in the ICU for 1-6 days. Each patient was infected with one type of bacteria or fungi, which presented as a respiratory infection, bacteremia, and skin infections. A total of six different pathogens were detected in the samplings and considered the infecting organisms. The most abundant types wereA. fumigatus started therapy with fluconazole 200 mg/day. Since then, 100% of the patients with fungal infections have been successfully treated. Considering different regimens had notable distinct outcomes, analysis was performed to determine the association linking antimicrobial therapy class and the ICU stay or death  received ceftriaxone 2 g/day, and 30.5% (98) patients had received ampicillin and sulbactam 12 g/day; both regimens were administered intravenously (IV). Upon ICU admission, every patient received at least one IV antibiotic regimen throughout their ICU stay. 43.0% (138) received combination of meropenem 2 g/day, and vancomycin 1 g/day, and 35.5% (114) were given piperacillin/tazobactam 13.5 g/day and levofloxacin 500 mg/day. By January and after getting financial support from the Ministry of Health, patients infected withr death . After hP=0.035):  of patients with no chronic diseases have died after being admitted to ICU compared to  of patients diagnosed with at least one chronic disease. Add that a significant association was found between the residency duration and SpO2 (P=0.032): patients whose SpO2 levels were <90%  were admitted in the ICU for a shorter duration (1-6 days) compared to patients whose SpO2 read >90% .P=0.008). The patients suffering from fungal co-infection  spent fewer days in the ICU than patients with bacterial co-infection .P<0.001). Patients administered ceftriaxone  were more likely to stay in the ICU for fewer days than patients administered ampicillin/sulbactam . In addition, patients who received fluconazole  significantly stayed for fewer days in the ICU compared to those administered piperacillin and tazobactam with levofloxacin  or meropenem with vancomycin  respectively (P<0.001).The selection of empirical antimicrobial options was associated with the length of hospital stay. There was a significant association between ICU residency duration and the empirical antibiotics (P<0.001).Moreover, patients that were administered iron supplements as part of their therapy regimen  were significantly more likely to stay for a shorter duration of time compared with those who were not administered iron  for patients admitted to the ICU due to Covid-19 coinfections found by this study is much lower than other reported rates of 25.7 % in a systematic review that included 15 studies in different countries. Based on the knowledge of SARS in 2003 and the invasive Aspergillosis, it is vital to consider the possibility of a life-threatening fungal infection accompanying COVID-19. At the beginning of blood/sputum culturing, the number of cases infected byA. fumigatus was 48.9% (157). Those patients were initially given antibacterial regimens before and during their ICU stay without fluconazole due to medication cost. Fluconazole was added to the hospital formulary by January and confirmed fungal infections were treated with fluconazole. The addition of fluconazole to empirical therapy had reduced the average ICU stay from six days to less than two days, and the mortality rate fromA. fumigatus decreased from 4.5% to 0%. Infection disease specialists realized the risk of fungal co-infection through the pandemic; the French High Council for Public Health recommended that clinicians concentrate on fungal infections in COVID patients, particularly in severe disease cases.COVID-19 patients are at risk of fungal infections during the latter stages of the disease due to seriously damaged alveoli and the decline in leukocyte counts.Enterobacter infected patients; this may be due to its known drug resistance. It should be noted that normal oral flora colonization or contamination may occur, particularly in the sputum specimens. In general, the empirical treatment with ceftriaxone or ampicillin/sulbactam showed minimal benefits to the clinical status. However, we observed a better prognosis with ceftriaxone than ampicillin/sulbactam, with mortality rates at 4% (9) and 17.3% (17), respectively; more studies are needed to confirm this association.Bacterial co-infection was recorded in 51.1% (164) of cases, with higher mortality rates among Furthermore, after the recovery and discharge from the hospital, all outpatients were prescribed azithromycin, which also has antiviral activity and may decrease the incidence of acute organ failure.The wide-spectrum antimicrobial regimens are administered once the bacterial co-infection is confirmed and the patient is admitted into the ICU. Unfortunately, there is no available data to compare COVID-19 patients who received antibacterial agents with those who did not, which could help determine therapeutic efficacy. However, a regimen of piperacillin with tazobactam and levofloxacin resembles meropenem and vancomycin in terms of clinical outcomes and management rate. Other studies had revealed a higher rate of mortality and organ failure in patients administered meropenem. In our study, it appeared to induce a good prognosis. Ceftriaxone, meropenem, and vancomycin regimens have been linked with more favorable outcomes and lower mortality rates. Until solid evidence is available, antimicrobials should be maintained for critical cases and constantly re-evaluated based on the patient's progress. The antimicrobial therapy must only cover the suspected or confirmed bacterial infection.Earlier examinations illustrated that multiple antibiotic administrations did not alter the disease progression or patients' higher mortality rates. This inappropriate behavior will lead to the evolution of high levels of antibiotic-resistant bacteria.Antibiotic resistance and allergic reactions are multifactorial issues, and the pandemic has impacted the health system and provided a suitable environment for bacteria to become resistant to antimicrobials. In our study, all COVID-19 patients were admitted to the ICU and received at least four diverse types of broad-spectrum antibacterial agents; in addition, the accessibility of over-the-counter antimicrobials had undeniably grown through the pandemic., This significant finding is due to the characteristics of critically ill patients receiving therapy via invasive catheters and being at risk of infection by nosocomial pathogens. Moreover, the unusual rate of infection has been credited to the exhaustion in the clinical care system, creating a prolonged hospital exposure, principally in the major waves of the virus.This study's unusual incidence of bacterial or fungal infections and mortality rates differs from other published studies. Leukocytosis aids in the disease progress evaluation and reflects the severity of COVID-19 infection; it is exacerbated by the cytokine storm and inflammatory mediators that drive apoptosis and pulmonary microvascular destruction, creating alveolar oedema. The increased level of CRP is a diagnostic biomarker for coronavirus in distinguishing moderate and critical patients. The pathogenesis of COVID-19 involves a vigorous inflammatory response that manages a dysregulated flood of immune cells and signaling molecules. In general, viral respiratory infections have been linked to hypoxia. COVID-19 patients are considered hypoxic if their oxygen saturation level is <90%, while the normal SpO2 is ≥95% at rest in healthy people. Hypoxia is a fearful condition that is monitored and adjusted by mechanical ventilation. Although several studies, reported links between laboratory findings and clinical outcomes, our cases did not show a significant link.Patients included in this study were 100% severe-critical ill. Therefore, it is necessary to differentiate between mild-moderate and severe patients and prioritize the ICU admittance. Fever was the notable symptom of SARS-CoV-2 infection identified at the early stages of the disease. Regarding laboratory findings, leukocytosis occurred in critically ill patients with distinct grades, and it was observed in 11.4% of severe COVID-19 cases. indicated that smokers are twice as likely to develop severe COVID-19 as nonsmokers, as smoking tobacco induces alterations in the respiratory tract and cell-mediated immune response. Furthermore, current smokers have higher ACE-2 gene expression than non-smokers; this gene is responsible for ACE-2 receptors production, which COVID-19 attaches to and penetrates the cells, thus raising the chance of infection. Our study did not find an association between smoking habits and the duration of ICU stay or clinical prognosis.Throughout the coronavirus pandemic, tobacco smoking issues and the risk of infection was constantly reviewed. Published research, found that older COVID-19 patients aged ≥50 years were correlated with a higher risk for severe signs, atypical presentation, the opportunity for co-infections, and higher fatality rates than patients <50 years of age. The rate usually increases rapidly with age, which is not surprising due to the drop in natural immunity with aging and associated comorbidities. In addition, it is believed that older people are prone to adverse drug reactions. In general, people of older ages are more prone to becoming infected with the COVID virus than younger people. A review reported that the fatality rate is doubled in males compared to females; it stated that male patients might have higher ACE-2 enzyme activity, directed by male sex hormones, contributing to more risk factors for SARS-CoV-2 infection worsening clinical outcomes. Additionally, the smoking rate is higher in males.Numerous investigations, There was no association between age, gender, or comorbidities with the clinical outcomes and ICU stay duration in our study.Effects of comorbidities such as hypertension, diabetes mellitus, coronary heart disease, and cancer were compared between survivors and non-survivors of COVID-19. Participants with comorbid conditions have a significantly greater fatality rate than those without them because they have decreased natural immunity and are poly-pharmacy patients. the innate immune system limits the bioavailability of iron in order to diminish viral replication and infection. Accordingly, iron absorption from the diet is reduced, and the liver generates hepcidin, which blocks iron from carrying out of the cell. Accordingly, iron supplementation may exacerbate the disease and increase the inflammatory process. However, no solid investigations were performed on the relation between iron and clinical results in COVID-19 patients. In the study, 62.6% of the patients received IV iron supplements for three days based on a randomized clinical trial. 99% had improved and stayed for a shorter time (1-6 days) in the ICU than those who did not receive IV iron; thus, it can be suggested that the iron provided an enhancement to immunity. Therefore, there is a strong association between low serum levels of iron and an increased infection rate and morbidity.Previous reports described mild anemia in COVID-19 patients at the ICU; due to severe inflammation that consumes iron, In our study, patients received NAC 1200 mg/day during the hospital stay, and even after discharge, they showed a good prognosis and improvement in their health status.COVID-19 produces oxidative stress irregularity, and this process has been enhanced by glutathione reduction. Thiones are synthesized in a multi-step process involving N-acetyl-cysteine (NAC). Thiones are also ACE-2 blockers, thereby diminishing SARS-CoV-2 penetration into the cell. In a placebo-controlled study, NAC administration had reduced plasma inflammatory biomarker levels via several mechanisms. Besides antioxidant activity, NAC has vasodilator activity, especially in the intravenous route. In addition, it has mucolytic properties, inhibits RNA virus replication, and has confirmed protective effects against comorbid conditions, including cardiovascular diseases.This is the first research addressing co-infection among COVID-19 patients in Palestine and offering clinical base recommendations for patient management. Our study shows a high prevalence of fungus and bacterial co-infection among COVID-19 patients admitted to the ICU, which requires appropriate management and attention. The study findings support the importance of assessing fungus co-infection in COVID-19 patients, and the early initiation of an antifungal agent will decrease morbidity and mortality. Our examination of the impacts of employing antifungals to manage COVID-19 patients can be a successful reference for future COVID-19 therapy.This research has some limitations: first, it is a retrospective cross-sectional study holding obstacles restricting the potential bias and difficulty proofing the relation between the exposure and the outcome. Additionally, it is a single-center study, and its results could vary in another setting. Nevertheless, these conclusions present data supporting a conservative antibiotic administration for severely unwell COVID-19 infected patients.The COVID-19 pandemic exerts pressure on healthcare professionals, including a high probability of infection. It is eminent to save lives during this pressure, even if it means multi-drug antimicrobial regimens for prevention or treatment. However, the insufficiency of data about antibiotic types, dosage, and duration of treatment through the pandemic continues to be challenging to health care providers. In addition, bacterial and fungal co-infection is common among COVID-19 patients at the ICU in Palestine; it is not evident if these cases are attributed to SARS-CoV-2 or coincidental as there is little available data. Finally, antimicrobial stewardship, appropriate patient assessment, and selecting the appropriate antimicrobial agents for the right patient at the right time will decrease hospital stay, mortality, and health care costs.https://doi.org/10.5061/dryad.08kprr53r.DRYAD: Raw data and SPSS analysis for the article Bacterial and fungal co-infections among ICU COVID-19 hospitalized patients in a Palestinian hospital: Incidence and antimicrobial stewardship.-raw_data.xlsx (raw underlying data)-Readme.docx (data key)-variabels_and_Output_final.pdf (SPSS output file)This project contains the following underlying data:Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).Data are available under the terms of theHN Project Administration, Supervision, Writing – Review & Editing, UM and YS Data Curation, Writing – Original Draft Preparation, Formal Analysis, NA Formal Analysis, Writing – Original Draft Preparation, AA Methodology, Writing – Review & Editing, MD Methodology, Writing – Review & Editing, IA Data Curation, MF Writing – Review & Editing. All authors read and approved the final manuscript. All changes are made to the manuscript, no additional comments. I believe that the revised version is acceptable.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Bacterial and fungal co-infections among ICU COVID-19 hospitalized patients in a Palestinian hospital: a retrospective cross-sectional study - version 2 have substantially addressed all questions raised during the review process for the manuscript. The authors I can assure readers that the study adds value to the health policy maker and international literature.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:clinical pharmacy, pharmacy practice, pharmaceutical care, medications, drug utilization, disease management.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Please, add the duration of ICU stay (day) chronic cross tabulation.Please, if it's possible, classify patients according to the number of chronic diseases for each patient.Table 1 the author(s) provide the percent for: Diabetes mellitus 250 (77.9%) Atrial hypertension 213 (66.4%) Obesity 118 (36.8%) Coronary heart disease 74 (23.1%) Cancer However; in table 2 "Impact of different non-significant values on the duration in the ICU", they did not mention the data for coronary heart disease and for cancer. Please add the data in table 2 and make a discussion for the results concerning patients with coronary heart disease and cancer.The manuscript entitled "Bacterial and fungal co-infections among ICU COVID-19 hospitalized patients in a Palestinian hospital: a retrospective cross-sectional study" is a study to investigate the burden of bacterial and fungal co-infections outcomes on COVID-19 patients. It is a single center cross-sectional study of hospitalized COVID-19 patients at Beit-Jala hospital in Palestine. The study is important and well written; however there are some comments, such as:Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Dear Dr. Hamza, Thank you for your valuable comments. Following are our responses point-by-point to your comments: 1- Comment 1: Done. 2- Comment 2: Done, added to table 2.P= 0.035):  of patients with no chronic diseases have died after being admitted to ICU compared to  of patients diagnosed with at least one chronic disease." 3- Comment 3: Done "A significant association was found between the residency duration and having a personal history with no chronic diseases .Study design should be clearer to readers.458 records screened and 321 positive (this will result in 70% infected); if this is the case, please add the over all co-infection in the sample of 70% to your results.Between 4.5-8.5 mg/dL was rated as moderate and ≥8.5 mg/dL was rated as severe. Leukocyte results in the 4.6-8 g/L range were considered mild, while >8 g/L indicated seriously ill patients: this is not mentioned in your results or in the abstract and you can find a good correlation between the severity and co-infection, I think this will make the abstract much better.How did you calculate the mortality rate ?Some significant data in tables 2 and 3 worth mentioning in the results of abstract with P values.Under the tables, please state the test you used (Chi square) and be sure the abbreviations match too.In the discussion  do you think there is under-reporting or documentation of co-infection in Palestinian hospitals, or is this due to the broad antibiotic used which is restricted in other countries due to resistance concerns? The paper and subject are both valuable and are important to the scientific community, especially in this situation during the pandemic Covid-19. The paper is well-written, however some issues were raised during the review process and should be addressed:Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:clinical pharmacy, pharmacy practice, pharmaceutical care, medications, drug utilization, disease management.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Dear Dr. Maher Thank you for your valuable comments, when the article has received a second peer review report I will submit a revised version 2 of the article incorporating the changes as you requested. Dear Dr. Maher Thank you for your valuable comments. Following are our responses point-by-point to your comments: 1- comment 1: Clarified "with a confirmed diagnosis of COVID-19 via reverse transcriptase-polymerase chain reaction assay conducted on a nasopharyngeal swab and has a positive culture for bacteria or fungi as upon hospital admission". 2- comment 2: Done in all the text. 3- comment 3: As per the Article Guidelines: the abstract should be up to 300 words long, The abstract of the manuscript fits the journal's instructions. 4- comment 4: Changed and clarified the text. 5- comment 5: Clarified  " A total of 458 records of moderate-severe COVID-19 ill patients were screened and evaluated. Of those, 321 patients with positive cultures for bacteria or fungi were included in the study, and patients with negative cultures were excluded". 6- comment 6: This is already done and written in Table 2, but due to the absence of the association, as the chi-square result revealed, we did not mention it either in the text or in the abstract. 7- comment 7: Rewritten: "The overall mortality rate for our sample in this study was (26/321*100%= 8.1%)". 8- comment 8: Done " A significant association was found between the residency duration and SpO 2 ( P=0.032). The results revealed a significant association between ICU residency duration and the empirical antibiotics ( P<0.001)." 9- comment 9: Done for tables 2 and 3. 10- comment 10: Done "The mortality rate of 8.1% (26) for patients admitted to the ICU due to Covid-19 coinfections found by this study is much lower than other reported rates of 25.7 % in a systematic review that included 15 studies in different countries. Despite the absence of antimicrobial stewardship in urgent response, the hospital's initiation of drastic empirical administration was crucial for preventing or treating suspected infections. In addition, the hospital’s guideline adherence to empiric antimicrobial therapy and the other drugs was adequate. Furthermore, many factors could affect this finding, including the age and living situations; in our sample, two-thirds of participants were less than 65 years old. In addition, all participants did not live in nursing homes or elderly homes where a higher rate of antimicrobial resistance is expected."


Several studies have described potential microRNA (miRNA) biomarkers associated with migraine, but studies are scarcely reproducible primarily due to the heterogeneous variability of participants. Increasing evidence shows that disease-related intrinsic factors together with lifestyle , influence epigenetic mechanisms and in turn, diseases. Hence, the main objective of this exploratory study was to find differentially expressed miRNAs (DE miRNA) in peripheral blood mononuclear cells (PBMC) of patients with migraine compared to healthy controls in a well-controlled homogeneous cohort of non-menopausal women.Patients diagnosed with migraine according to the International Classification of Headache Disorders (ICHD-3) and healthy controls without familial history of headache disorders were recruited. All participants completed a very thorough questionnaire and structured-interview in order to control for environmental factors. RNA was extracted from PBMC and a microarray system  was used to determine the miRNA profiles between study groups. Principal components analysis and hierarchical clustering analysis were performed to study samples distribution and random forest (RF) algorithms were computed for the classification task. To evaluate the stability of the results and the prediction error rate, a bootstrap (.632 + rule) was run through all the procedure. Finally, a functional enrichment analysis of selected targets was computed through protein–protein interaction networks.After RF classification, three DE miRNA distinguished study groups in a very homogeneous female cohort, controlled by factors such as demographics (age and BMI), life-habits , comorbidities and clinical features associated to the disease: miR-342-3p, miR-532-3p and miR-758-5p. Sixty-eight target genes were predicted which were linked mainly to enriched ion channels and signaling pathways, neurotransmitter and hormone homeostasis, infectious diseases and circadian entrainment.A 3-miRNA  novel signature has been found differentially expressed between controls and patients with migraine. Enrichment analysis showed that these pathways are closely associated with known migraine pathophysiology, which could lead to the first reliable epigenetic biomarker set. Further studies should be performed to validate these findings in a larger and more heterogeneous sample. Migraine is a genetically-driven, chronic brain disease that ranks second on the most disabling neurological disorders of the Global Burden of Disease Study , 2. If nFrom large-scale genome-wide association studies (GWAS) performed in the last decades, we have learnt that migraine has a polygenic heritability pattern and, up to now, we have identified more than 120 risk loci associated to migraine , mainly Among the epigenetic regulatory mechanisms, microRNAs (miRNA) are a subtype of noncoding RNA of ∼22 nucleotides long that act as key regulators of genetic expression by inhibiting transcription or promoting degradation of selected messenger RNAs (mRNAs). A single miRNA sequence could regulate multiple mRNA, exerting a pleiotropic modulation of cellular processes. miRNA have been found intracellularly and in all body fluids, including plasma, saliva and urine . AccessiSeveral pilot studies have described miRNAs as potential peripheral biomarkers of migraine disease –26. NeveHence, the goal of this exploratory study is to find differentially expressed miRNAs (DE miRNA) in PBMC of patients with migraine compared to healthy controls in a well-controlled homogeneous non-menopausal female cohort.The study was approved by our Institutional Review Board (PR(IR)224/2016). All participants provided written informed consent before participation. We recruited patients treated for migraine in the Headache Outpatient Clinic. Patients had a diagnosis of migraine with or without aura, confirmed by a neurologist according to the International Classification of Headache Disorders, 3rd edition (ICHD-3)  days/month (d/mo) and median MAMI was 7.5  d/mo. Main demographic and clinical characteristics are shown in Table Participant recruitment is represented in Fig. p = 0.420.No statistically significant differences were found in terms of RNA quality  between study groups: 6.9  HC vs. 6.7  patients; During microarrays QA, we distinguished two samples (from patients) with higher values of intensity in all their probe sets. Similarly, normalized unscaled standard errors values and relative log expression values for the same two samples diverged from the rest, indicating aberrant expression. Hence, we discarded these 2 samples from further analysis Fig. . Control2FC: -0.551), miR-532-3p (log2FC: -1.109) and miR-758-5p (log2FC: -0.508).Adjusting by STAI-trait values, we found 191 DE miRNA between study groups: 59 over-expressed and 132 under-expressed transcripts in patients  between controls and patients with migraine in a very homogeneous female cohort, controlled by factors as demographics, life-habits and comorbidities  . This isSeveral authors have made an effort in previous studies to identify potential miRNAs as peripheral biomarkers of migraine . NumerouFunctional analysis showed that targeted genes associated to the 3-miRNA signature enriched pathways have been previously described and associated with migraine pathophysiology. One of the most enriched targets is CACNA1C which encodes for the alpha-1 subunit of a voltage-dependent calcium channel. Calcium channels mediate the influx of calcium ions into the cell upon membrane polarization and they are encoded by different subunits of the CACNA1 gene (CACNA1A-S) , 83. FroOther enriched pathways codifying for vascular functions which may have and important role in migraine etiopathogenesis were the notch signaling pathway, the inflammatory mediator regulation of TRP channels and the HIF-1 signaling pathway. Notch receptors (Notch1-4) are a family of type-1 transmembrane proteins which are essential for embryonic development. Mutations in the Notch pathway genes, like NOTCH2 and JAG1, are associated with vascular abnormalities . In migrThe relationship between hormones and neurotransmitters with migraine is not entirely clear, but we do know it exists and plays a fundamental role in its pathophysiology. On one hand, thyroid hormones, along with PTX3 and, insulin resistance share common mechanisms in the development of endothelial dysfunction , a vascuAltogether, the 3-miRNA signature found could be a reliable biomarker for migraine diagnosis not only because they are differentially expressed between female patients and controls, but they are also involved in enriched biological processes which have been previously described in migraine pathophysiology. So, the under-expression of these transcripts may cause a dysregulated expression of genes associated with the vascular dysfunction and neurohormonal imbalances characterized by patients with migraine.This study has limitations. First, RNA-seq is the most commonly used NGS technique to explore differences at transcript level to date. RNA-seq is able to detect novel transcripts with higher specificity and sensitivity. However, at the moment of designing and planning the current study, arrays where the more standardized technology. In addition, the RNA-Seq procedure has a few disadvantages compared to arrays: a lack of optimized and standardized protocols for analysis , 108; thA 3-miRNA signature  has been found differentially expressed between controls and patients with migraine in a very homogeneous cohort of non-menopausal women, controlled by factors such as demographics, life-habits and comorbidities. Enrichment analysis show that these three miRNAs are closely associated with migraine pathophysiology, maybe becoming the first reliable biomarker of disease. Further studies will be performed to validate them in a larger and more heterogeneous sample.


Food energy under-reporting is differentially distributed among populations. Currently, little is known about how mental health state may affect energy-adjusted nutrient intakes among food energy under-reporters.n = 8,233) who were deemed as under-reporters based on Goldberg's cutoffs.Stratified analysis of energy-adjusted nutrient intake by mental health (poor vs. good) and age/sex was conducted using data from Canadian Community Health Survey (CCHS) respondents  < 0.05). For women (51–70 years), all micronutrient intakes, except iron, were significantly lower among those reporting poor mental health (p < 0.05). For men (31–50 years), B vitamin and most mineral intakes, except sodium, were significantly lower among those reporting poor mental health (p < 0.05). Among women (31–50 years) who reported poor mental health, higher energy-adjusted intakes were reported for vitamin B9 and phosphorus (p < 0.05).Most were experiencing good mental health (95.2%). Among those reporting poor mental health, significantly lower energy-adjusted nutrient intakes tended to be found for fiber, protein, vitamins A, BAmong food energy under-reporters, poor mental health tends to lower the report of specific energy-adjusted nutrient intakes that include ones critical for mental health. Future research is needed to discern if these differences may be attributed to deviations in the accurate reports of food intakes, measurement errors, or mental health states. A longstanding criticism of self-reported dietary intake data is the underestimation of dietary energy intake (EI) in relation to requirements, commonly referred to as food energy under-reporting , 2. ThisFood energy under-reporting is differentially distributed among populations. Factors associated with food energy under-reporting include female sex, older age, income, body weight status and history, diet composition , eating behaviors, social desirability, body image, and physical activity –10. ThesThe limited research related to mental health state and food energy under-reporting has mainly focused on individuals with a diagnosed condition. A small study, which compared food energy under-reporting in women with schizophrenia and controls, found that food energy under-reporting was more prevalent among those with the mental health condition (77%) vs. those without (50%) . In anotTo help address gaps in knowledge about the effects of mental health state on nutrient intake analysis results among food energy under-reporters, data from a large, national sample from the CCHS were analyzed. The objective of the analysis was to examine if there are differences in energy-adjusted nutrient intakes among food energy under-reporters experiencing good and poor mental health by age and sex categories. It is hypothesized that the energy-adjusted nutrient intakes among food energy under-reporters will be significantly lower among those experiencing poor mental health when compared to those who report good mental health. The results from the analysis of this national survey may help to determine if mental health state is a factor to account for in studies that include dietary intakes.The sample was derived from Statistics Canada's CCHS – Cycle 2.2 (2004), which provides the only Canadian national data to date that includes both detailed nutrient intake data and a measure of mental health . This suThe sample included CCHS respondents between the age of 14 and 70 years 22,709) who were considered food energy under-reporters as defined by Goldberg's cutoffs for EI-to-basal metabolic rate (BMR) . EI plau2,709 whoEnergy under-reporting is an important challenge in nutrition epidemiology as it affects the estimation of EI and consequently of other nutrients, which then may lead to a mis-estimation of nutrient inadequacy and bias in the associations between diet and diseases. Given that key characteristics of under-reporters are being women, younger age, and having non-favorable self-reported health perception status , the focDietary intake data were based on 24-h dietary intake recalls that were conducted in-person and included the use of the multi-pass method. For a subset of CCHS respondents, a follow-up 24-h recall was done by telephone between 3 and 10 days after the first interview and this data helped to adjust for day-to-day variability. Energy-adjusted nutrient intakes were derived using the density method where values are reported per 1,000 kcal . The CanPerceived mental health, a variable that captures the various dimensions of mental health experiences, was used to stratify the sample by mental health status. The variable is based on responses to the question “How would you say your mental health is: excellent? very good? good? fair? poor?”. The variable was dichotomized as poor mental health (poor/fair responses) and good mental health (good/very good/excellent responses) as has been commonly done in various studies –21. PercU tests.For those who were food energy under-reporters, stratified analysis was conducted according to perceived mental health and sex/age categories . The secured data were analyzed in the Statistics Canada Research Data Center at the University of British Columbia using SAS  and Software for Intake Distribution Estimation in IML language . Survey weights provided by Statistics Canada were incorporated into the calculations to provide national representation, and the bootstrap re-sampling technique was used . Nutrienn = 8,233), 95.2% reported good mental health and 51.3% were women.Of those who participated in the CCHS, between 14 and 70 years , 36.3% were considered as food energy under-reporters and formed the basis of the sample used in this investigation. Based on weighted frequencies, 8.9% were between 14 and 19 years, 21.2% were between 20 and 30 years, 41.8% were between 31 and 50 years, and 28.0% were between 51 and 70 years. Within this sample (p) < 0.05; p < 0.05; Among men between 31 and 50 years, energy-adjusted fiber and protein intakes were significantly lower in those reporting poor mental health state  for men between 31 and 50 years (p < 0.05) for men between 51 and 70 years  were significantly lower among those reporting poor mental health (p < 0.05) were significantly lower as compared to those reporting good mental health . The confidential microdata files contain information collected during the survey, derived variables, and the Bootstrap weights used to calculate the exact variance. Requests to access these datasets should be directed to Statistics Canada: https://www.canada.ca/en/health-canada/services/food-nutrition/food-nutrition-surveillance/health-nutrition-surveys/canadian-community-health-survey-cchs.html.The data analyzed in this study is subject to the following licenses/restrictions: The data used is from Statistics Canada. Data is secured by Statistics Canada and permission to share data publicly cannot be granted as it might compromise patient confidentiality or participant privacy. The Canadian Community Health Survey data for this analysis was collected by Statistics Canada (third party data). Details about how to access Statistics Canada data are available at: Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.KD submitted the project proposal that included the research plan to Statistics Canada for approval to access the secure data. KD and LG analyzed the data. KD and VA drafted the manuscript. All authors read and provided edits on manuscript drafts and approved the final manuscript.This project was partially supported by Fulbright Canada funds.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This cohort study investigates changes in the proportions of racial and ethnic groups among COVID-19 vaccine recipients before and after digital and community-based outreach interventions. Online self-scheduling via the patient portal (Epic Systems) was initially enabled for all New York State residents. Beginning January 28, 2021, self-scheduling was restricted to residents from local zip codes with high racial and ethnic minority populations. In parallel, direct outreach with a focus on local Spanish-speaking and underserved communities was conducted through CBOs, such as community and senior centers, faith-based organizations and local primary care practices, beginning on February 3, 2021.STROBE) reporting guideline for cohort studies. χ2 tests were used to assess differences in race and ethnicity categories between patients who self-scheduled prior to zip code restrictions, those who self-scheduled after, and those scheduled through CBO outreach. Two-sided P < .05 was considered statistically significant. Statistical analysis was performed using Stata version 16 (StataCorp).The Columbia institutional review board approved waiver of informed consent due to the study being minimal risk. We extracted scheduling data and analyzed demographic characteristics of all patients who received at least 1 COVID-19 vaccination at the Armory site, including self-reported race and ethnicity and zip code. The daily proportion of patients receiving a first-dose COVID-19 vaccination who were from a racial and ethnic minority population was tabulated. We followed the Strengthening the Reporting of Observational Studies in Epidemiology   were female, 10 215 (9%) were Black, 40 879 (38%) were Hispanic, and the mean (SD) age was 57.8 (18.2) years. After the interventions were implemented, there was an immediate and sustained increase in the proportion of racial and ethnic minority patients receiving first-dose COVID-19 vaccination . Black parisons) .6 and may mitigate distrust of COVID-19 vaccination in Hispanic and Black communities.In this analysis of data from a mass COVID-19 vaccination site, the proportion of Black and Hispanic patients receiving the COVID-19 vaccine was substantially higher with CBO outreach than when self-scheduled through the patient portal. Restriction to local zip codes for self-scheduling was also associated with a higher proportion of racial and ethnic minority patients receiving the COVID-19 vaccine. These findings suggest that direct outreach from trusted community resources can address challenges navigating self-scheduling technologyLimitations of our study include its nonrandomized, observational design, and the use of a convenience sample from a single site at the beginning of the COVID-19 vaccine rollout that may limit generalizability. Nonetheless, our results highlight the importance of direct, community-based engagement and appropriate digital workflow design for vaccination and public health campaigns and suggest that such efforts can potentially mitigate health disparities.


At follow-up, HRV was not different between groups (p > 0.05). Additionally, no differences were observed in PA between moments and groups. This study provides evidence of ANS recovery after SARS-CoV-2 insult in young adults over a follow-up period, independent of changes in PA.Coronavirus disease 2019 (COVID-19) has detrimental multi-system consequences. Symptoms may appear during the acute phase of infection, but the literature on long-term recovery of young adults after mild to moderate infection is lacking. Heart rate variability (HRV) allows for the observation of autonomic nervous system (ANS) modulation post-SARS-CoV-2 infection. Since physical activity (PA) can help improve ANS modulation, investigating factors that can influence HRV outcomes after COVID-19 is essential to advancements in care and intervention strategies. Clinicians may use this research to aid in the development of non-medication interventions. At baseline, 18 control (CT) and 20 post-COVID-19 (PCOV) participants were observed where general anamnesis was performed, followed by HRV and PA assessment. Thus, 10 CT and 7 PCOV subjects returned for follow-up (FU) evaluation 6 weeks after complete immunization (two doses) and assessments were repeated. Over the follow-up period, a decrease in sympathetic (SNS) activity (mean heart rate:  The coronavirus disease COVID-19) is a rapidly spreading condition caused by SARS-CoV-2 virus that infiltrated global populations at alarming rates 9 is a ra,4, and oAutonomic modulation was shown to be impaired, even in young adults short after mild and moderate COVID-19 ,9,10. ThCases of COVID-19 among young adults are concerning worldwide since this population can account for 70% of those infected globally . These fIt is well established that ANS plays a major role in modulating homeostasis through influencing systemic bodily functions. Dysfunction of the ANS could result in detrimental effects of downstream physiological processes associated with respiratory, vascular, immune, hematological, and renal processes ,18. IncrAdditionally, investigating factors that can influence better ANS outcomes after COVID-19 is essential to advancements in care and intervention strategies. Previous research has found that physical activity (PA) levels can directly influence autonomic modulation ,24 and cAn improved understanding of the influences of the long-term effects of COVID-19 on ANS and, consequently, multiple body systems is vital for developing public-health strategies that can reduce the impact of the disease. Clinicians may consider evidence from this literature as a means for guidance to improve clinical assessment and develop non-medication intervention strategies in the prevention and recovery from infection in young adults.Recently, our group demonstrated the short-term effects of COVID-19 on ANS in young adults  emphasizTherefore, the primary aim of this study was to observe the effects of mild to moderate COVID-19 on ANS function over a follow-up period, including before and after six weeks of immunization, in young adults. Secondarily, we aim to identify PA behavior over that period and analyze possible correlations with ANS modulation.The study was conducted based on the ethical standards described in the Declaration of Helsinki. All participants were notified about the study purpose and protocols and provided written informed consent to all protocols. The Ethical Institutional Review Board approved the study .This is an observational prospective case-control study, part of a broader project: FIT-COVID Study . The stuIndividuals previously infected with COVID-19 (PCOV) were initially recruited before immunization to participate in the study through local media  and social media via electronic access to participants’ database of the Municipal Health Secretariat of Presidente Prudente São Paulo, Brazil ). An age-matched healthy control group (CT) that was negative for COVID-19 was also recruited. Six weeks after full immunization, individuals in both groups were invited to repeat assessments .Inclusion criteria were male and female subjects aged 20–40 years with a diagnosis of mild or moderate clinical COVID-19, with a previous positive polymerase chain reaction (PCR) test. Mild cases were considered when patients presented slight clinical symptoms and absence of imaging findings of pneumonia. Moderate cases were considered when patients reported fever or respiratory symptoms . ParticiWe excluded subjects that presented severe clinical manifestations of COVID-19, including respiratory distress and a respiratory rate > 30 times per minute, fingertip blood oxygen saturation < 93% at rest, and partial arterial oxygen pressure (PaO2)/fraction of inspiration oxygen (FiO2) < 300 mmHg. Subjects that reported critical conditions, including respiratory failure requiring mechanical ventilation, shock, and other organ failure, or requiring intense care treatment, were also excluded [Initially, general anamnesis was taken, including sociodemographic characterisitics and self-rated health and medical history . Participants were then assessed regarding their body mass index (BMI)  and PA lBody mass index (BMI) was calculated according to previous literature . We consANS function was measured through heart rate variability (HRV), which is considered a simple, dependable, and noninvasive method . For thi® software  was used to complete the HRV analysis [Heart rate was recorded beat to beat to evaluate cardiac autonomic modulation. We used a cardio-frequency meter  at a 1 kHz sampling rate. Participants were equipped with a chest strap and monitor and remained at rest with spontaneous breathing for 25 min . HRV wasanalysis ,37.®. For the time domain, the mean RR intervals  were used. Additionally, the indexes presented in The HRV was assessed in both time and frequency domains using Kubios HRVPA level was measured using a triaxial accelerometer . Participants were instructed to wear the accelerometer above the waist for seven consecutive days during waking hours. A minimum of four days with at least 10 h per day was considered valid accelerometer data. Participants were instructed not to use the accelerometer while bathing, sleeping, or performing water activities. Every morning, a researcher sent a WhatsApp message reminding the participant to use the accelerometer.Non-wear periods were defined as time intervals of at least 60 consecutive minutes of zero counts, with an activity interruption allowance of 0–100 counts per minute lasting a maximum of two consecutive minutes . Counts t-test or Mann–Whitney U-test was used according to data distribution. Additionally, the Welch’s correction was used for comparison of variables with different standard deviations. For intragroup paired analysis, paired t-test or Wilcoxon test was performed. The Chi-square test was used to assess for differences within the categorical variables of PA. The Fisher exact test was performed to assess for differences between sex distribution.Statistical procedures were performed using GraphPad Prism 9 . Data distribution was analyzed using the Shapiro–Wilk test. For primary analysis of intergroup comparisons between the post-COVID-19 (PCOV) and control groups (CT), the unpaired Effect size (ES) was calculated using the difference between moments to determine the magnitude of differences over time. ES was represented by Cohen’s d values and was classified as d (0.01) = very small, d (0.2) = small, d (0.5) = medium, d (0.8) = large, d (1.2) = very large, and d (2.0) = huge .p < 0.05.Secondarily, the data were analyzed using analysis of covariance (ANCOVA) to better understand the influences of PA on the change in HRV indexes . The depIn terms of participants, 239 control and 154 post-COVID subjects were assessed for eligibility for this study. Further, 92 control and 33 post-COVID subjects were deemed eligible to participate in this study and 268 individuals did not meet the inclusion criteria. Moreover, 57 of these subjects were evaluated at baseline. After 19 exclusions due to errors in HRV recordings, 38 subjects with complete data were included in the baseline analysis, where 18 subjects were in the CT and 20 in the PCOV group. Subjects then returned six weeks after receiving full COVID-19 immunization. At this stage, 20 participants were excluded due to declining a follow-up assessment and one individual was excluded due to SARS-CoV-2 reinfection. The number of individuals at each stage of the study is presented in p = 0.1119). Descriptive characteristics of age, weight, height, and body mass index were uniformly distributed and not different between groups, as indicated in No differences in sex distribution were observed between the groups (p > 0.05) in PA between CT and PCOV groups  and between baseline and follow-up moments .There were no statistical differences  regarding SNS activity (p = 0.0312) and pNN50 (p = 0.0312) for PCOV group (p > 0.05). The intragroup analysis between moments also revealed a difference in global variability, reflected by RR triangular index  and SNS index  and PNS index  when compared to CT (ed to CT . No intep > 0.05).Intergroup comparisons between PCOV and CT at the follow-up moment revealed that there were no significant differences between the groups in any HRV index   .This study observed the effects of mild to moderate COVID-19 on the ANS in young adults, before and a minimum of six-weeks after complete SARS-CoV-2 immunization. The relationship between PA and the changes in ANS were also analyzed. The primary finding of this study is that autonomic function was improved in young adults who were infected by SARS-CoV-2 after approximately five months of follow-up. This change was characterized by significant decreases in SNS indexes (mean HR and SNS index), while also having significant increases in PNS HRV indexes (mean RR and PNS index). Additionally, when both groups were compared at the follow-up moment, our results revealed that the young adults infected by SARS-CoV-2 presented similar autonomic function when compared to CT. Secondarily, no differences were observed in PA between PCOV and CT groups over the follow-up period. The changes in HRV data were maintained even after statistical adjustments using PA levels.To our knowledge, this study is the first to observe improvements in autonomic function after mild to moderate post-COVID-19 infection in a young adult population within 164.41 ± 91.47 days. Much of the existing literature focuses on older populations who present with greater risk of negative outcomes ,4,42 or Previous work by Freire et al. , as partIncreases in the SNS are associated with a systemic inflammatory condition characterized by perfusion of inflammatory cytokines in bloodstream and other biomarkers associated with inflammation ,8,11,13.It is important to highlight that age plays an important role in ANS regulation. Our study observed young adults without any known chronic diseases. In young adults, protective factors can be related to better ANS regulation and might help explain the responses of ANS after virus infection observed in our study. Healthy young adults can present lower levels of arterial and ventricular stiffening, better myocardial contractility, and preserved organ innervation when compared to elderly individuals ,47. AddiThis study did not observe changes in PA over time in either group, nor were PA levels between PCOV and CT different from one another. Although there is a lack of statistical difference to explain observations in this study, which may have been a result of an underpowered sample, PA levels still may have had an influence on the improvements in ANS observed in the PCOV group as median PA levels increased from baseline to follow-up. PA aids in ANS modulation, as the peripheral stress induced by skeletal muscle contraction or mechanical stress on organs sends afferent signals to the central nervous system, thus, inducing catecholamine (epinephrine and norepinephrine) release to alter ANS function to meet metabolic demands of exercise . The relThe World Health Organization recommends that adults should participate in 150 min of moderate PA per week or 75 min of vigorous PA to observe physiological benefits that can protect against COVID-19 outcomes and reduce the risk of many diseases ,52.These barriers were discussed in observations by Huber et. al. , in whicPA is important in the modulation of immune responses, where increased levels of PA are associated with improved cytokine responses, thus, reducing the severity of COVID-19 disease . PA helpThis study presents significant clinical relevance, as it provides further information on the relationship of PA behaviors on recovery after mild to moderate COVID-19 infection in a young adult population. We were able to observe alterations in ANS activity after a five-month follow-up period in a young adult population, highlighted by reductions in SNS activity and increases in PNS activity. Although we hypothesize that this observation could be related to PA levels, our experimental design does not allow us to establish causal effects in this matter. Therefore, we strongly suggest that future studies further investigate this aspect, investigating ANS responses across different ranges of PA, which was not possible in our study due to the small sample size.This evidence better informs health professionals on non-medicinal approaches to reduce the risk and severity of COVID-19 outcomes by using PA as an alternative medicine. Future research should continue to observe the effects of common population behaviors  on PA levels and the influence of these factors on COVID-19 outcomes. Further research may also look to observe the relationships of frequency, intensity, and duration of PA necessary to improve modulation of cytokine immune responses.Since we evaluated young adults before and after SARS-CoV-2 immunization, the interpretation of ANS response over time should also consider the potential effects of the vaccine. Although the time point for testing the long-term effects of the vaccine is still relatively short, previous studies comprehensively observed the safety and effectiveness of the COVID-19 vaccine . ReportsIn our study, the aspect of immunization in our study was used as a controlling factor to avoid bias . Therefore, the absence of a non-vaccinated group in our design limits our ability to differentiate and account for the specific effects of immunization on ANS. Due to ethical aspects and the high rates of immunization after the availability of immunization in Brazil (over 88% of the population received at least one shot of immunization), it was difficult to incorporate a non-vaccinated group. Future investigations should consider the investigation of ANS function in non-vaccinated individuals to further advance knowledge in this aspect.Limitations from this study include the loss of follow-up information from baseline to follow-up. CT had 45% and PCOV had 65% loss of participants between observational moments, which may be attributed to the general difficulty in subject compliance for young adults. This high loss of follow-up increases the likelihood of an underpowered sample, which would undermine the statistical findings or explain the lack of statistical differences (50). The effect of the underpowered sample on the statistical findings in this study can only be determined by referencing other studies employing similar methods. Lastly, although we excluded individuals that required intensive care from our sample, subjects may have experienced symptoms, such as chest pain or severe myalgias, indicative of myocarditis or pericarditis, while still not requiring intensive care. This aspect was not controlled in our study and needs to be considered for the interpretation of our results.Previous research throughout the literature has employed HRV methods that require prolonged monitoring, are subjective in nature, or require expensive equipment that is not accessible to the general population or small-practice clinics. The methods employed in this study are less cumbersome for both healthcare professionals and the patient being monitored, as HRV monitoring can be completed within a single, relatively short visit. Observing changes in ANS activity may be helpful to health professionals to detect signs of infection, track viral progression, and observe dysfunctions caused by the virus, which can aid in the development of individualized intervention strategies that are better informed by HRV data.Overall, this study observed ANS improvements over a follow-up of an approximately five-month period that may be related to recovery after SARS-CoV-2 infection. To our knowledge, this study is the first of its kind to investigate these outcomes within a four- to six-month period. Lastly, the methods for monitoring ANS function could be used by healthcare professionals to observe the progression of SARS-CoV-2 infection to form individualized non-medication intervention strategies.We observed improvements in ANS function after mild to moderate SARS-CoV-2 infection in young adults vaccinated over a five-month period. Additionally, no changes in physical activity levels were observed over the follow-up period.