This review analyzes scientific data published in the first two years of the COVID-19 pandemic with the aim to report the cardiorespiratory complications observed after SARS-CoV-2 infection in young adult healthy athletes. Fifteen studies were selected using PRISMA guidelines. A total of 4725 athletes  practicing 19 sports categories were included in the study. Information about symptoms was released by 4379 (93%) athletes; of them, 1433 (33%) declared to be asymptomatic, whereas the remaining 2946 (67%) reported the occurrence of symptoms with mild , moderate , severe  and unknown  severity. The most common symptoms were anosmia (33%), ageusia (32%) and headache (30%). Cardiac magnetic resonance identified the largest number of cardiorespiratory abnormalities (15.7%). Among the confirmed inflammations, myocarditis was the most common (0.5%). In conclusion, the low degree of symptom severity and the low rate of cardiac abnormalities suggest that the risk of significant cardiorespiratory involvement after SARS-CoV-2 infection in young adult athletes is likely low; however, the long-term physiologic effects of SARS-CoV-2 infection are not established yet. Extensive cardiorespiratory screening seems excessive in most cases, and classical pre-participation cardiovascular screening may be sufficient. In December 2019, the novel “Severe Acute Respiratory Syndrome CoronaVirus 2” (SARS-CoV-2) was identified in Wuhan, China. SARS-CoV-2 is responsible for the Coronavirus disease 2019 (COVID-19) . The priWith the term athletes, we indicate young and healthy subjects who place a high demand on their cardiorespiratory system due to a high level of physical activity. During the acute phase of the COVID-19 pandemic, several types of physical activity were suspended or postponed to both protect athletes’ health and limit the viral spread. However, when the infection diffusion decreased enough to allow resuming such activities, questions about the correct strategy to safely manage the return to play (RTP) of athletes were raised ,6. IndeeThis review analyzes the scientific data published in the first two years of the pandemic relative to complications after SARS-CoV-2 infection in young adult healthy athletes. Here, the condition of health mainly refers to physical aspects, indicating absence of disease or infirmity. The aim was to report the symptomatology and the clinical complications observed after SARS-CoV-2 infection in young adult healthy athletes.The literature search and method reporting performed here followed the PRISMA guidelines for systematic reviews and studies that evaluate healthcare interventions . DiscrepA systematic literature search was conducted in three electronic bibliographic databases, namely, PubMed, Scopus, and Web of Science, and in the organizational COVID-19 database of the WHO containing global research data on COVID-19. The literature was screened in the period from January 2020 to December 2021.Athlet *, Sport *;* cardi *, respirat *;SARS-CoV-2, COVID-19.The roots ‘Athlet’ and ‘Sport’ were used to search for studies in the sport field. The roots ‘cardi’ and ‘respirat’ were used to search for studies on the cardiovascular system and respiratory system, respectively. The virus name ‘SARS-CoV-2’ and the related disease ‘COVID-19’ were used to search for studies related to the current pandemic. The search terms were organized into three concepts:Terms within each concept were combined with the Boolean operator ‘OR’ and then combined with the Boolean operator ‘AND’. ‘Title’ was used as a limit for the field of search, while English language was used as a limit to filter the documents. Only in the organizational database, the search query was constructed with the first two concepts, since the WHO database already contains only documents addressed by terms of the third concept (‘SARS-CoV-2’ and ‘COVID-19’).Documents (research papers and letters) were imported into the Mendeley reference management system for duplicate removal. Titles were analyzed to include only documents about clinical complications after SARS-CoV-2 infection and COVID-19 syndrome in young adult athletes. Documents were excluded if related to sport industry management, sociological and psychological aspects of isolation and remote sports education. Research papers for which the abstract was not available were also excluded.Mean age of the athletes’ population greater than 18 years but lower than 35 years;Population of athletes with previous SARS-CoV-2 infection;Study on clinical complications after SARS-CoV-2 infection.The eligibility criteria for abstract analysis were:A full-text review was performed for both research articles and research letters describing observational or descriptive studies on clinical complications after SARS-CoV-2 infection and COVID-19 syndrome. Full text articles were excluded if evaluated of low quality according to the Joanna Briggs Institute Critical Appraisal tools checklist .Data were collected and analyzed in Microsoft Excel. Each study was described in terms of study design, athletes’ population characteristics , clinical tests for screening and time between infection and clinical screening. Additionally, the populations were described in terms of practiced sports and main predictors of infection outcome in relation to age, sex, ethnicity, anthropometric data and symptoms. Continuous features  were reported as mean ± standard deviation (SD) if normally distributed or as median and interquartile range (IQR) otherwise. Categorical features  were reported as counts, ratio and/or percentage. Eventually, the subjects were classified as asymptomatic and symptomatic; the symptoms were characterized based on their severity, type and body region involved.Quality appraisal was performed by two authors, independently, by assessing data quality and risk of bias using the Joanna Briggs Institute Critical Appraisal tools checklist .Limitation of the selected studies was assessed based on the presence of control populations, which could consist of athletes with no SARS-CoV-2 infection, non-athletes with no SARS-CoV-2 infection, athletes with screening before SARS-CoV-2 infection (Pre-SARS-CoV-2 infection screening) and athletes with screening after infection by different respiratory viruses.Overall, 201 studies were identified in the bibliographic and organizational databases; of these, 123 were duplicate, so that 78 were left for further analysis. After title, abstract and text analysis  athletes released information about symptoms ; 1433  athletes needed hospitalization ,16,17; nThis review systematically analyzed the scientific data relative to complications after SARS-CoV-2 infection in athletes in order to report symptomatology and clinical complications after SARS-CoV-2 infection in young adult healthy athletes. Overall, 15 studies were included in the review. Selection was based on the language of the reports (English) and on athlete age (between 18 years and 35 years). Being English the language mostly used in science, we think that the choice of English as the only language for study selection had no impact on the study conclusions and, at the same time, makes the study easily understandable and repeatable. The age criterion was considered because subjects older than 35 years are likely less active and with a higher risk of comorbidities than young adult subjects ,31,32.Data from 4725 athletes, mainly males (78%), were analyzed and resulted very heterogeneous . The athMost athletes were symptomatic (67%), even though generally with a mild or moderate symptoms. Thus, a severe symptomatology appears rare in athletes (only 1 case out of 4725 athletes in our study). Symptom classification was difficult due to the existence of different guidelines to classify symptoms, leading to inhomogeneous reports among studies. Indeed, some studies classified symptoms based on their severity ,27,29, wElectrocardiography is a simple, affordable and thus common test for the non-invasive assessment of cardiac abnormalities. In sport, it is frequently included in the pre-participation screening protocols and may contribute to prevent sport-related sudden cardiac death . In the In our study, cardiac imaging indicated a higher cardiac involvement due to SARS-CoV-2  this preliminary findings need to be confirmed by future studies. Thus, the results of this review should be definitely but critically considered in future position papers or consensus guidelines.


With the highest HIV incidence and prevalence globally, the government of Eswatini started a substantial scale-up of HIV treatment and prevention services in 2011. Two sequential large population-based surveys were conducted before and after service expansion to assess the impact of the national response. Cross-sectional, household-based, nationally representative samples of adults, ages 18 to 49 years, were sampled in 2011 and 2016. We measured HIV prevalence, incidence , viral load suppression  and unsuppressed viremia  and assessed for temporal changes by conducting a trend analysis of the log ratio of proportions, using a Z statistic distribution. HIV prevalence remained stable from 2011 to 2016 . HIV incidence significantly declined 48% . Incidence remained higher among women than men , with a smaller but significant relative reduction among women  than men . The proportion of seropositive adults with viral load suppression significantly increased from 35% to 71% [p < .001]. The proportion of the total adult population with unsuppressed viremia decreased from 21% to 9% [p < .001]. National HIV incidence in Eswatini decreased by nearly half and viral load suppression doubled over a five-year period. Unsuppressed viremia in the total population decreased 58%. These population-based findings demonstrate the national impact of expanded HIV services in a hyperendemic country. HIV remains a formidable global health threat. Thirty-eight million people were living with HIV (PLHIV) in 2019, and 1.7 million became newly infected. Nonetheless, substantial investment to stem the epidemic is yielding results. Global uptake of antiretroviral therapy (ART) more than tripled from 7.7 million in 2010 to 25.4 million in 2019, with a coinciding 39% reduction in HIV-related mortality .The Kingdom of Eswatini (formerly Swaziland), an African country of nearly 1.1 million people, has experienced the highest national levels of HIV . In 2011The two surveys consisted of unique cross-sectional, household-based, nationally representative samples assessed five years apart. Each sample was based on a two-stage, cluster-based design and varied in size due to different primary objectives and statistical power considerations. The Swaziland HIV Incidence Measurement Survey  8], was, was8], Selected households were approached by study staff trained in survey procedures and Good Clinical Practice . IndividSurvey staff collected information in or near participants’ homes on demographics, sexual behaviour, prior HIV diagnosis, ART initiation, and male circumcision status followed by HIV counselling, condom provision, and venipuncture. Household-based HIV rapid testing was done with immediate return of results and referral to HIV care for those testing HIV-seropositive.Estimates of prior HIV diagnosis and current ART use were based on self-report. HIV prevalence estimates were calculated as a proportion using the number of individuals testing HIV-seropositive among all participants testing for HIV. Rapid HIV testing was conducted with Determine™ HIV-1/2 Ag/Ab Combo (in 2011) or Determine™ HIV-1/2 (in 2016). Determine-reactive samples were confirmed with Uni-Gold™ HIV Test. Laboratory-based confirmatory testing and resolution of discrepant results were conducted according to established test algorithms . HIV incThe SHIMS1 sample size methodology is described elsewhere . The SHIAnalysis methods were comparable between samples, incorporating design weights, based on selection probabilities of enumeration areas and households, as well as non-response and post-stratification adjustments. Standard errors and confidence intervals for population proportions were calculated using Taylor series estimation  and jackOf the 14,891 and 6,417 households selected for participation in 2011  and 2016Between 2011 and 2016, national HIV prevalence remained stable  and remained higher among women than men , with significant increases in women  and men . The proportion with unsuppressed viremia among the national population, regardless of HIV serostatus, significantly decreased by 57% between 2011 and 2016 .Among those testing HIV-seropositive in each survey, prevalence of prior HIV diagnosis significantly grew from 62% in 2011 to 84% in 2016 , with a significant increase among women  and larger significant increase among men  . PrevaleAmong those reporting a prior diagnosis, the conditional prevalence of reporting current ART use significantly increased from 53% in 2011 to 86% in 2016 . This was observed among women  and men  with a larger significant increase among younger individuals  versus older individuals .Among those reporting current ART use, the conditional prevalence of viral load suppression significantly grew from 85% in 2011 to 91% in 2016 . The increase in viral suppression prevalence was significant among women  but not among men . While viral load suppression was more common among older compared to younger persons in 2011 and 2016, a significant increase was observed from 2011 to 2016 among 18- to 24-year-olds  but not among 25- to 49-year-olds .We also assessed the changes in unconditional measures of the HIV care continuum among all seropositive persons in 2011 and 2016 by sex-specific age groups . While wWe describe one of the first direct measures of the population-level impact of HIV program expansion on national HIV incidence, population viremia, and viral suppression. Two rigorous population-based surveys conducted five years apart in Eswatini, the country with the highest levels of HIV in the world, show significant growth in national ART coverage paralleled by a twofold increase in the proportion of PLHIV with viral load suppression and a decrease in HIV incidence by nearly half, providing the first quantified evidence for the effectiveness of treatment scale-up on HIV incidence at a national level.This decline in HIV incidence most likely resulted from the rapid expansion of ART services, an explanation supported by the observed doubling of national viral load suppression from 35% to 71%. Expanded treatment increased viral suppression, leading to fewer incident cases. The almost 60% decrease in the prevalence of unsuppressed HIV viremia among the entire population (regardless of HIV status) signifies a substantial decline in HIV transmission risk in the population . DespiteSeveral national policies were instituted in Eswatini between 2011 and 2016. Decentralization of HIV programs was enhanced, broadening access in rural areas. HIV testing points increased through task-shifting to lay test counsellors and growth in community-based testing. These boosted case-finding efforts resulted in a near tripling in the number of HIV tests conducted from 2011 to 2016 . ART accMore recently, community randomized trials of “universal test and treat” have shown inconsistent results regarding the impact on HIV incidence at a community level, potentially due to limits in ART coverage in hard-to-reach populations, like men and young people, both within and outside of evaluated communities –37. Our Another key finding from our study is the notable improvement in ART use among young people. From 2011 to 2016, 18- to 24-year-olds exhibited a greater relative increase of current ART use among those previously diagnosed than compared with 25- to 49-year-olds, and the proportion of all HIV-seropositive 18- to 24-year-old women and men on ART grew over three and fivefold, respectively. The proportion of all HIV-seropositive 18- to 24-year-old women and men with viral suppression in 2011 multiplied by four and seven times, respectively, by 2016. Taken together, these findings provide encouraging news that young people and men can be engaged in sustained HIV care, setting a future pathway for reduced population-level HIV transmission risk and continued reductions in incidence in hyperendemic countries on track to achieving global targets , 38.Other factors seem less plausible to substantially account for the observed sizable decrease in HIV incidence. VMMC coverage among men likely had limited effect on HIV incidence across the general population, since impact manifests over a minimum 10-year period in populations with comparatively higher VMMC prevalence, relatively higher levels of risk behaviors, and comparatively lower HIV prevalence than Eswatini , 40. TheDespite the impressive progress in hard-to-reach populations, substantial gaps remain among men, particularly young men. In 2016, prior HIV diagnosis among HIV-positive men still lagged behind women (75% versus 88%); more than half of HIV-positive young men (53%) were unaware of their HIV status, and only 27% of those aware and on ART had viral suppression, compared to 44% of young women. These findings provide important context for the continued high national incidence in Eswatini, highlighting the need for male- and youth-friendly HIV services for this sizable segment of the population.This study has several strengths. Results are derived from large, population-based, nationally-representative samples distinguished by rigorous biomarker testing and high participation rates, providing robust outcome and external validity to our results. However, study findings may have been affected by self-report biases regarding prior HIV diagnosis and ART uptake due to stigma, which may have under-reported knowledge of HIV status and either under or over-reported ART coverage. Also, the lack of antiretroviral detection in the incidence algorithm, when combined with an assumed false recency rate of 0%, may have resulted in a small proportion of long-term infections misclassified as recent in both surveys. However, use of a non-zero FRR would be inappropriate, given the differences in FRR among populations over time and that a non-zero FRR reduces recent cases without improving the positive predictive value of the algorithm . Lastly,In conclusion, expansion of HIV services in Eswatini between 2011 to 2016 coincided with a reduction in HIV transmission in the country by nearly half. This is the first national-level demonstration that HIV treatment, when scaled countrywide, is associated with substantial reductions in unsuppressed HIV viremia and new infections. These findings show the feasibility in low-resource, hyperendemic countries to rapidly expand HIV services and dramatically alter epidemics. Further efforts are needed in Eswatini to extend these achievements towards universal ART coverage for all PLHIV and to continue expansion of services focused on the subpopulations that have yet to benefit from these interventions.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(CSV)Click here for additional data file.S4 File(XLSX)Click here for additional data file.S5 File(DOCX)Click here for additional data file.


To evaluate parameters of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) as early imaging indicators of tumor histologic response to pre-operative neoadjuvant chemotherapy and as probable prognostic factors for event-free survival (EFS) and overall survival in osteosarcoma (OS) in both tumoral and peritumoral areas.Thirty-four OS patients who received three courses of neoadjuvant chemotherapy followed by surgery during 2014–2018 were enrolled in this study. All patients underwent baseline and post-chemotherapy DWI and DCE-MRI. Lesion region was defined as the tumoral area and peritumoral area. Parameters of apparent diffusion coefficient, capacity transfer constant (Ktrans), elimination rate constant, extravascular extracellular space volume ratio (Ve), and initial area under the curve as well as corresponding differences between pre- and post-chemotherapy in lesion regions were evaluated. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of these parameters. The associations of all parameters with tumor histologic response, EFS, and overall survival were also calculated.p = 0.04, false discovery rate [FDR] corrected), and ΔKtrans exhibited significant between-groups differences . Weak evidence for the between-groups difference was found in the Ve in the peritumoral area . Furthermore, lower post-Ktrans in the tumoral area and lower pre-Ve in the peritumoral area were significant prognostic indicators for longer EFS  and overall survival .In the tumor area, moderate evidence was found that post-Ktrans was lower in responders as compared with that in poor responders (In OS, DWI and DCE-MRI parameters in both tumoral and peritumoral areas can reflect the chemotherapy response and prognosticate EFS and overall survival.• Peritumoral MRI parameters can reflect the chemotherapy response in OS patients.• Peritumoral MRI parameters can predict EFS and overall survival in OS patients.• MRI parameters may be predictive factors for evaluating chemotherapy efficacy and EFS. Osteosarcoma (OS) is the most common malignant bone tumor with peak incidence in children and adolescents . The curIn OS, chemotherapy-induced necrosis is a well-accepted predictive factor for prognosis. Post-chemotherapy tumor necrosis in more than 90% cases is associated with significantly higher survival rate , 8. HoweMagnetic resonance imaging (MRI) has been developed to be the most important method for primary bone tumor diagnosis and post-operative tumor relapse detection. Among different MR measurements, dynamic contrast-enhanced MR imaging (DCE-MRI)  andIn this study, we investigated the diagnostic and prognostic value of DW-MRI and DCE-MRI parameters in post-chemotherapy OS patients in both tumoral and peritumoral areas.Thirty-four patients with high-grade non-metastatic and potentially resectable OS  were enrolled in this study from January 2014 to June 2018 in the orthopedics department of Xijing Hospital, Fourth Military Medical University. Exclusion criteria were inability to give informed consent, history of surgical resection, radiotherapy or chemotherapy, non-lower extremity OS, and contraindications to MR or MR contrast media. Two patients deemed to be ineligible after enrollment were also excluded, resulting in a total of 34 patients in the study. This retrospective diagnostic study was approved by the institutional review committee of our center.2) at week 9, cisplatin (60 g/m2) and doxorubicin (120 mg/m2) at week 6, and ifosfamide (12 g/m2) at week 3 before surgical resection. The treatment and imaging schedules are shown in Fig. All patients received three courses of neoadjuvant chemotherapy before operation: ifosfamide 12 g/m2 g/m2 atb value high-resolution diffusion-weighted imaging examination at week 0 (before neoadjuvant therapy) and week 9 (before tumor resection/post-neoadjuvant therapy), respectively. A standard examination was performed including coronary and transverse fat-saturated T1WI and T2WI.In this study, a 1.5-T MRI system  was used. All patients underwent MRI examinations twice including DCE-MRI and multi–b value high-resolution DWI examination was performed with the RESOLVE sequence (readout segmentation of long variable echo-trains), and the ADC value was generated automatically after scanning. The details of scan parameters are as follows: TR = 2000 ms, TE1 = 59 ms, TE2 = 95 ms, 150° flip angle, matrix = 360 × 288, slice thickness = 5 mm, readout segments = 7, echo spacing = 0.38 ms, b value = 0, 50, 100, 150, 200, 300, 500, 800 s/mm2; totally scan time was 6.16 min.For DCE-MRI protocols, firstly the T1 map was acquired by using the VFA method (variable flip angle technique) with the unenhanced T1-weighted VIBE (volumetric interpolated breath-hold examination) sequence, with flip angles of 2° and 15°, which was automatically calculated by the Tissue 4D software  at the workstation. The patient was given injections of 0.1 mmol/kg of gadodiamide at a rate of 4 ml/s followed by a saline flush. Dynamic imaging was performed using the VIBE sequence with the parameters as follows: TR/TE = 3.79/1.35 ms, slice thickness = 3.5 mm, acquisition matrix = 340 × 244; the total acquisition time was almost 6 min for 60 measurements. Multi–After definitive surgery at week 9, histologic response was assessed by experienced pathologists using the four-grade system of Huvos , 4. TumoFor metastatic disease is an overwhelming factor in predicating survival, only patients with localized disease can be included in the analyses of event-free survival (EFS) and overall survival. EFS was defined as the time interval from the date of study enrollment to the date of the first event  or to the date of last follow-up for patients without events. Overall survival was defined as the time from the date of study enrollment to the date of death from any cause or to the last follow-up date.DCE-MRI raw dates were uploaded to the Siemens post-processing station, and the Tissue 4D software was used to analyze DCE data. Tumor delineation was performed by two pediatric radiologists  using an interactive display to select the region of interest (ROI) of the tumoral area on each slice that ensured that tumor boundary selection was consistent across all time points. The adjacent area of the ROI  refers to the periphery area within 2 cm from the soft tissue mass . All measurements were kept away from the vessels to avoid interference of parameters.Five tumoral areas were randomly delineated on the axis of ADC map and DCE map as ROI. The tumor region and peritumoral region of each layer were manually delineated, and the average ADC value was calculated.Firstly, the motion correction of the images in each period was carried out; secondly, T1 mapping images were automatically registered; thirdly, by referring to the two-compartment pharmacokinetic model, AIF -slow was fitted with TIC (time of intensity curve) type to generate false color images; fourthly, for each pixel inside the tumor region and peritumoral region ROI, the four quantitative parameters, Ktrans, elimination rate constant (Kep), extravascular extracellular space volume ratio (Ve), and IAUC, were computed.The corresponding differences  of each averaged kinetic parameter between pre- and post-neoadjuvant therapy of tumoral and peritumoral ROI were also computed for further statistical analysis. All parameters were used for assessing neoadjuvant therapy response, EFS, and overall survival.In this study, 34 patients underwent HE staining before and after chemotherapy. Paraffin sections were immersed in xylene for dewaxing for 15 min, hematoxylin staining was performed for 2 min, 1% hydrochloric acid alcohol for 3 min, water washing tablets, gradient alcohol for gradual dehydration, eosin staining for 2 min, and neutral gum sealing piece.Non-parametric Wilcoxon’s signed-rank tests were used to examine the difference of ADC and eight DCE-MRI parameters ). Mann-Whitney tests were used to examine the difference of each parameter between responders and poor responders. Bonferroni’s and false discovery rate corrections were used for multiple comparison corrections. Receiver operating characteristic (ROC) curves were generated to compare parameters for differentiating responders and poor responders. Area under the curve, standard error, 95% confidence interval (95% CI), and optimal cutoff were estimated in the ROC analyses.p < 0.10 were then included in the multivariate analysis. Selection of variables included in the multivariate model was done with backward elimination based on covariates that were significantly associated with the primary efficacy endpoint (p > 0.10 for exclusion). Then, patients were categorized into two groups using the significant median parameter values as cut-points. EFS and overall survival distributions were estimated using the method of Kaplan and Meier, and differences were examined using the log-rank test.Univariate and multivariate analyses of EFS/overall survival at different areas  were performed utilizing Cox proportional hazard model to explore associations between outcomes  with each parameter, to adjust for potential confounding variables. Only covariates that were associated with the risk of primary study endpoint at univariate analysis with p values < 0.05 were considered statistically significant.All the statistical analyses were performed using the Prism 6.02 and SAS software (version 9.1); two side A total of 34 patients were available for analysis in the study. The responder group consisted of 19 patients (55.9%) and the poor-responder group of 15 patients (44.1%) , and ΔKtrans exhibited a significant between-groups difference . In the peritumoral area, post-ADC of the responder group was higher than that of the poor-responder group , and ΔADC exhibited a significant between-groups difference . Additionally, weak evidence for the between-groups differences was also found in the Ve at different time points .First, we compared the parameters of pre- (week 0) and post-neoadjuvant therapy (week 9) between groups Table . In the p < 0.05, corrected). In the poor-responder group, only ADC showed significant changes both in the tumoral area and in the peritumoral area .Second, we measured the pre- and post-chemotherapy parameters in two groups with the self-contrasted method Table . In the The results of the tumoral area showed that the heteromorphic cells were oval or short fusiform; epithelioid and transparent cells were arranged in sheets and nests, with ribbon-like bone matrix, hyperchromatic nuclei, mitotic figure, partial bone trabecular degeneration and calcification, and proliferation of vascular fiber tissue. Gross pathological specimens were taken after the surgery and stained with HE after chemotherapy, large areas of necrotic cells were observed under the microscope, and few tumor cells survived. The results of HE staining showed that normal muscle tissue could be seen outside the tumor cells before chemotherapy. After chemotherapy, large areas of necrotic cells were observed under the microscope in the tumoral area, and few tumor cells survived, with a little calcification and pigmentation. A small number of muscle cells were seen in the para-tumoral area, and no obvious signs of tumor cell infiltration were observed.We generated best threshold values for above-mentioned significant different MRI parameters as determined by the ROC curves. The sensitivity and specificity of the respective parameters were also measured at each threshold value to predict good histological response.p < 0.01). In peritumoral area, lower pre-Ve (pre-neoadjuvant therapy/week 0) was significantly associated with longer EFS (p = 0.03). Moreover, analysis of the average post-Ktrans in the tumoral area as well as pre-Ve in the peritumoral area was performed using Kaplan-Meier curves stratified according to the median values for the cohort to explore the prognostic effect of these parameters. As shown in Fig. p < 0.001). Patients with lower values of peritumoral pre-Ve had a significant higher EFS rate (p = 0.017).A Cox proportional hazards model was used to analyze the associations between all MR parameters and EFS/overall survival. As shown in Fig. p = 0.023, p < 0.001). In the peritumoral area, lower pre- and post-Ve were significantly associated with longer OS , and higher post-ADC was significantly associated with longer OS (p = 0.036).Overall survival was also analyzed with the same method. As shown in Fig. In this study, DW- and DCE-MRI parameters in both tumoral and peritumoral areas were analyzed to explore their relationships with neoadjuvant therapy outcomes in OS patients. First, Ktrans was significantly decreased and ADC was significantly increased post-chemotherapy in responders and poor responders in both areas. Second, ΔKtrans and ΔADC were significantly different between groups in both the areas and well correlated with histologic response. Third, post-Ktrans in the tumoral area and pre-Ve in the peritumoral area were significant prognostic factors for both EFS and overall survival.OS, with peak incidence in children and adolescents, is the most common primary malignancy of bone. The main cause of mortality in patients with OS is lung metastasis, and approximately 10~20% of patients are diagnosed with metastatic OS upon identification of the disease in the USA . PrognosThe treatment response of OS is commonly verified by the necrosis rate with pathological examination after tumor resection which is the last procedure in the treatment process; thus, imaging diagnosis such as MR imaging was urgently needed to replace the lagged indicator for early evaluation response. DW and DCE-MRI were the most frequently used in tumor diagnosing with their own typical features, reflecting tumor characteristics. DW-MRI well reflected the membrane permeability between intra- and extracellular compartments with the surrogate marker of water diffusion, and DCE-MRI better indicated the leaky newly formed tumor capillaries, reflected by the contrast medium uptake capacity. Several studies have reported that ADC changes are greater in osteogenic patients with higher necrosis rate (> 90%) than in those with low necrosis rate (< 90%) post-chemotherapy , and lowMRI parameters can potentially reflect early changes in treatment especially in patients who resist or are unable to receive surgery for histologic response assessment. Currently, the existence of metastasis or not is the key prognostic factor that determines the treatment protocols for OS, and there is a pressing need to identify prognostic factors especially for the majority of patients who have localized disease. The prognostic significance of the DW- and DCE-MRI parameters will be useful to stratify patients in clinical trials and to identify the group of patients with private customized protocols.In this study, it was found that no tumor cells were observed in the peritumoral area before and after chemotherapy by HE staining, but the targeted genes or specific molecules in the edema zone were over-expressed to varying degrees, and their biological behaviors were also changed. We hypothesized that peritumoral capillary permeability would change; in fact, the research finding showed that DCE-MRI parameters had changed before and after neoadjuvant chemotherapy, which was the imaging basis of DCE-MRI.The DCE-MRI parameters have been shown to be associated with clinical outcome manifested as histologic response and survival in some trials. Reddick et al found that lower Kep post-neoadjuvant therapy was significantly predictive of EFS . This isTo our knowledge, it is one of the first studies to identify the diagnostic imaging values in peritumoral areas. Although few studies had reported the relationship between the tumoral area MR imaging and EFS or overall survival, we focused the adjacent area to supplement the understanding of MR imaging in predicting prognosis. Meanwhile, parameters in the peritumoral area may be better in consistency compared with the tumoral area that may be influenced by complex circumstances such as necrosis, hemorrhage, edema, and newly formed capillaries. Slaughter et al hypothesized that a residual “alterated field” in the area adjacent to the tumor could be the leading cause of treatment failure and local recurrence . SeveralThere are some limitations to this study. First is the single-centered study and limited case number. With the number of patients 34, two parameters were marginally significant that may need enlarged patient number. Second, peritumoral pathological sequencing should be performed to further demonstrate the correlation between imaging parameters and gene variations. Third, chemotherapy regimen was fixed; results can only prove the relationship between imaging parameters and chemotherapy response in such specified condition.In conclusion, we found that tumoral and peritumoral parameters can reflect the chemotherapy response and predict EFS and overall survival, which to some extent supplement and improve the diagnostic and prognostic value of MR imaging in OS patients.


COVID-19, caused by the SARS-CoV-2 virus, is a severe inflammatory condition. Patients with pre-existing conditions including diabetes, hypertension, and cardiovascular disease are at particularly high risk of complications. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare and debilitating genetic disorder that is characterized by a pro-inflammatory state, which leads to progressive heterotopic ossification and complications after trauma, including intramuscular vaccinations. To better understand the impact of COVID-19 on patients with FOP, we first examined the social impact of the pandemic using data from the FOP Registry managed by the International FOP Association. We also identified patients with FOP who were exposed to or contracted the SARS-CoV-2 virus, or who received a COVID-19 vaccine, to investigate if patients with FOP were at increased risks of complications from SARS-CoV2 exposure or vaccination.Data from 326 individuals in 69 countries in the International FOP Association FOP Connection Registry were examined using patient-reported outcomes measurement information system (PROMIS) global health scale scores. Twenty-six (28.9%) participants aged ≥ 15 years old rated their satisfaction with their social activities and relationships as poor in 2020, which was an increase from 18 (18.9%) in 2019, prior to the SARS-CoV-2 outbreak. Similar trends were noted for physical and mental health in the pediatric population. Frequency of physician visits was not changed, but a larger portion of patients reported missing dental visits in 2020 compared with 2019 (31.5% vs. 41.7%). A second cohort with 32 subjects was tracked after SARS-CoV-2 exposure or vaccination. Ten subjects were positively diagnosed with COVID-19, 15 received a COVID-19 vaccine, and seven had high-risk SARS-CoV-2 exposure but either did not have a confirmed clinical diagnosis or tested negative. Subjects who tested positive for the virus showed no major complications or increased FOP disease activity, though our sample size is very limited. Among the 15 subjects who received a COVID-19 vaccine, using the International Clinical Council on FOP guidelines for prophylaxis with ibuprofen or acetaminophen, only one person experienced flare-like activity at the injection site.Patients with FOP showed a significant decrease in social activities that was reflective of the isolation and mobility changes in this debilitated population. In our limited cohort, the majority of the patients with FOP who tested positive for COVID-19 showed no major complications. Also, although limited in sample size, the majority of patients who received a COVID-19 vaccination and followed guidelines from the FOP International Clinical Council tolerated vaccination well. Only one person experiencing flare activity following their injection. Thus, the risks and benefits of COVID-19 vaccination needs to be discussed carefully so as to support informed decisions. While c disease . In addi disease .Fibrodysplasia ossificans progressiva (FOP) is a rare genetic condition characterized by progressive heterotopic ossification (HO) of tendons, ligaments, and other soft tissues within the body . This ecACVR1 gene, which encodes ACVR1 , a bone morphogenic protein (BMP) type 1 receptor [ACVR1 R206H mutation in causing this heightened immune response [FOP is caused by heterozygous activating mutations to the receptor . The mosreceptor , which creceptor . Barruetreceptor . Specifiresponse . In FOP response , and depresponse . Furtherresponse , and is response .Clinically, FOP progression can be promoted by viral-like illnesses. A prior study assessed if FOP patients who had symptoms of influenza during the 2000–2001 influenza season experienced an increase in the incidence of HO-related flare-ups . The FOPThe severe respiratory compromise from thoracic insufficiency induced by HO formation in the chest wall, as well as the high risk of complications from intubation, put patients with FOP at particularly high risk of adverse outcomes in the event of severe COVID-19 complications . The thoA study looking at serum samples of patients with severe, active COVID-19 infections found that Activin A, Activin B, and follistatin were all upregulated during the time when COVID-19 patients tended to deteriorate . In a COSurprisingly, a small number of patients with severe COVID-19 appear at higher risk for developing HO , suggestA recent case report implicated the COVID-19 vaccine as a potential trigger for myositis ossificans-related intramuscular nodule formation and internal calcifications in a 51-year-old male patient . Three mIn this study, we set out to answer three main questions. First, how has the COVID-19 pandemic impacted the care and mental health of patients with FOP? Second, do patients with FOP who were exposed to SARS-CoV-2 have increased FOP disease activity? And third, does vaccination against SARS-CoV-2 impact FOP flare activity?The social impact of the COVID-19 pandemic on patients with FOP was examined using the FOP Patient Registry sponsored by the International FOP Association (IFOPA). The FOP Registry was launched by the IFOPA in 2015 with a vision to develop a unified global registry that assembles the most comprehensive data on patients with FOP. The FOP Registry is an ongoing international, voluntary, observational resource that captures demographic and disease data directly from individuals with FOP approximately every six months via a patient portal, and clinical data from treating FOP physicians on an annual basis via a secure web-based medical portal. The design of the FOP registry is described separately , 25. AllTo participate in the FOP Registry, patients were required to confirm their FOP diagnosis and provide informed consent via an electronic acceptance. As of March 24, 2021, 326 individuals from 69 countries were enrolled and active, representing ~ 36% of the known global FOP populations based on IFOPA estimates. Thus, this cohort is representative of the global FOP community.Domain scores of the PROMIS Global Health Scale  were calPatients with FOP who had either a known high risk exposure to the SARS-CoV-2 virus , tested positive for COVID-19, or received a COVID-19 vaccine, were recruited and enrolled into the study between July 14th, 2020 and August 23rd, 2021. The study was approved by the UCSF Institutional Review Board . After obtaining written consent, subjects with known exposure to the virus were given questionnaires covering symptoms experienced and their duration, test results, hospitalizations, complications, and any flare activity around the time of contracting the virus. Symptoms in the questionnaire included fever, chills or shakes, cough, sore throat, difficulty breathing, weakness or fatigue, unexplained muscle aches, loss of taste or smell, runny or congested nose, diarrhea, and eye redness. Subjects were followed at 2 weeks and 4 weeks to assess for any progression or changes in health status. For patients who reported their exposure retroactively, data was collected but follow-up in the aforementioned manner was forgone. Exposed subjects were considered positive if they developed COVID-19 symptoms within 2 weeks of exposure, or if they tested positive.Subjects who received a COVID-19 vaccine were given questionnaires to collect information about the vaccine manufacturer , injection route  and location, side effects, any hospitalizations or complications, and any flare-like activity. All subjects were asked to follow the FOP International Clinical Council (ICC) guidelines for vaccination  of the cohort  participants aged ≥ 15 years rated their satisfaction with their social activities and relationships as poor in 2020, which was an increase from 18 (18.9%) in 2019  participants reported seeing a physician one or more times, compared with 134 (84.2%) in 2020. The number of participants reporting zero visits to a physician related to their physical health remained unchanged, with 25 (14.6%) reporting no visits in 2019 and 25 (15.7%) in 2020  group was 31.2 years with an even split between males and females  followeWe recruited 15 patients with FOP who received a COVID-19 vaccine: 10 received the Pfizer-BioNTech vaccine, two received the Johnson & Johnson vaccine, two received the Moderna vaccine, and one received the CoronaVac vaccine. The mean age for the vaccination group was 31.2 years with females comprising 53.3% of the subjects  prednisone. Her antibody titer after this first injection was positive. Subject 4 chose not to receive the second dose of the Pfizer-BioNTech vaccine due to concern over additional side effects.Prior to the COVID-19 pandemic, loneliness and isolation were already major health concerns, with indications that 10–40% of people surveyed in Europe, China, and the United States were affected , 28. TheThe COVID-19 pandemic has disproportionately affected individuals with disabilities . While tUsing the IFOPA Patient Connection Registry, we identified that adult and pediatric patients with FOP had decreased participation in social activities between 2019 and 2020. This is particularly notable since mental health and pain are significant issues for patients with FOP . In addiAlthough FOP is a genetic disease characterized by progressive and severe HO and an overactive immune system, we found that most patients in our cohort with FOP and COVID-19 did not report major complications, hospitalizations, or an increase in FOP disease activity as a result of contracting COVID-19. This contrasts with recent case reports, including a 45-year-old female patient with known FOP who reported disease progression potentially linked to viral illness . A monthhttp://www.iccfop.org) and are summarized in Table Although intramuscular immunizations are largely avoided in patients with FOP due to the risks of complications , 17, we There are several limitations to this study. Since the reported cohort of patients with FOP who received a COVID-19 vaccine is very small, the absence of a pattern of complications or HO formation at the injection site is reassuring, but patients should be reminded that COVID-19 and any intramuscular injection still has risks in patients with FOP. Patients with FOP should still consult with their physicians before deciding to get a COVID-19 vaccine as there may be other factors that should be considered. Our study also does not provide information about the safety or efficacy of other vaccinations, so following the current treatment guidelines for patients with FOP (found at ICCFOP.org) remains important for maintaining patient safety. Notably, Subject 3 did not show IgG antibody production after receiving the first injection of the Pfizer-BioNTech vaccine subcutaneously, but did after the second dose that was given intramuscularly. While this is not proof that subcutaneous injections are ineffective, we support the ICC guidelines, which recommend that the COVID-19 vaccine be administered via the route recommended by the manufacturer, including intramuscularly, with anti-inflammatory medications given post-innoculation.Our results show that patients with FOP are at risk of decreased physical, mental, and dental health as a result of the COVID-19 pandemic. Among our limited cohort of patients with FOP, no one reported life-threatening complications with SARS-CoV-2 viral infection, although patients with FOP remain at high risk of complications from any respiratory illness because of cardiopulmonary involvement of FOP. Only one patient with FOP reported increased FOP disease activity in response to a COVID-19 vaccine; however, case reports in the literature and our own case studies suggest that patients with FOP remain at significant risk for complications such as flares and heterotopic ossification. Thus, the risks and benefits of COVID-19 vaccination needs to be discussed carefully so as to support informed decisions. Finally, our results provide a clinical foundation for future studies to understand the specific triggers of FOP-related immune responses.


Vaccination is a major strategy to prevent the coronavirus disease 2019 (COVID-19). However, information about factors associated with men and women intention to be vaccinated are scarce. To determine COVID-19 vaccine acceptance and identify factors associated vaccine hesitancy according to sex, we performed a cross-sectional population-based random survey in Salvador, Brazil between Nov/2020-Jan/2021. Participants were interviewed to obtain data on intention to receive and pay for a COVID-19 vaccine, as well as on demographics, comorbidities, influenza vaccination history, previous diagnosis of COVID-19, and exposures and perception of COVID-19 risk. Among 2,521 participants, 2,053 (81.4%) reported willingness to use a COVID-19 vaccine and 468 (18.6%) hesitated to take it. Among those intending to get vaccinated, 1,400 (68.2%) would pay for the vaccine if necessary. Sex-stratified multivariable analysis found that men who were working and who had comorbidities were less likely to hesitate about using the vaccine. Among women, higher educational level and high perception of COVID-19 risk were associated with less vaccine hesitancy. In both groups, reporting influenza vaccination in 2020 reduced the chance of COVID-19 vaccine hesitancy. COVID-19 vaccine campaigns targeting to reduce vaccine hesitancy are urgently needed. These campaigns should consider gender differences in order to be successful. Given the continued transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) worldwide and the lack of effective pharmacological measures against virus infection and disease, vaccination became a major strategy to prevent and control the coronavirus disease 2019 (COVID-19). However, despite the rapid development of COVID-19 vaccines in response to the pandemic, little information about intention to be vaccinated is available. Furthermore, some studies show an increasing trend towards vaccine hesitancy over time [Brazil is one of the countries most affected by the COVID-19 pandemic. In December 2020, a second wave of COVID-19 initiated in the north state of Amazonas, in association with the emergence of the Gamma (P1) variant of SARS CoV-2 . From thFrom November 16, 2020 to January 15, 2021, we conducted a door-to-door survey in Salvador, Brazil. Participants were household-based randomly selected using a cluster sampling method, as follow: in each of the 12 sanitary districts used to organize the city’s public health system, 50 postal codes (each representing one street) were randomly selected from a list of postal codes by health district. Then, five houses were systemically selected in each of the 50 selected streets within each sanitary district . In each of the selected houses, one of the residents fulfilling the inclusion criteria and who were available to participate in the survey at the time of the visit was drawn for inclusion in the study, aiming at a target sample of 3,000 participants.Inclusion criteria for participation in the survey, which had as its primary goal to estimate the prevalence of antibodies against COVID-19, were age ≥5 years; living in the selected house, defined as sleeping ≥4 nights per week in the house; being at home at the time of the survey; and verbally consenting to participate prior to the drawing of one participant per house . However, to accomplish the secondary aims of assessing the acceptance level of a COVID-19 vaccine, we restricted the analyzes to participants aged ≥18 years old and nonpregnant women; pregnant women were not included because at the time of the survey there were several concerns about vaccination during pregnancy. Participants were interviewed using a structured questionnaire  Files toData were summarized using descriptive statistics. To investigate differences between those who accepted and those who hesitated about COVID-19 vaccination, we used the chi-square test for dichotomous variables and the linear-by-linear test for ordinal variables. A p-value <0.05 was considered statistically significant. Then, because we found sex as a factor associated with vaccine hesitance, we repeated these analyses for male and female participants and used their results to choose variables  to include in multivariable binomial logistic regression analyses, stratified by sex, to determine factors independently associated with vaccine hesitancy among men and among women. To measure associations, we used odds ratios (ORs) and 95% confidence intervals (CIs). The final model was built using a stepwise selection method, which used likelihood ratios as the criterion for adding significant variables to the model. We evaluated multicollinearity in final model by calculating the variance inflation factors (VIF), multicollinearity was defined if VIF > 10. The analysis was performed using R Statistical Software version 3.1.6.The study was approved by the Ethics Committee of Instituto Gonçalo Moniz, Fundação Oswaldo Cruz . Written informed consent was obtained from all studied participants.Among 2,537 nonpregnant participants aged ≥ 18 years, 2,521 (99.4%) had available data on intention to vaccinate against COVID-19. Of these, 2,053  indicated willingness to accept a COVID-19 vaccine and 468  hesitated in receiving the vaccine . VaccineBivariate sex-stratified analysis showed some differences between men and women . Among mAfter running stepwise multivariable regression models for men and women separately, the final models showed that a history of influenza vaccination in 2020 reduced the chance of COVID-19 vaccine hesitancy similarly for men  and women  . HoweverOur citywide survey, conducted prior to the initiation of the COVID-19 vaccination campaigns in Brazil, found a relatively high rate of intention to receive a COVID-19 vaccine (81.4%) in a large Brazilian urban center. It also identified that men and women had different factors associated with hesitancy regarding receiving a COVID-19 vaccine.It has been shown that the context of SARS-CoV-2 transmission can determine the population’s intention to be vaccinated, according to the perception of risk , 8. Our Likewise, an online survey conducted in Brazil around the peak of the first wave of COVID-19, in June 2020, found that 85% (95% CI 83–88%) of the general population reported a willingness to receive a COVID-19 vaccine  and all In our study, female sex was associated with hesitancy regarding the intention to use a COVID-19 vaccine. However, the role of gender in COVID-19 vaccine hesitancy seems to vary, depending on the social and cultural background of the studied population. Previous studies have highlighted that woman tended to perceive themselves at risk for COVID-19 more often than men and that they were also more likely to accept a COVID 19 vaccine , 14. In As expected, we found that both men and women who got the influenza vaccine during 2020 had lower rates of COVID-19 vaccine hesitancy, suggesting that they had a vaccine-prone behavior. In addition, we also found gender-specific factors associated with vaccine hesitancy. Men who were working were less likely to hesitate to get vaccinated, probably because they fear losing their job or having to stop if they get sick, a fear that may be reinforced by the economic crisis and the rising unemployment rate associated with the COVID-19 pandemic. It was also shown that 48.1% of people who would accept a COVID-19 vaccine considered the employer’s recommendation in their decision –20, and The finding that both presence of comorbidities among men and having a higher perceived risk of having COVID-19 among women reduced the likelihood of COVID-19 vaccine hesitancy may suggest that personal concerns about developing severe forms of the disease are important motivators for vaccine acceptance. This is consistent with results from a large, well-designed, randomized clinical trial conducted in the United Kingdom, which assessed whether brief statements about vaccination against COVID-19 would reduce vaccine hesitancy . InteresPrevious studies found that hesitancy about vaccination against COVID-19 and influenza vaccination was more common among younger individuals , 24. We The Brazilian Unified Health System (Sistema Único de Saúde - SUS) has several success stories in implementing health programs . Among tOur study has some limitations. As a cross-sectional study, it was not possible to assess any changes in vaccine hesitancy rates that may have occurred due to the increase in COVID-19 cases and deaths during the second epidemic wave or due to the start of COVID-19 vaccination campaigns in Brazil , 5. FurtWe found a relatively low rate of COVID-19 vaccine hesitancy following the first COVID-19 epidemic peak and before the second wave peak in a large Brazilian city. Gender was a factor associated with vaccine hesitance and most other associated factors differed between men and women. Thus, based on this survey performed in Salvador, Brazil, differences between men and women in vaccine hesitancy rate should be considered when defining health policies and designing campaigns to promote COVID-19 vaccination and reduce vaccine refusal rates. Additional studies are warranted to evaluate and monitor specific concerns about COVID-19 vaccination and antivaccine attitudes. In addition, longitudinal studies should be carried out because the perception of COVID-19 risk, a factor that we found to be associated with vaccine hesitancy among women, can change over time, according to the COVID-19 epidemiological context, which can affect the intention to be vaccinated.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Database(XLS)Click here for additional data file.


Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy “de-labeling” as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18–0.30) penicillin courses per year before de-labeling and 0.80 (0.67–0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06–2.54) to 1.79 (1.59–1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, “other” non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns. Clostridium difficile diarrhea  are common with 8–25% of individuals labeled as allergic to penicillin, depending on the patient group studied . PALs ardiarrhea , inapprodiarrhea , increasdiarrhea , and incdiarrhea .Clarifying a patient's penicillin allergy status has the potential to improve their access to appropriate and safe antibiotic therapy while also contributing to antimicrobial stewardship efforts in the era of increasing antimicrobial resistance , 12. AssElectronic dispensing data repositories are powerful potential tools for research on community antibiotic use . The patElectronic pharmacy dispensing records allow the direct comparison of community antibiotic dispensing before and after penicillin allergy evaluation. Here, we contrast antibiotic prescribing before and after penicillin allergy de-labeling through the analysis of several years of pharmacy dispensing records, thus providing information on antibiotic use over longer periods than previously reported. We characterize the use of specific non-penicillin antibiotics that are important targets for antimicrobial stewardship efforts. Further, we compare both the antimicrobial spectrum and cost of antibiotics dispensed before and after de-labeling.Adult patients who underwent an observed penicillin challenge through the Penicillin Allergy Clinic in the Department of Clinical Immunology at Auckland City Hospital between 01/01/2012 and 31/12/2017 were identified from electronic records of Immunology Day Ward attendances. There are approximately 70 penicillin challenges performed through the Antibiotic Allergy Clinic at Auckland City Hospital annually. Further, those with positive penicillin skin testing were identified from electronic records of penicillin skin testing results in the Penicillin Allergy Clinic in the same time period. Patients were excluded from the final analysis if they were aged <15 years at the time of assessment, if they had no medication entries in the TestSafe database prior to assessment, and if they had no antibiotic dispensing entries in the TestSafe database across the pre- and post-assessment periods.Penicillin skin tests were performed by medical laboratory scientists using increasing doses of commercial testing reagents . Skin prick testing (SPT) was followed by intradermal testing (IDT) using a standard protocol with a total of either three or five testing steps, as outlined in the Electronic community pharmacy antibiotic dispensing records for patients in the study cohort were retrieved from the “TestSafe” pharmacy dispensing record repository; this repository contains community pharmacy dispensing records for patients living in four of the ten District Health Boards in the catchment area for our clinic. Patients can opt to have their dispensing records excluded from the TestSafe database. For these reasons, coverage is not universal in our clinic population. Dispensing records specifically relating to oral and intravenous antibiotics were identified by ATC code see , groupedThe primary outcome of the study was the change in penicillin antibiotic dispensing rates before and after penicillin allergy assessment, stratified by allergy assessment outcome . Secondary outcomes, all stratified by allergy assessment outcome, were: the change in non-penicillin antibiotic dispensing rates .Dispensing rates and proportions after assessment were compared with those before assessment using paired Patients with a positive  or negative  penicillin challenge in the Auckland City Hospital Immunology Clinic between 01/01/2012 and 31/12/2017 were identified. There were 483 negative challenges and 17 positive challenges. A review of skin testing records from the same clinic identified 43 patients who were labeled as penicillin allergic based on positive skin test results without an oral challenge. Antibiotic dispensing data, defined as at least one dispensing record for an antibiotic in either the pre- or post- intervention period, was available for 304/483 (62.9%) negative challenge patients, 12/17 (70.6%) positive challenge patients, and 25/43 (58.1%) positive skin testing patients; these 341 patients comprised the study cohort , giving n = 304) and no change in confirmed penicillin allergic patients (n = 37), with 2.75 (95% CI 1.59–3.91) and 2.33 (95% CI 1.33–3.33) courses dispensed per year before and after assessment, respectively  were subsequently dispensed a penicillin antibiotic , compareectively .n = 304, For clinical reasons, the total number of annual antibiotic courses is likely to differ between patients. To control for this, dispensing of penicillin antibiotics as a proportion of total antibiotic courses was calculated for each de-labeled patient before and after penicillin allergy de-labeling n = 304, . The mean = 304, The effect of penicillin allergy de-labeling on the use of non-penicillin antibiotics was assessed by comparing non-penicillin antibiotic dispensing rates before and after de-labeling n = 304, . Macrolin = 304, p < 0.001, Non-penicillin antibiotic use was also measured as a proportion of each de-labeled patient's total antibiotic use before and after penicillin allergy de-labeling n = 304, . MacroliPenicillin allergy de-labeling is increasingly recognized as safe and has the potential to impact antibiotic prescribing. However, longer-term, high-quality data on antibiotic use following penicillin allergy de-labeling is limited. In this pre- and post- study, penicillin antibiotic use increased significantly in those who had their penicillin allergy removed following an observed challenge. After de-labeling, 70.6% of patients went on to use a penicillin antibiotic over a mean follow up period of 4.55 years. Further, patients who had their penicillin allergy confirmed had a lower penicillin antibiotic dispensing rate post-assessment, indicating that there may be benefits of undergoing assessment with skin testing and/or an observed penicillin challenge even for patients who are confirmed to be allergic to penicillin.Our findings support those from patients enrolled in a study of penicillin skin testing reagents, 94/196 (47%) received at least one penicillin antibiotic in the year following negative skin testing compared with 40/196 (20%) in the year prior . At a meIn de-labeled patients, the increased use of penicillin antibiotics in our study did not result in an overall increase in antibiotic use; total antibiotic use was lower following de-labeling. At 0.80 (95% CI 0.67–0.93) penicillin courses per patient per year, penicillin use in our de-labeled cohort exceeded the national rate of 0.48 penicillin antibiotic courses per year , likely This study also demonstrated that non-penicillin antibiotic use, when measured by either dispensing rate or as a proportion of a given patient's total antibiotic courses, reduced significantly across a range of classes that are important targets for antimicrobial stewardship . Further, rates of broad-spectrum antibiotic use were lower following penicillin allergy de-labeling. A reduction in tetracycline use was an inconsistent finding perhaps reflecting that tetracycline has indications outside of the treatment of acute infections (such as for acne) and so may be prescribed specifically in certain situations without consideration given to alternative antibiotics. This represents an important limitation of the study: no data were available on the indication for each antibiotic course as these data are housed in separate health record systems e.g., in primary care, acute clinics, etc. Some antibiotic use captured in our dispensing data will have been for empiric treatment of infections where penicillin antibiotics are first line, others will have been prescribed for infections where other antibiotics are recommended preferentially  , and somThe retrospective and observational nature of this study means that other factors could have affected antibiotic use in this cohort and, therefore, changes in antibiotic dispensing patterns cannot solely be attributed to the effect of the penicillin allergy assessment. Results should be interpreted acknowledging that antibiotic dispensing data were used as a surrogate for antibiotic consumption and were available for 341/543 (63%) patients assessed in the Penicillin Allergy Clinic. As a regional service, some patients attending our clinic may reside in areas outside of the greater Auckland region that is covered by the TestSafe dispensing repository. Further, patients can opt to have their dispensing data excluded from the repository and it is possible that some patients did not use any antibiotics in the pre- and post- assessment periods . Clinical information on the nature of the reaction that gave rise to the penicillin allergy label was not available. We do not know whether subsequent antibiotic courses resulted in allergic or adverse drug reactions. Previous work indicates that in patients with negative skin testing, after a mean follow-up period was 4.5 years, and after exposure to a mean of 8.2 therapeutic antibiotic courses, the rate of new antibiotic “allergy” to penicillin antibiotics was 2.9% . Lastly,In conclusion, this pre- and post- study of the effect of penicillin allergy assessment on antibiotic dispensing patterns demonstrates that penicillin allergy de-labeling is associated with increased penicillin antibiotic use, decreased non-penicillin antibiotic use, and reduced antibiotic costs. This study provides support for penicillin allergy evaluation in a specialist clinic as an important intervention in the era of antimicrobial stewardship. It is not clear if other de-labeling interventions delivered outside a specialist clinic, such as pharmacist-led penicillin allergy de-labeling, which have the potential to improve access to penicillin allergy de-labeling, will be associated with similar changes in antibiotic use although early data are promising . WhetherThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Auckland Health Research Ethics Committee (AHREC 000130). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.TH designed the study, performed data analysis, and wrote the manuscript. NA performed the dispensing data extract and data analysis. ED performed data analysis and wrote the manuscript. JC performed data entry and analysis. AJ designed the study. PF designed the study and wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In this study, we evaluated the improvement of image quality in digital breast tomosynthesis under low-radiation dose conditions of pre-reconstruction processing using conditional generative adversarial networks [cGAN (pix2pix)]. Pix2pix pre-reconstruction processing with filtered back projection (FBP) was compared with and without multiscale bilateral filtering (MSBF) during pre-reconstruction processing. Noise reduction and preserve contrast rates were compared using full width at half-maximum (FWHM), contrast-to-noise ratio (CNR), peak signal-to-noise ratio (PSNR), and structural similarity (SSIM) in the in-focus plane using a BR3D phantom at various radiation doses  and phantom thicknesses . The overall performance of pix2pix pre-reconstruction processing was effective in terms of FWHM, PSNR, and SSIM. At ~50% radiation-dose reduction, FWHM yielded good results independently of the microcalcification size used in the BR3D phantom, and good noise reduction and preserved contrast. PSNR results showed that pix2pix pre-reconstruction processing represented the minimum in the error with reference FBP images at an approximately 50% reduction in radiation-dose. SSIM analysis indicated that pix2pix pre-reconstruction processing yielded superior similarity when compared with and without MSBF pre-reconstruction processing at ~50% radiation-dose reduction, with features most similar to the reference FBP images. Thus, pix2pix pre-reconstruction processing is promising for reducing noise with preserve contrast and radiation-dose reduction in clinical practice. Digital tomosynthesis provides limited three-dimensional 3D) structural information about body structures by combining the advantages of digital imaging ,2 and coD structuTo date, several digital mammography-based DBT systems have been developed ,6,7, andWith the aim of overcoming the drawbacks of previous algorithms, a recent report described the development of an improved processing method for iterative DBT reconstruction   with theExisting DBT techniques used in clinical diagnostic studies have enabled the visualization of fine tissue structures with a shorter scan time. Nevertheless, all DBT systems are limited by the issue of patient radiation exposure, which highlights the need to preserve contrast in order to improve the sharpness of the image and detectability of the object. Furthermore, radiographic images can be degraded by quantum mottle, a consequence of spatial incident photon fluctuation. Quantum mottle is inversely associated with exposure, and therefore, any decrease in patient dose would be restricted by the degree of quantum mottle, even with a perfect detector. Even with a perfect detector, other factors are present, including X-ray scatter and X-ray spectrum, number of views, and other factors, to avoid minimizing image reconstruction and image processing, both of which are very important. Therefore, further decreases in patient doses and improvements in detection rely on innovations such as a new detector type, alternative X-ray sources, and an algorithm that improves image quality by incorporating suitable approaches.Moreover, DBT involves the reconstruction of images limited by a low signal-to-noise ratio due to the superposition of several low-exposure projection images. Furthermore, this characteristic causes a concurrent loss of plane-relevant details, which reduces the contrast of the reconstructed images. Several methods have been proposed to suppress this irrelevant plane information and enhance the image quality of DBT ,19. In rIn the accelerating evolution of deep learning, the transition from a convolutional neural network  to a genStudies conducted to date have quantitatively compared various DBT algorithms in terms of image quality and radiation doses ,39. AlthIn this paper, we report our experience using the application of pix2pix pre-reconstruction processing (FBP reconstruction after preprocessing pix2pix) to improve image quality with dose reduction and amend processing. Because the usefulness of preprocessing has been reported in improving image quality using deep learning processing of tomosynthesis , in thisThis study used a DBT system  that consists of an X-ray tube with a 0.3 mm focal spot  and a digital flat-panel amorphous selenium detector. A total acquisition time of 3.7 s and an acquisition angle of 15° were set for all DBT procedures. The projection images were sampled during a single tomographic pass . To produce reconstructed tomograms of the required height, we used a 512 × 1024 matrix with 32 bits (single-precision floating number) per image.The BR3D phantom  comprises multiple heterogeneous slabs and is intended to mimic the composition of glandular and adipose tissues and parenchymal patterns in the human breast. The slabs are composed of epoxy resins with X-ray attenuation properties corresponding to 50% glandular or 50% adipose breast tissue. In the phantom, the target slab was surrounded by nontarget slabs .For each radiation-dose setup, the reference radiation-dose  was set at 29 kVp 145 mA 310 ms, 31 kVp 170 mA 310 ms, and 33 kVp 200 mA 320 ms. The average glandular dose (AGD) for DBT was calculated according to Dance et al. . The MSE was calculated between the reference dose and low dose FBP images.We used a α: 0.375, wα: 5 × 5 Laplacian filter, rσ: 0.01) [This study compared the performance of pix2pix pre-reconstruction processing with that of MSBF pre-reconstruction processing. Here, the parameter settings (reported . In thisr: 0.01) .The impulse shape of each reconstructed image was restored using two-dimensional image filtering, which multiplied the Fourier transform by a Ramachandran and Lakshminarayanan kernel, which generally produced precise 3D reconstruction images .p) values < 0.05 were considered statistically significant.In this study, we compared the FWHM values with and without MSBF pre-reconstruction processing at different radiation doses between the four groups . The numbers of samples in the groups were reference dose , low dose without MSBF pre-reconstruction processing , low dose with pix2pix pre-reconstruction processing , and low dose with MSBF pre-reconstruction processing . Statistical analyses were performed using IBM SPSS Statistics version 21.0 for Windows . Probability  and radiation doses (approximately 50% and 75% reduction of AECrd), the optimal epoch was selected at the lowest MSE and highest SSIM. Using the results of the optimization verification, each training network image was generated by setting 300 epochs for pix2pix, and then evaluated and compared with those of the images obtained using the conventional approach with and without MSBF pre-reconstruction processing . The trap < 0.05; There was no deterioration in image quality with pix2pix pre-reconstruction processing under the low dose level (approximately 50% reduction of AECrd) conditions associated with changes in BR3D phantom thickness in FWHM, SSIM, and MSE, except for the contrast of masses. This result indicates that pix2pix may be useful for radiation-dose-reduction technology without a subsequent deterioration in image quality.Our experimental results clearly demonstrated the ability of pix2pix pre-reconstruction processing to improve the quality of DBT images for the low dose condition. In this study, the in-focus plane intensities of pix2pix pre-reconstruction processing, as compared with existing MSBF pre-reconstruction processing, improved spatial resolution, similarity, and image error without deterioration of the MCs images with whole image. Furthermore, pix2pix pre-reconstruction processing has the potential to reduce the radiation-dose by approximately 50% reduction of AECrd. Thus, pix2pix pre-reconstruction processing is a promising new option for imaging denoising, as it generated noise-reduced images and reduced radiation doses that were far superior to those obtained from images processed using conventional algorithms. The flexibility of pix2pix pre-reconstruction processing in the choice of imaging parameters, which is based on the desired final images and low dose DBT imaging conditions, promises increased usability.The projection-space combination of adversarial training approaches described here can be used to generate images to formulate denoising as a deep learning algorithm for projection completion problems, with the aim of improving the generalization and robustness of the framework. Because the direct regression of accurate projection data is difficult ,18, we pThe ability of pix2pix pre-reconstruction processing to obtain denoising and contrast-preserving images and to reduce the radiation-dose by approximately 50% reduction of AECrd  may be dIn MSBF pre-reconstruction processing, Laplacian pyramid decomposition (LPD) is used to achieve multiscale structure decomposition during MSBF pre-reconstruction processing. However, this function is not unique to LPD, and other multiscale analysis methods may be sufficient. In this regard, however, the MCs detected via MSBF pre-reconstruction processing may not have strong directional geometric features. Therefore, a directional multiscale analysis method, such as wavelet transform, may not be superior to the LPD method .The image artifacts from MCs leads to the appearance of noticeable objects comprising artifact-free voxels that contrast with the background. These artifacts from MCs are a drawback of the FBP algorithm and are conspicuous when images generated using this method are compared with artifact-free images. Therefore, based on the results of this study, future research should consider conducting evaluations using the IR algorithm.There were some limitations to this phantom study. First, the materials constituting the BR3D phantom were only simulations of the mammary gland, because actual mammary gland tissues were not tested. Alternatively, we suppose that the consistency of the BR3D phantom indicates that it is an accurate representation of actual mammary gland tissue. Second, we did not perform a clinical study using human subjects. The utility of pix2pix pre-reconstruction processing was confirmed by basic evaluation. In a future observational study, we plan to investigate the correlation between spatial resolution and contrast. We believe that pix2pix pre-reconstruction processing will allow for optimization of the use of dose in future DBT imaging and radiation-dose reduction technology and improve the accuracy of medical images. Third, the experiment was evaluated by a single vendor system. We think that a study using a multi-vendor system is necessary. Fourth, optimization of projection data analysis of MSE and SSIM was for the central projection only; the performance at other angles will depend on the object’s shape. Evaluations will be relevant to checking the sensitivity of optimization according to the projection view angle with respect to the detector. Fifth, evaluation of the in-focus slice of the reconstruction volume only; consideration of any out-of-plane features/artefacts is necessary. Sixth, use of the FBP algorithm only, without optimization . This leaves opportunities for future work . Seventh, we believe that the CNR evaluation of masses is limited and requires assessment using a wider variety of sizes, shapes and margin types  to improve accuracy. In addition, we considered using more advanced methods such as a detectability index , where tp = 0.996; 0.23 mm: p = 0.886; 0.29 mm: p = 0.321) in terms of preserving the structure of MCs as compared with variant phantom thickness. Thus, pix2pix shows promise for integration into the clinical application workflow to reduce image noise while maintaining image quality in breast tomosynthesis.This phantom study revealed that an approximately 50% reduction in radiation-dose is feasible using our proposed pix2pix pre-reconstruction processing. The pix2pix pre-reconstruction processing was particularly useful in reducing noise and yielded better results equivalent to that of the reference dose, with no significant difference in the statistical results (0.196 mm:


The COVID-19 pandemic has changed work life profoundly and concerns regarding the mental well-being of employees’ have arisen. Organizations have made rapid digital advancements and have started to use new collaborative tools such as social media platforms overnight.Our study aimed to investigate how professional social media communication has affected work engagement before and during the COVID-19 pandemic and the role of perceived social support, task resources, and psychological distress as predictors and moderators of work engagement.Nationally representative longitudinal survey data were collected in 2019-2020, and 965 respondents participated in all 4 surveys. Measures included work engagement, perceived social support and task resources, and psychological distress. The data were analyzed using a hybrid linear regression model. Work engagement remained stable and only decreased in autumn 2020. Within-person changes in social media communication at work, social support, task resources, and psychological distress were all associated with work engagement. The negative association between psychological distress and work engagement was stronger in autumn 2020 than before the COVID-19 outbreak.The COVID-19 pandemic has exerted pressure on mental health at work. Fostering social support and task resources at work is important in maintaining work engagement. Social media communication could help maintain a supportive work environment. The rapid spread of the COVID-19 pandemic has affected our lives and work profoundly . The COVIn remote work conditions during the COVID-19 pandemic, the use of digital tools and social media platforms has increased at work for information and document creation, sharing, and exchange and for video meetings and discussions . These tWork engagement, a key positive motivational state of well-being at work, is a comprehensive and enduring positive mental state that employees experience at their workplace and consists of three dimensions: vigor , dedication , and absorption  ,13. WorkAccording to job demands-resources model, work engagement is particularly driven by job resources, which are positive psychological, physical, social, and organizational characteristics of work, such as a good organizational climate and social support from colleagues and supervisors, which help employees accomplish work goals and foster learning and personal growth ,14. SociBased on the Conservation of Resources (COR) theory, people tend to obtain and protect valuable resources, and loss of resources plays a significant role in the development of psychological stress . Work enThe COVID-19 pandemic, along with its associated increase in digital and remote work, has potentially transformed ways of working for good . Prior lAccording to the COR theory  resourceSocial media communication at work has increased during the COVID-19 pandemic , and priThis longitudinal study analyzed changes in work engagement among employees in Finland before and during the COVID-19 pandemic. Our study investigated whether changes in social media communication at work, perceived social support, task resources, and psychological distress are related to changes in employees’ work engagement, especially at a time of a prolonged pandemic. We proposed the following hypotheses: (1) increased social media communication predicts an increase in work engagement; (2) increased perceived social support and task resources at work predict an increase in work engagement; (3) increased psychological distress predicts decreased work engagement; and (4) the association between work engagement and (i) social media communication, (ii) social support, and (iii) psychological distress have been stronger during rather than before the COVID-19 pandemic.=1081), and September to October 2020 . The fourth survey was sent to all original respondents, whereas the third survey was sent only to those who had responded to the second survey.Data from a 4-timepoint longitudinal survey on social media usage at work in Finland from 2019 to 2020 were acquired to represent the working population in Finland. The first survey was conducted in March to April 2019 . The participants were recontacted in September to October 2019 , March to April 2020  included respondents who answered all 4 surveys, and the response rate was 53.11%. We found no major bias when conducting nonresponse analyses and when comparing the sample with official census figures of the working population in Finland , an, an43], Task resources were measured using 4 questions from the work organization and job content dimension of the second version of the Copenhagen Psychosocial Questionnaire  43]. Sc. Sc43]. We measured psychological distress using the 12-item General Health Questionnaire . ExampleSociodemographic variables considered herein included age, gender, and education. All background variables were assessed at every timepoint; that is, every 6 months.As descriptive statistics, we expressed data as mean (SD) values for continuous study variables and frequencies and proportions for categorical variables  and 2. IFor all our hypotheses, we analyzed whether the within-person variation in social media communication, perceived social support, task resources, and psychological distress predicted changes in work engagement. We tested our hypotheses using a hybrid (or within-between) linear regression model . This meOur analysis proceeded in 2 steps. Model 1 included all our within-person and between-person main effects and a random intercept. For work-related and nonwork-related social media communication, perceived social support, task resources, and psychological distress, the effects were estimated as within- and between-person effects. For time, we estimated only within-person effects. Time was included as binary variables (T2-T4) with T1 as a reference category. Gender, age, and education at T1 were added to the model as between-person variables, as they varied only between persons.P value), the variance of random intercept, and a log pseudolikelihood estimate in f2 coefficients for all the significant predictors. These coefficients were calculated using the approach described by Selya et al [To test our hypothesized moderation effects, within-person interaction terms including work-related and nonwork-related social media communication, perceived social support, task resources, and psychological distress at T4 were added to the model; Schunck  has descya et al  and theyya et al .P=.02) (f2<.01). Among the other within-person variables, an increase in work-related social media communication , social support , and task resources  were associated with increased work engagement. Increased psychological distress, in turn, was associated with reduced work engagement . The variance in work engagement was mainly explained by social support (Cohen f2=.06), task resources (Cohen f2=.05), and psychological distress (Cohen’s f2=.04), and the effect size for work-related social media communication was low (Cohen f2<.01).The results of descriptive statistical analysis are shown in P=.02) . The efff2<.01; P=.003), social support , and task resources  were positively associated with average work engagement, yet they only explained a marginal share of the variance in work engagement. Between-person differences in psychological distress, in turn, were negatively associated with work engagement . The effect size for this association was low (Cohen f2<.01). In addition, female gender  and age  were associated with between-person differences in work engagement. This implies that females reported higher work engagement on average than males, and older respondents also had higher work engagement on average. However, the effect size was low both for gender (Cohen f2<.01) and age (Cohen f2<.01).Between-person differences in nonwork-related social media communication . As expected, the negative association between within-person differences in work engagement and psychological distress was stronger in autumn 2020 (Β=–0.39) than at T1 . However, the overall proportion of the variance in work engagement explained by this interaction was low (Cohen f2<.01).Among our moderations (model 2), only the interaction effect between T4 and psychological distress was significantly related to work engagement .Our study is timely and the first one to offer longitudinal evidence regarding internal and external social media communication, both work-related and nonwork-related, in organizations and the related well-being implications, before and during the COVID-19 pandemic. Our findings revealed that work engagement remained considerably state at the onset of the COVID-19 pandemic during spring 2020. Hence, our results provide interesting insights and are in contrast with those of prior studies reporting that major disasters usually provoke stress and reduce resources ,51. HoweIncreased psychological distress was associated with reduced work engagement in the within-person model, which is in line with prior reports on stress and social media use ,54. IndiThe significant role of various job resources in work engagement construction has been established in prior studies and in the context of social media ,13,14. OOur findings have practical implications for organizations by demonstrating that work engagement decreased during autumn 2020, while psychological distress was stronger at that timepoint. Employees continued to work under uncertain conditions in autumn 2020 with no certain signs of future relief. Thus, providing mental health support for employees in such situations is crucial. The importance of supervisor support in alleviating employees’ emotional exhaustion and feelings of uncertainty regarding COVID-19 has been previously reported , which oIncreased nonwork-related social media communication did not explain within-person variation in work engagement. We observed only between-person differences because those with high nonwork-related social media communication also had a higher level of work engagement on average. Employees who use social media actively for informal communication are also the ones who engage more in their work. This is because when engaged, employees invest energy into their work-related roles and therefore behave more proactively  and haveMoreover, increased social support and task resources were related to enhanced within-person and between-person work engagement. The results emphasize the importance of supporting employees in using their expertise, maintaining a sense of meaningfulness, providing possibilities to influence their work content and load, and offering and receiving social support.We used a longitudinal, nationally representative sample, which enabled the analysis of timepoints before and during the COVID-19 crisis and the related effects on well-being, which can regard as one of the strengths of this study. The response rate was high, and our survey included a very limited number of missing observations. The study design with work-related and nonwork-related social media communication was novel, and a similar longitudinal study has not been performed before. The study was conducted with employed people in Finland and did not examine the COVID-19 crisis cross-nationally. Because this was an observational study, the associations reported herein should not be directly interpreted as causal relationships. Some effect sizes were low, but effect sizes for the main results remained significant even though our model was adjusted for a number of factors. This study was also limited to self-reported information.Work engagement decreased during autumn 2020 at a time when psychological distress had a stronger negative association with work engagement. Social media communication at work, perceived social support, and task resources were also associated with higher work engagement. Overall, work engagement remained relatively stable during the COVID-19 crisis. However, providing mental health support during a prolonged crisis is crucial for organizations. Moreover, supporting employees’ resources at work is important in maintaining employee work engagement, in which social media communication can be of help.