While several studies have described the clinical course of patients with coronavirus disease 2019 (COVID-19), direct comparisons with patients with seasonal influenza are scarce. We compared 166 patients with COVID-19 diagnosed between February 27 and June 14, 2020, and 255 patients with seasonal influenza diagnosed during the 2017–18 season at the same hospital to describe common features and differences in clinical characteristics and course of disease. Patients with COVID-19 were younger  and had fewer comorbidities at baseline with a lower mean overall age-adjusted Charlson Comorbidity Index  than patients with seasonal influenza. COVID-19 patients had a longer duration of hospitalization , a more frequent need for oxygen therapy  and invasive ventilation  and were more frequently admitted to the intensive care unit  than seasonal influenza patients. Among immunocompromised patients, those in the COVID-19 group had a higher hospital mortality compared to those in the seasonal influenza group . In conclusion, we show that COVID-19 patients were younger and had fewer baseline comorbidities than seasonal influenza patients but were at increased risk for severe illness. The high mortality observed in immunocompromised COVID-19 patients emphasizes the importance of protecting these patient groups from SARS-CoV-2 infection. While the strain that COVID-19 places on healthcare systems, economies, and societies worldwide is unprecedented, comparisons have often been drawn with the 1918 influenza pandemic4. Also, the pandemic preparedness plans currently used in many countries are largely based on the experience of several influenza pandemics during the last decades5. Thus, a detailed understanding of common features and differences of patients with SARS-CoV-2 and influenza virus infections in the hospital setting can help to plan resources in this ongoing outbreak. COVID-19 and seasonal influenza are viral respiratory infections that are primarily transmitted from person-to-person via respiratory droplets or aerosols among close contacts8. The clinical presentation of both infections is highly variable and ranges from only mildly symptomatic cases to acute respiratory distress syndrome (ARDS) and death9. However, there remains substantial uncertainty regarding the differences between COVID-19 and seasonal influenza with respect to high-risk-populations, clinical course, and case-fatality rates. Most previous studies describing the clinical course of COVID-19 lack a control group13, and data comparing patients with SARS-CoV-2 infection to patients with other viral respiratory infections such as seasonal influenza in the hospital setting are limited19. This single-center observational study aimed to systematically compare demographics, clinical characteristics, and disease outcomes of two non-selected cohorts of consecutive patients with SARS-CoV-2 infection and influenza virus infection, respectively, who were all treated at the University Medical Center Hamburg-Eppendorf.On March 11, 2020, the WHO declared the coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemici.all adult patients with SARS-CoV-2 infection confirmed by RT-PCR between February 27 and June 14, 2020, treated at the University Medical Center Hamburg-Eppendorf.ii.21.all adult patients with seasonal influenza virus infections confirmed by RT-PCR treated at the University Medical Center Hamburg-Eppendorf between December 25, 2017, and April 8, 2018, which is the definition of the influenza season by the Robert Koch Institute, Germany's national public health institute22.The study was reviewed and approved by the Ethics Committee of the Medical Council of Hamburg (WF-017/18 and WF-052/20). Informed consent was waived by the same ethics committee since only anonymous data were analyzed and published. All experiments were performed in accordance with relevant guidelines and regulations. We did not include psychiatric patients and patients younger than 18 years in the study. Also, employees who were diagnosed with COVID-19 by our institution’s screening algorithm but did not require hospitalization were not included in the studyWe conducted a retrospective observational study at the University Medical Center Hamburg-Eppendorf to compare two patient cohorts:23 throughout the influenza season. After the first case of COVID-19 was confirmed in Germany in January 202024, all symptomatic patients were additionally screened for SARS-CoV-2 infection by RT-PCR using either a laboratory developed test for the NeuMoDx 96 system 25, a Cobas6800 IVD , a GeneXpert Xpress System  or a Cobas6800-based UCT 26. Only patients with influenza or SARS-CoV-2 infection confirmed by RT-PCR were included in this analysis.According to our hospital standards, all patients admitted with fever or respiratory symptoms were screened for influenza infection by RT-PCR using either the GeneXpert Xpress System  or a laboratory-developed assay21. For the current study, COVID-19 and influenza patients were stratified according to whether they were treated as outpatients in our emergency department, were admitted to regular wards of our hospital, or had to be admitted to the intensive care unit (ICU). The age-adjusted Charlson Comorbidity Index (ACCI) was applied to assess comorbidities28. Patients were classified as immunocompromised if they were allogeneic stem cell transplant recipients, had a hematopoietic malignancy known to cause immune dysfunction or if they received systemic immunosuppressive therapy, chemotherapy, or immunomodulatory agents .Antiviral treatment was defined as administration of a specific antiviral agent against influenza and COVID-19, respectively. Patients who participated in placebo-controlled, double-blind treatment studies were assigned to the treatment group for this analysis. Immunotherapy was defined as administration of convalescent plasma, the anti-IL-6 antibody tocilizumab, or the anti-adrenomedullin antibody adrecizumabContinuous variables were expressed as mean and standard deviation (SD) or median and interquartile range (IQR) and compared with Student’s t-test. Categorical variables were expressed as number (%) and compared by Fisher's exact test. A log-rank test was used to compare the proportion of patients discharged alive during the first 90 days of hospitalization. P values less than 0.05 were considered statistically significant. Figures were designed using GraphPad Prism version 8 for macOS . All other analyses were performed using SPSS, version 21.0 .21. The baseline characteristics of both groups are listed in Table Between February 27 and June 14, 2020, a total of 166 patients with SARS-CoV-2 infection were treated at the University Medical Center Hamburg-Eppendorf. During the 2017–18 influenza season, 255 patients with laboratory-confirmed seasonal influenza were treated at our centerAmong COVID-19 patients, the proportion of men was higher than in influenza patients . Patients with SARS-CoV-2 infection were younger  and had a lower overall ACCI  than patients with seasonal influenza  and renal replacement therapy  than influenza patients. The rate of patients receiving extracorporeal membrane oxygenation (ECMO) did not significantly differ between the two groups. A total of 27 (16.3%) patients with COVID-19 and 62 (24.3%) patients with seasonal influenza received specific antiviral therapy (P = 0.05). In addition, 15 (9.0%) patients in the COVID-19 group received immunotherapy with convalescent plasma, tocilizumab, or adrecizumab. There was no statistically significant difference between the two groups in the rate of patients receiving antibiotic therapy during the hospitalization  , bacterial  and fungal  co-infections was similar in both groups and also the overall spectrum of pathogens did not significantly differ between COVID-19 patients and influenza patients . Among those patients admitted to the ICU, no differences in mortality were observed between the two groups . Among all immunocompromised patients, those in the COVID-19 group had a higher mortality compared to those in the seasonal influenza group . Among patients with SARS-CoV-2 infection, mortality was significantly increased in immunocompromised compared to immunocompetent individuals . In contrast, no significant difference in mortality was observed between immunocompromised and immunocompetent patients with seasonal influenza .Notably, all five allogeneic stem cell transplant recipients in the COVID-19 group and one in the seasonal influenza group (14.3%) died  and 176 were infected with influenza B virus (IBV). While the hospital mortality did not differ between patients with IAV and IBV infections , the rate of patients requiring mechanical ventilation was significantly higher in patients with IAV virus infections  compared to patients with IBV infections .We further compared demographic information, comorbidities, and immune status of patients treated as outpatients, those admitted to regular wards and those admitted to the ICU between the COVID-19 group and the seasonal influenza group (see Supplementary Table In this current study, we directly compared a cohort of 166 consecutive patients with COVID-19 with all 255 patients diagnosed with seasonal influenza during the 2017–18 season treated at the University Medical Center Hamburg-Eppendorf. This comparative approach allowed us to identify common features and differences between those two respiratory infections in the identical hospital setting and provide indications of the strain the COVID-19 pandemic places on hospital resources and capacities.32. Even though currently available data indicate similar overall COVID-19 case numbers in men and women33, male sex has been linked to a generally more severe course of disease with more frequent need for hospitalization and an excess in case fatality rates35. While the detailed mechanisms underlying those observed sex-differences remain to be established, our study contributes to the growing body of evidence suggesting that male sex is a major risk factor for severe COVID-1918.An important finding to emerge from this comparison is that the majority of COVID-19 and influenza patients were men and that this male predominance was even more pronounced in COVID-19 patients. These observations are consistent with previous studies that have demonstrated a higher overall incidence of seasonal influenza and higher disease severity in male compared to female patients37 and with a recent cohort study analyzing electronic healthcare databases of the US Department of Veterans Affairs that observed a mean age of 69 years19. However, our observation that patients with SARS-CoV-2 infection are generally younger than seasonal influenza patients is consistent with previously published data18. Interestingly, among patients that were admitted to the ICU, age did not significantly differ between the two groups. Also, patients requiring ICU admission were significantly older than those treated on regular wards or as outpatients in the COVID-19 group but not in the seasonal influenza group. These findings suggest that age may potentially be a more important driver of disease severity for COVID-19 than for seasonal influenza37.Another remarkable observation is that patients with SARS-CoV-2 infection were significantly younger than those with seasonal influenza. The median age of COVID-19 patients in our study was lower than in recent multi-center cohort studies of patients hospitalized with SARS-CoV-2 infection in Germany that observed a mean age of 68–70 years18. In our study, COVID-19 patients had a significantly lower ACCI than influenza patients, reflecting a lower overall prevalence of comorbidities. Interestingly, among patients admitted to the ICU, mean ACCI did not differ between the two groups, suggesting that comorbidities may be stronger determinants of disease severity in COVID-19 patients than in seasonal influenza patients. This is further supported by the fact that in the seasonal influenza group, patients admitted to the ICU even had a lower mean ACCI than seasonal influenza patients treated on regular wards. These results may imply that COVID-19 more frequently causes severe disease requiring hospitalization in relatively healthy individuals compared to seasonal influenza but that patients at highest risk for critical disease requiring admission to the ICU are primarily older individuals with comorbidities for both respiratory infections. Remarkably, we observed a significantly lower prevalence of chronic respiratory diseases in COVID-19 patients than influenza patients in the subgroups admitted to regular wards as well in those admitted to the ICU. While underlying respiratory diseases are associated with more severe outcomes of both viral respiratory infections39, our observations suggest that chronic respiratory conditions may have an even higher impact on the severity of seasonal influenza than on the severity of COVID-19.Assessing the prevalence of specific comorbidities in COVID-19 patients is paramount to identify and protect patient groups at high risk for severe disease. However, many studies characterizing COVID-19 patients are hampered by the lack of control groups, and the comparability of patient cohorts from different countries or different clinical settings is limited. For example, a large cohort study based on electronic health records and claims data showed that compared to influenza patients, COVID-19 patients had fewer comorbidities in the USA but more comorbidities in South Korea40 and 5–8% for seasonal influenza42. Of note, a number of patients with acute leukemia with SARS-CoV-2 infection experienced a severe clinical course with high hospital mortality and contributed to the relatively high overall mortality in the COVID-19 group. Indeed, while the attributable risk of many immunocompromising conditions and immunosuppressive therapies on severity and outcome of COVID-19 yet needs to be established, there is some evidence that patients with hematological malignancies are at increased risk of severe COVID-1945. Likewise, there is evidence that immunocompromised individuals have a higher risk for influenza-associated complications46. However, no significant effect of immunosuppression and immunodeficiency on overall mortality was observed for influenza patients in our cohort. This might either result from a generally lower severity of immunocompromised state in patients with seasonal influenza compared with COVID-19 patients or reflect a lower impact of immunocompromised state on disease outcome of seasonal influenza compared to COVID-19. Notably, amongst immunocompetent patients, those with COVID-19 had a more severe overall course of disease than those with seasonal influenza, but mortality did not significantly differ between the two groups.Even though COVID-19 patients were generally younger and healthier than influenza patients, the overall course of disease was more severe, with fewer patients treated as outpatients, longer overall duration of hospitalization, more frequent admission to the ICU, more frequent need for oxygen therapy, and invasive ventilation. The overall in-hospital mortality in our cohort was 15.9% in COVID-19 patients and 9.0% in influenza patients. This significantly higher case fatality rate among patients hospitalized with SARS-CoV-2 infection is generally in line with large multi-center observational studies, which have shown an overall in-hospital mortality of 15–22% for COVID-1947, HFNC has been suggested to benefit COVID-19 patients with acute hypoxemic respiratory failure without this increased risk of SARS-CoV-2 transmission to patients and healthcare workers49.Remarkably, eight patients with SARS-CoV-2 infection were successfully treated with HFNC and did, therefore, not require tracheal intubation. While NIV is associated with an increased risk of aerosolization and nosocomial transmission50. More recently, several studies have reported a high prevalence of invasive pulmonary aspergillosis in COVID-19 patients admitted to the ICU54, suggesting that those patients might be at equally high risk to develop co-infections with Aspergillus. Our observations emphasize that clinicians need to be aware of this complication in order to conduct prompt and comprehensive analysis in high-risk patients55.In our cohort, the prevalence of invasive pulmonary aspergillosis was similar among critically ill influenza and COVID-19 patients, even in the absence of underlying immunocompromising conditions and was associated with significant mortality. While invasive pulmonary aspergillosis typically occurs in severely immunocompromised hosts, it has also been shown to be a frequent complication in immunocompetent but critically ill patients with influenza infectionsWhile bacterial co-infections in general and the different causative bacterial pathogens, in particular, were equally common in seasonal influenza patients and COVID-19 patients, the latter were significantly less frequently treated with carbapenems and glycopeptides. The reason for this less frequent use of these broad-spectrum antibiotic classes may be a more established antibiotic stewardship program at our hospital in the 2020 outbreak versus the 2017–2018 season.21. Notably, the rate of patients requiring mechanical ventilation was significantly higher in patients with IAV infections compared to patients with IBV infections. These findings demonstrate that extrapolation of disease outcomes related to other influenza seasons should be performed with caution. Fourthly, the screening and treatment algorithm at our center was different for seasonal influenza and COVID-19. While generally only symptomatic patients are tested for influenza infections, all patients admitted to our hospital were screened for SARS-CoV-2 infection from April 20 onwards, which may contribute to sampling bias and result in a higher number of COVID-19 patients with mild or subclinical infections. COVID-19 patients were treated strictly according to a hospital-wide algorithm and, therefore, may, for example, have received low-flow oxygen at higher blood oxygen saturation levels than seasonal influenza patients. Lastly, it is important to note that the significantly lower age and fewer comorbidities in COVID-19 patients compared with influenza patients admitted to regular wards may also, to some extent, reflect a lower threshold for admitting patients with SARS-CoV-2 infection to the hospital due to the challenges of self-quarantine from household members and less data on reliable predictors for disease severity. Likewise, duration of hospitalization in COVID-19 patients may be prolonged due to PCR positivity and not due to clinical necessity, which may place additional strain on healthcare systems.Our study is subject to a number of limitations. Firstly, patients diagnosed at and referred to our tertiary care center may have generally more baseline comorbidities and a more severe course of disease than patients in different clinical settings, so our results may not apply to all other patient cohorts. Secondly, while COVID-19 and seasonal influenza are both viral respiratory infections that share a common transmission route and cause similar symptoms, they are subject to several important differences that considerably limit the comparability of our cohorts. While most humans have pre-existing immunity to seasonal influenza virus strains and vaccines are available for high-risk populations, the COVID-19 pandemic has demonstrated the potential impact of a novel pathogen on an immunologically naive population. Remarkably, only four of the 23 deceased seasonal influenza patients in our study cohort were vaccinated against seasonal influenza. Thirdly, given relatively low influenza case numbers throughout the 2019–2020 season, we compared COVID-19 patients to patients diagnosed with seasonal influenza throughout the 2017–18 season, when most laboratory-confirmed influenza cases were attributed to influenza B virus, and mismatch between the trivalent vaccine and the circulating strains occurredDespite those limitations, our study can provide some relevant insights into common features and differences in clinical characteristics and required hospital resources between patients with COVID-19 during the early phase of the pandemic and those with seasonal influenza. Prospective multi-center studies using standardized admission, treatment, and outcome protocols are needed to confirm the current findings and to assess the changes in morbidity and mortality of COVID-19 as well as of seasonal influenza throughout this evolving pandemic.In conclusion, we demonstrate that patients treated with SARS-CoV-2 infection during the early phase of the pandemic were younger and healthier than those with seasonal influenza infections. However, patients with SARS-CoV-2 infection had a generally more severe course of disease. These results suggest that this phase of the COVID-19 epidemic was associated with a higher demand for both critical care and regular care hospital beds than seasonal influenza epidemics with similar patient numbers. Importantly, the high mortality in COVID-19 patients with hematological malignancies and older patients emphasizes the importance of protecting these patient groups from SARS-CoV-2 infection. While patients hospitalized with SARS-CoV-2 infection in the future will likely differ from those in our cohort in clinical characteristics and disease outcome due to changes in disease epidemiology and novel therapeutic agents and strategies, our observations provide important insights for the future course of the COVID-19 pandemic.Supplementary Information.


For patients with suicide attempts or self-harm, acute-care hospitals often function as the primary or sole point of contact with the healthcare system. However, little is known about patient characteristics or clinical trajectories of suicide attempts and self-harm episodes among those admitted to acute-care hospitals. This study aimed to describe the characteristics of suicide attempts and self-harm among patients admitted to acute-care hospitals, and the clinical practices provided in these hospitals, using a nationwide inpatient database in Japan.Using data from the Japanese Diagnosis Procedure Combination inpatient database from June 2015 to March 2017, we identified patients with emergency admission for suicide attempts or self-harm. We did not include patients with elective admission to psychiatric hospitals or outpatients. We described patient characteristics, treatments for physical injuries, psychiatric interventions, and discharge status.We identified 17,881 eligible patients during the 22-month study period. Overall, 38% of the patients did not have any psychiatric or behavioral comorbidities at admission. The most common suicide method was drug overdose (50%), followed by hanging (18%), jumping from a height (13%), cutting or piercing without wrist cutting (7.1%), poisoning (6.6%), and wrist cutting (5.4%). Suicide was completed by 2,639 (15%) patients. Among patients discharged to home, 51% did not receive any psychiatric intervention. In 468 acute-care hospitals (54%), no psychiatric intervention was provided during the study period.We found that half of acute-care hospitals did not provide any hospital-based psychiatric care for patients with suicide attempts or self-harm. In Japan, 21,321 people  committed suicide in 2017,5 Because many suicide attempts and self-harm episodes result in emergency department visits, acute-care hospitals often function as the primary or sole point of contact with the healthcare system.6 Therefore, the Japan Cabinet Office has tried to establish a system of psychiatry liaison teams and coordination between general and psychiatric hospital departments through the medical fee revision of 2012.5 However, little is known about the patient characteristics or the current status of clinical management for these patients in Japan.One type of support for people with a history of suicide attempts or self-harm described in this policy is the enhancement of the psychiatric medical care system in emergency medical facilities.7–11 A systematic review of descriptive studies of suicide attempters in emergency departments in Japan described these patients’ characteristics; however, the results of this study may have been biased because the review included only published articles.12 No previous study has examined the psychiatric medical care system after individuals who have attempted suicide or engaged in self-harm are admitted to acute-care hospitals. Therefore, this study aimed to describe the characteristics and clinical trajectories of suicide attempts and self-harm episodes using a nationally representative sample of patients admitted to acute-care hospitals in a nationwide inpatient database in Japan.Previous descriptive studies on suicide attempts and self-harm have been conducted only in single institutions.This study was a retrospective nationwide cohort study in Japan. The reporting of this study conforms to the RECORD statement. The Institutional Review Board of the University of Tokyo approved the study . No information allowing the identification of individual patients, hospitals, or physicians was obtained. The requirement for informed consent was waived because of the anonymous nature of the data.We used the Japanese Diagnosis Procedure Combination inpatient database, which includes discharge abstracts and administrative claims data. For 2016, this database contains information from 1,200 acute-care hospitals, covering 90% of all beds for critically ill patients and 70% of all beds for acute-phase patients throughout Japan. This database does not include patients admitted to psychiatric hospitals without need for general ward admission to treat physical injuries. The database includes information on age, sex, diagnoses , procedures, and discharge status. In addition, from June 2015 to March 2017, it was mandatory for health care providers to input codes for suicide attempts and self-harm for all patients admitted to acute-care hospitals, regardless of whether or not the admission was specifically for suicide attempt or self-harm. In this code, the definition of suicide attempt/self-harm specifies an intent to die or to engage in self-directed, potentially injurious behavior. Suicide methods were categorized as (i) hanging; (ii) jumping from a height; (iii) poisoning; (iv) drug overdose; (v) cutting or piercing without wrist cutting; (vi) wrist cutting; (vii) other; and (viii) unspecified. When health care providers could not confirm at admission that the behavior was a suicide attempt or self-harm, they assigned the code of (ix) none.Annual Report for Functions of Medical Institutions 2016, which contains all facility information and statistics.13In the Japanese Diagnosis Procedure Combination inpatient database, diagnoses are recorded using International Classification of Diseases Tenth Revision (ICD-10) codes and written in Japanese text. We also extracted data from the 14; (iii) patients whose data could not be combined with the Annual Report for Functions of Medical Institutions 2016; and (iv) patients who were admitted to primary emergency facilities. To account for history of suicide attempts, when patients were admitted for suicide attempt or self-harm multiple times during the study period, we used the last admission.We identified patients hospitalized for suicide attempts or self-harm from June 2015 to March 2017 using the codes for suicide or suicide attempt in the database . Again, the database does not include outpatients or patients who were admitted only to a psychiatric hospital. We excluded (i) patients with unknown suicide methods; (ii) those aged <10 years, following previous literature15 Charlson comorbidity index at admission ,16 comorbid mental or behavioral disorders at admission, past history of suicide attempts, prior hospital admission for any reason within 1 year, suicide method, ambulance use, academic hospital, and type of emergency facilities. Comorbid mental or behavioral disorders at admission were identified using ICD-10 code-based diagnoses. Prior suicide attempts were identified from either prior admission with the codes for suicide/self-harm or the ICD-10 codes for comorbidities in suicide cases, following previous studies.17,18Data on patient characteristics included age, sex, pregnancy, Japan Coma Scale (JCS) at admission,Clinical practices, psychiatric interventions, and hospital characteristics were also identified. Psychiatric interventions during hospitalization included psychiatric ward admission, psychotherapy with a psychiatrist, consultation-liaison psychiatry, and the use of antidepressants. Hospital-based psychiatric interventions were defined as psychiatric interventions performed on eligible patients in a hospital at least once during the study period.19–21 Suicide methods were classified as high lethality (hanging or jumping from a height) and low lethality .22,23 Psychiatric interventions during hospitalization are presented only for patients discharged to home. We also present the hospital characteristics by type of emergency facilities (secondary or tertiary).We present patient characteristics, clinical practices, psychiatric interventions, and hospital characteristics by suicide method because lethality of suicide method is strongly correlated with patient characteristics, including impulsivity, intentness, and psychiatric severity.Values of categorical variables are reported as counts (%), and values of continuous variables are reported as medians with interquartile range (IQR). All analyses were performed using Stata/MP 15.0 .A total of 17,881 patients met our eligibility criteria during the 22-month study period  and a high-lethality suicide methods group . In the low-lethality suicide methods group, patients were relatively young and more likely to be female (67%). Most of these patients had a comorbid mental or behavioral disorder at admission (72%), with depressive disorder (33%) being especially common. In-hospital mortality was low, and length of stay was short. Most of these patients were discharged to home, and half received psychotherapy during hospitalization.We categorized patients into a low-lethality suicide methods group , especially within 24 hours of admission (38%). One-third of survivors were transferred to a different hospital. About half of the patients discharged to home did not receive psychotherapy during hospitalization.Table Using a nationwide database in Japan, we described the overall patient characteristics and the management of patients admitted to acute-care hospitals for suicide attempts or self-harm in a large Japanese population. To the best of our knowledge, this is the first study of its kind. Our results have several implications for current practices.24 According to previous studies, psychiatric interventions following self-harm may reduce subsequent repetition of self-harm.25,26 During hospitalization, a psychiatric care system in acute-care hospitals can provide prompt medical/social crisis intervention, grasp emergency response needs, and ensure timely service provision by, for example, local social resources. Even when hospitals without a psychiatric care system refer suicide attempters to hospitals with psychiatric departments after the physical injury is treated, it is challenging to determine whether these patients need emergency psychiatric hospitalization. Furthermore, failure to adhere to discharge recommendations is common among patients who have attempted suicide.27 Although psychiatric care systems are not always available and are costly, our findings suggest that it may be necessary to continue promoting access to psychiatric care systems and evaluating the psychiatric care in acute-care hospitals using nationwide data.First, our study revealed that 54% of acute-care hospitals did not have any hospital-based psychiatric care system in place, despite admitting patients who were at high risk for attempting suicide or engaging in self-harm. Easy access to health care—especially psychiatric care—is an established protective factor against suicide.28 Hospitalization is a costly treatment option, both financially and otherwise; therefore, more education about suicide attempts and self-harm is encouraged for non-psychiatric physicians.29Second, we found that, in the low-lethality suicide methods group, some patients (such as those with wrist cutting or drug overdose) may not have needed hospitalization to treat physical injuries. The World Health Organization has recommended against routine hospitalization in non-specialized departments of general hospitals for persons who have engaged in self-harm but who do not need physical treatment, with the goal of preventing further acts of self-harm.14 Intensive aftercare is, therefore, warranted following suicide attempts, especially among surviving patients who have used high-lethality methods.Third, our study showed that 50% of patients discharged to home in the high-lethality suicide methods group did not receive any psychiatric interventions during their hospitalization. However, a previous national cohort study revealed that patients with a prior high-lethality suicide attempt were three to six times more likely to complete suicide, compared with those with a prior low-lethality suicide attempt.30 because of the lack of rigorous terminology and definitions in our database. Third, we did not account for repeated suicide attempts/self-harm or suicide mortality over a long period because of the short study duration.This study had several limitations. First, our study did not include patients who had attempted suicide or engaged in self-harm who were treated in emergency departments without being hospitalized or those who were hospitalized only in psychiatric hospitals. Thus, our results may present a distorted view of the epidemiology of suicide attempts and self-harm. Second, the identification of suicide attempts and self-harm in our study did not follow the internationally accepted definition of “deliberate self-harm”In conclusion, using a nationwide database in Japan, we described the patient characteristics and clinical trajectories of suicide attempts and self-harm among individuals admitted to acute-care hospitals in a large Japanese population. We found that half of acute-care hospitals did not have any hospital-based psychiatric care system to treat patients who had attempted suicide or engaged in self-harm.


Coronavirus disease 2019 (COVID-19) is an emergent disease that has spread rapidly to infect more than 210 countries across the world. With the increasing number of infected pregnant women, many physicians hypothesized the perinatal transmission as a potential route of transmission. Some cases of perinatal transmission have been described, but it is unclear if these occurred via the transplacental or the transcervical routes or through environmental exposure. In this report, we described a case of a female infant who was delivered by caesarean section at 34 weeks’ gestation to an infected mother. The neonate was transferred into the Neonatal Intensive Care Unit (NICU) Level 3, with the precaution of airborne and contact isolation. All required investigations were performed, including blood gases, nasopharyngeal swab, chest x-ray, and echocardiogram. On the fifth day of delivery, her investigations demonstrated a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Despite applying all recommended guidelines and following the treatment protocol, she developed severe respiratory symptoms with persistent pulmonary hypertension, which progressed significantly to her death. Coronavirus disease 2019 (COVID-19) has spread rapidly across the world since December 2019, when it initially emerged in Wuhan , and millions of confirmed cases have been reported worldwide . As far Since the emergence of the pandemic in March 2020, 45 pregnant women with positive reverse transcription polymerase chain reaction (RT-PCR) results for SARS-CoV-2 have been admitted into our institute, Maternity and Children’s Hospital in Al-Ahsa, Saudi Arabia. All of their newborns were screened for SARS-CoV-2 following the Ministry of Health COVID-19 protocol . There wA 37-year-old primigravida woman visited our obstetric emergency department on June 2020, at 31 weeks’ gestation with intermittent bloody spotting and leg swelling. She had a history of pregnancy-induced hypertension on methyldopa treatment and gestational diabetes controlled through her diet. Fundal ultrasonography showed a low-lying placenta. The patient was admitted for bleeding observation and medical management. She completed a dexamethasone course six days after admission, and the course was not repeated.One day before the delivery, the patient experienced shortness of breath and fever (38˚C). On examination, she demonstrated harsh bronchial breathing on chest auscultation, and she required low-flow oxygen to maintain her oxygen saturation above 90%. Her chest x-ray showed bilateral multifocal peripheral airspace opacities, suggesting COVID-19  was not reassuring, with a decrease in beat-to-beat variability; therefore, an emergency caesarean was planned.2) of 100%. The baby shifted to the Neonatal Intensive Care Unit (NICU) Level 3, with the precaution of airborne and contact isolation. All staff who attended the delivery were following full precautions as per the protocol for suspected or confirmed COVID-19 cases.On the day of delivery, a female infant was delivered by caesarean section at 34 weeks’ gestation, with a birth weight of 2,475 g (on the 70th percentile), head circumference of 30 cm (on the 22nd percentile), and length of 43 cm (on the 25th percentile). She cried immediately after birth, and the Apgar score was 8 and 8 at 1 and 5 minutes, respectively. The baby was intubated at 15 minutes of age, and positive pressure ventilation was provided because she was grunting, severely retracting, and having low oxygen saturation despite application of continuous positive airway pressure (CPAP) and a fraction of inspired oxygen  0.5 mg/kg every 12 hours for seven days and then 0.5 mg/kg once daily for three days . This waThe creatinine level rose, accompanied by a decrement in the urine output, indicating acute kidney injury. There was a substantial drop in the platelet count during the hospital stay, and the baby required frequent platelet transfusions. She also required a blood transfusion once. The coagulation profile was normal. By day 6, the neonate developed an abnormal cyclic movement in all limbs associated with decreasing oxygen saturation and tachycardia; therefore, she was loaded with phenobarbital followed by maintenance doses. A brain ultrasound showed grade ΙΙΙ germinal matrix haemorrhage with mild dilatation in lateral ventricles.Over the following days, the neonate remained critically ill with cardiorespiratory failure, persistent pulmonary hypertension, and acute kidney injury. Antibiotics were upgraded to imipenem/cilastatin and vancomycin. SARS-CoV-2 PCR testing was repeated twice 72 hours apart, and the results were positive in all samples. She was on high-frequency ventilation and nitric oxide, with low oxygen saturation and poor perfusion supported by dopamine, dobutamine, and epinephrine. At day 11, she developed bradycardia, and cardiopulmonary resuscitation was initiated; however, she died.The SARS-CoV-2 novel virus is known to cause severe pneumonia in adults. The early neonatal infection has been reported frequently, but the reports by Vivanti et al. and Patane et al. are probably the first and only reports confirming vertical transmission ,6. In ouIn reviewing the presentation of coronavirus among different settings and ages, the clinical picture varies from asymptomatic carriers, severe pneumonia, shock, and thromboembolism to multisystem inflammatory syndrome in children (MIS-C). Neonates have been reported to be asymptomatic or to have mild respiratory symptoms or mild pneumonia . One casTo date, there have been no reported cases of a neonate with severe respiratory symptoms and a severe picture of pneumonia as in our case. The case also exhibited severe persistent pulmonary hypertension that responded poorly to inhaled nitric oxide and respiratory support. The severity of vertical infection of SARS-CoV-2 may depend on advancing gestational age, with less infectivity early in pregnancy and a more severe picture, as in our case, associated with late-trimester infection. Although MIS-C has been highlighted in children infected with the SARS-CoV-2 virus and has been linked to poor prognosis , the mulIn our reported case, the mother was infected and symptomatic shortly before delivery. A caesarean section was performed due to bleeding and abnormal CTG. Our healthcare workers were strictly following the infection-control guidelines related to COVID-19 and followed the pathway for suspected or confirmed COVID-19 cases, which includes the assignment of a trained team from all related subspecialties to attend the delivery, the limitation of healthcare workers to a minimum in a designated isolated operating room, and the use of an N95 mask by everyone. The operation was held under spinal anaesthesia, and no arousal-generating procedures were needed. The mother was wearing a surgical mask because she was suspected of having SARS-CoV-2 infection. Resuscitation of the neonate was conducted 3 m away from the operation site, with full personal protective equipment (PPE). Delayed cord clamping was not applied, and no skin-to-skin contact was allowed between the mother and the newborn. The transferring team was wearing full PPE, and the patient had been in airborne precaution since admission to NICU Level 3. None of the healthcare providers who dealt with the neonate or her mother had symptoms of COVID-19.The application of all these measures and precautions suggests that the SARS-CoV-2 infection in the neonate was caused by vertical transmission, although droplet transmission cannot be ruled out. Further investigating tools such as sampling the amniotic fluid for the virus, a placenta pathology examination, and a neonate blood sample test for antigens and antibodies would have been required to validate a vertical transmission claim.Neonatal pneumonia has been reported in babies born to COVID-19 mothers ,9. In thOwing to the quick deterioration of the neonate, SARS-CoV-2 does not appear to be a benign entity in neonates. It could be very well stated that COVID-19 may be considered as a possible cause of severe pneumonia and subsequently the mortality. Although not the usual presentation, it could have been secondary to a severe course of respiratory distress syndrome of prematurity or other comorbidities, such as primary persistent pulmonary hypertension of the newborn.


Aurora kinases B (AURKB), which plays a critical role in chromosomal segmentation and mitosis, greatly promotes cell cycle progression and aggressive proliferation of cancers. So far, its role and underlying mechanisms in mediating poor outcome of lung adenocarcinoma (LUAD) remained largely unclear. Analyses on multiple omics data of lung adenocarcinoma cohort in The Cancer Genome Atlas (TCGA) were performed based on AURKB expression, and demonstrated its association with clinical characteristics and the potential of using AURKB as a biomarker in predicting patients’ survival. This study found aberrant alterations of genomics and epigenetics, including up-regulation and down-regulation of oncogenic genes and tumor suppressors, pathways involved in the cell cycle, DNA repair, spliceosome, and proteasome, hypermethylation enrichments around transcriptional start sites, which are all related to AURKB expression. We further discovered the possible role of tumor suppressors DLC1 and HLF in AURKB-mediated adverse outcome of LUAD. To conclude, this study proved AURKB as a potential prognostic factor and therapeutic target for lung adenocarcinoma treatment and provide a future research direction. Lung adenocarcinoma (LUAD) is the main type of lung cancer. Although epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs)  and progAlthough some mechanisms of AURKB have been shown above, the important role of AURKB in lung adenocarcinogenesis and aggressiveness leading to poorer survival requires further exploration. Through analysis of the genome-wide mRNAs, microRNAs (miRNAs) and methylation profiles from LUAD project in The Cancer Genomics Atlas (TCGA) and the web-based bio-tool Lung Cancer Explorer (LCE) , we showTCGA-LUAD cohort was used to compare the expression of AURKB in lung adenocarcinoma patients. As shown in high and AURKBlow groups, with 245 samples each group. As shown in As AURKB is high-expressed in lung adenocarcinoma tissues and correlates with more advanced tumor stage, we hypothesized that AURKB might be a prognostic factor in LUAD. Thus, the expression distribution of AURKB and prognosis of each sample were examined. We observed that the expression of AURKB of each individual was  concentrTo evaluate the potential of AURKB as a prognostic marker in blood samples, we obtained the data of 80 LUAD tumor samples and 80 normal control samples from the GEO database (GSE20189). The original data of the chip were downloaded, and the R software package Affy was used to perform data conversion and RMA standardization for obtaining a gene expression profile data set. The expression of AURKB in tumor samples was found to be higher than that of control samples with significant margins p=0.072, . Furtherhigh group and AURKBlow group and examined their correlations with AURKB using the T-test and the rank-sum test, respectively . Only genes with correlation coefficients larger than 0.3, fold change >2, and the p-value < 0.01 either in the T-test or the rank-sum test were considered as DEGs. As visualized by volcano plot and heatmap  between AURKB heatmap , 3B, 348 heatmap . These p heatmap . Since A heatmap . HoweverWe also found certain DEGs were enriched in the miRNA pathways of LUAD, thus, genome-wide miRNA profile analysis was performed. In a further Pearson correlation analysis with AURKB, 926 miRNAs with at least 30% sample expression values were included. A total of 54 miRNAs met the threshold, with a FDR of less than 0.05 and a correlation coefficient of above 0.3. Specifically, 50 of these miRNAs were positively correlated with AURKB expression, while 4 were negatively correlated with AURKB expression. The distribution relationship of correlation coefficients with FDR is shown in high and AURKBlow groups. 49 miRNAs were screened based on FDR < 0.05 and fold change > 1.5. Then mirWallk database was used to predict the target genes of these differential miRNAs and to construct mRNA-miRNA regulatory network, as shown in Correlated miRNAs were analyzed by the T-test and rank-sum test to compare the expression changes between AURKBin vitro, we tested the protein expression levels of AURKB among 4 lung adenocarcinoma cell lines, including A549, H1299, PC9 and H1975  and affects cancer cell behaviors. We analyzed differences in the transcription of the three methyltransferases, and as shown in By examining the position distribution of the 2311 differential methylation regions (DMR) around the CpG islands, as shown in We extracted the corresponding genes of these DMRs based on the TSS and ran a KEGG enrichment analysis using R package ClusterProfiler. The data demonstrated that genes corresponding to hypermethylation were enriched into 36 pathways, such as cAMP signaling pathway, axon guidance, viral carcinogenesis, and chemokine signaling pathway p<0.05, . Howeverhttp://gepia.cancer-pku.cn/) also confirmed that AURKB was significantly negatively correlated with DLC1 and HLF , and DLC1 was determined to be a protective factor to the survival of patients with LUAD (p=0.078)  . Howeverhigh expression and AURKBlow expression subgroups based on the median value and were used for further analyses. Lung Cancer Explorer  online analysis was used to compare the expression levels between tumor and normal tissues and survival changes based on AURKB expressions. All the results were calculated by the meta-analysis of multiple LUAD datasets from TCGA and Gene Expression Omnibus (GEO).The expression profiles of mRNAs and miRNAs were sequenced by RNA-seq and 450K genome-wide methylation profile. LUAD clinical data, including 513 tumor samples and 59 para-cancer tissues in the Cancer Genome Atlas (TCGA) were downloaded from Genomic Data Commons Data Portal . According to the clinical data, samples acquired from patients with follow-up time more than 30 days were selected to match the expression profiles of mRNAs, miRNAs, and methylation information for final analyses. The detailed statistical description is listed in 2 atmosphere. All the media were supplemented with 10% fetal bovine serum , 100 U/ml penicillin and 100 μg/ml streptomycin.LUAD cell lines  were purchased from the American Type Culture Collection (ATCC) Cell Bank and cultured in RPMI 1640  at 37° C in a 5% CO-ΔΔCT method, with U6 and ACTB served as normalization controls, respectively. All primers used are listed in Total RNA from cell pellets was extracted using the Total RNA Miniprep Kit  according to the manufacturer’s protocol. The quantity and quality of extracted RNA were assessed with a Nanodrop 2000c . Then, complementary DNA was synthesized from 500 ng of total RNA using PrimeScript™ RT Master Mix kit . For the stem-loop reverse transcription of microRNAs, PrimeScript™ RT Reagent Kit  was used to syntheze cDNA with miRNA-unique stem-loop primers. PCR analysis was performed in a Applied Biosystems 7500 Fast Real-Time PCR System  with SYBR Premix Ex Taq II . The expressions of miRNAs and mRNAs were calculated using the 2Total protein were extracted from cell pellets using RIPA buffer. Protein concentration was determined by BCA assay  using bovine serum albumin as a standard. 30 ug protein samples were separated in 10% SDS-PAGE gel and transferred to a PVDF membrane, which was blotted with antibodies , rabbit anti-GAPDH , rabbit anti-beta-actin ), then rinsed and incubated with secondary IgG-HRP antibodies goat anti-rabbit  and goat anti-mouse  according to the manufacturer’s instructions. All antibodies came from HuaBio in China.Briefly, pLenti-CMV-GFP-Puro-AURKB and pPLK/GFP+Puro-AURKB shRNA were constructed on the backbone of pLenti-CMV-GFP-Puro and pPLK/GFP+Puro plasmids, respectively, and each was then co-tranfected with lentiviral packaging plasmids pMD2.G and psPAX2  into HEK 293T cells to generate lentivirus particles, followed by the transfection of the particles into target cells. The cells were incubated with lentivirus for 24 hours (h) and then replaced with fresh medium. When cells stably grew to proliferative status, cell pellets were collected for protein and total RNA extraction.high and AURKB low expression groups. All the analyses were performed using the R 3.6 software packages.The chi-squared test was used to examine the correlation between AURKB expression and clinical or pathological variables. The endpoint event overall survival (OS) was defined as the time starting from the occurrence of LUAD to death due to any cause. Progression-free survival (PFS) was defined as the time starting from the onset of LUAD to progression after the first-line treatment or death. Kaplan-Meier analysis with the log-rank test was applied to compare the survival differences between two groups of patients, while multivariate cox regression analysis was used to examine potential independent factors related to survival. Student’s t-test and false discovery rate (FDR) were used to identify differences in mRNAs, miRNAs, and methylation data between AURKBSupplementary Figures


Is the STOP-Bang  questionnaire a valid obstructive sleep apnea screening tool for patients referred to sleep clinics in different geographical populations?This systematic review and meta-analysis of 47 studies including 26 547 individuals found that the STOP-Bang questionnaire has adequate sensitivity and diagnostic accuracy for detecting moderate to severe obstructive sleep apnea across geographic regions.These findings suggest that the STOP-Bang questionnaire can be used as a screening tool in different geographical regions for triaging patients suspected of having obstructive sleep apnea who are referred to sleep clinics. This systematic review and meta-analysis evaluates the utility of the STOP-Bang  questionnaire in the sleep clinic setting to screen for and stratify the risk of obstructive sleep apnea among populations from different geographical regions. Obstructive sleep apnea (OSA) is a highly prevalent global health concern and is associated with many adverse outcomes for patients.To evaluate the utility of the STOP-Bang  questionnaire in the sleep clinic setting to screen for and stratify the risk of OSA among populations from different geographical regions.MEDLINE, MEDLINE In-process, Embase, EmCare Nursing, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals@Ovid, Web of Science, Scopus, and CINAHL electronic databases were systematically searched from January 2008 to March 2020. This was done to identify studies that used the STOP-Bang questionnaire and polysomnography testing in adults referred to sleep clinics.Clinical and demographic data were extracted from each article independently by 2 reviewers. The combined test characteristics were calculated using 2 × 2 contingency tables. Random-effects meta-analyses and metaregression with sensitivity analyses were performed. The Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guideline was followed.The combined test characteristics and area under summary receiver operating characteristic curves (AUCs) were used to compare STOP-Bang questionnaire accuracy with polysomnography testing.A total of 47 studies with 26 547 participants  met the criteria for the systematic review. Studies were organized in different geographic regional groups: North America, South America, Europe, Middle East, East Asia, and South or Southeast Asia. The prevalence rates for all OSA, moderate to severe OSA, and severe OSA were 80% , 58% , and 39% , respectively. A STOP-Bang score of at least 3 had excellent sensitivity (>90%) and high discriminative power to exclude moderate to severe and severe OSA, with negative predictive values of 77%  and 91% , respectively. The diagnostic accuracy of a STOP-Bang score of at least 3 to detect moderate to severe OSA was high (>0.80) in all regions except East Asia .The results of this meta-analysis suggest that the STOP-Bang questionnaire can be used as a screening tool to assist in triaging patients with suspected OSA referred to sleep clinics in different global regions. Its prevalence varies depending on geographic and demographic factors.9The criterion-standard test for OSA diagnosis is laboratory polysomnography (PSG), but it is costly and inconvenient. Home sleep apnea testing (HSAT) is an acceptable alternative; however, accessibility is lacking in resource-limited areas. Since waitlists are long for patient assessment at a sleep clinic, an effective screening tool is necessary to triage patients.10 Because of its high diagnostic accuracy, ease of use, and clear thresholds for risk stratification,11 the STOP-Bang questionnaire has been used worldwide. Two STOP-Bang questionnaire items, BMI and neck circumference, are influenced by region-specific body characteristics, which may affect the performance of STOP-Bang questionnaire in different geographic areas. The objective of this systematic review and meta-analysis was to determine the utility of the STOP-Bang questionnaire as an OSA screening tool to assist in triaging patients referred to sleep clinics in different global regions.The STOP-Bang questionnaire was developed as an OSA screening tool consisting of 4 self-reportable  and 4 demographic  items. In the initial validation study, at a score of at least 3, the STOP-Bang questionnaire demonstrated a sensitivity of 84%, 93%, and 100% to detect all OSA (apnea-hypopnea index [AHI] ≥5), moderate OSA (AHI ≥15), and severe OSA (AHI ≥30), respectively.PRISMA) reporting guideline.12 One of us, a medical information specialist (M.E.), designed a literature search strategy using free-text and index terms  and systematically searched the following databases from January 2008 to March 2020 with no language restrictions: MEDLINE, MEDLINE In-process, Embase, EmCare Nursing, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO and Journals@Ovid with full-text searching using the Ovid search interface; Web of Science , Scopus (Elsevier), and CINAHL. A Web of Science citation search was run on the initial STOP-Bang validation article to capture publications in which it has been cited.10 A manual citation search was performed. Continued literature surveillance was done through August 2020. The electronic search strategy appears in eTable 1 in the The protocol of this systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020196952) and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (Two of us (B.P. and L.C.) independently screened titles and abstracts of identified studies. After initial exclusion, full-text articles were assessed for the following inclusion criteria: (1) assessment of the STOP-Bang questionnaire to screen for OSA in adults (age ≥18 years); (2) patients referred to sleep clinic; (3) laboratory PSG or HSAT results confirmed the OSA diagnosis; and (4) AHI or respiratory disturbance index (RDI) was used to diagnose and grade the severity of OSA. Exclusion criteria were (1) pregnant populations; (2) use of a modified STOP-Bang questionnaire; (3) no analysis of test characteristics at a STOP-Bang score of at least 3; and (4) inadequate description of methods  or insufficient data for meta-analysis. Disagreements were resolved by discussion and consensus among 4 of us .13 Discrepancies were addressed with another author (M.N.).Two of us (B.P. and L.C.) independently extracted clinical and demographic data using a predesigned form. Internal and external validity of the included studies was assessed independently according to the Cochrane Methods group’s guidelines on screening and diagnostic tests.14Studies were organized into groups dependent on their geographical location . Asian countries were separated into East Asia and South or Southeast Asia to match population demographic characteristics and mitigate factors affecting OSA prevalence .Meta-analysis was performed using Review Manager version 5.3 (The Cochrane Collaboration) and Stata/SE version 14.2 (StataCorp). Summary statistics were computed for all variables of interest. Mean and standard deviation were used as appropriate for descriptive statistics. When applicable, frequencies and percentages were reported. Sample size was considered when calculating the means and standard deviations for age and BMI from individual studies.17 This method analyzed paired outcomes, ie, sensitivity and specificity values from individual studies, while incorporating correlations between outcomes. For cells with a 0 value, a correction factor of 0.5 was added to prevent problems associated with sensitivity and specificity equaling.18 The following test characteristics were recalculated with 95% CIs: prevalence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and log scale DOR. The summary area under the receiver operating characteristic (AUC) curves were calculated by logistic regression. Combined test characteristics were recalculated for each regional group at each OSA severity cutoff. Forest plots were designed using a random-effects model, while log scale DOR and AUC curve analysis were presented to assess diagnostic ability. Heterogeneity (I2) was assessed using the χ2 test, with P < .05 indicating that heterogeneity was present.The following AHI cutoffs were adopted: all OSA (AHI ≥5), moderate to severe OSA (AHI ≥15), and severe OSA (AHI ≥30). A STOP-Bang score of 3 or greater was adopted as a threshold. A 2 × 2 contingency table was reconstructed for each AHI cutoff at a STOP-Bang score of 3 or greater for each study. The random-effects bivariate analysis model was used to combine results from individual studies to obtain the following log-transformed summary estimates with 95% CIs: sensitivity, specificity, and log scale diagnostic odds ratio (DOR).To determine the association between STOP-Bang score and probability of moderate to severe and severe OSA, posttest probabilities were calculated as previously described and combined from studies that assessed the performance of the STOP-Bang questionnaire at scores from 3 to 8. Results were produced as a bar graph.16 for continuous variables  and categorical variables . This aimed to measure these variables’ associations with the combined estimates of sensitivity, specificity, and log scale DOR. Robustness of the combined estimates was checked by leave-one-out meta-analysis to assess individual study association with the combined estimates and heterogeneity. A 2-tailed P < .05 was considered statistically significant.Metaregression and sensitivity analyses were performed on various subgroups for each factor at each OSA severity using the Open MetaAnalyst software65 The initial search yielded 3871 studies, with 162 additional studies identified through citations ; (2) South America ; (3) Europe ; (4) the Middle East ; (5) East Asia ; and (6) South or Southeast Asia .Study characteristics and demographic data are summarized in The combined test characteristics in the sleep clinic at a STOP-Bang threshold of 3 or greater are presented in For all OSA, the combined prevalence ranged between 75%  in East Asia and 87%  in the Middle East . The comFor moderate to severe OSA, the STOP-Bang questionnaire demonstrated an excellent combined sensitivity  and low specificity (<33%) in North America, South America, Europe, and the Middle East. In East Asian, sensitivity was 93% ; in South or Southeast Asia, sensitivity was 89% . In South or Southeast Asia, specificity was 45%  . A STOP-The STOP-Bang questionnaire demonstrated an excellent combined sensitivity, ranging between 90%  in East Asia and 99%  in Europe, with lower combined specificities . The STOMetaregression and sensitivity analysis of continuous variables slightly changed the combined estimates but did not affect overall inference of the results . SimilarFor all OSA, as the STOP-Bang score increased from 3 to 8, the specificity increased from 40.6%  to 99.7% , while sensitivity decreased from 89.2%  to 3.6%  , 58% , and 39% . Patients referred to sleep clinics are already suspected of having OSA, which explains the high prevalence and diagnostic accuracy in our study. In this setting, the STOP-Bang questionnaire fulfills the role of a screening tool that may allocate resource-limited care according to severity. While STOP-Bang scores of 3 to 5 had similar posttest probabilities , individuals who scored 6 or greater had a 75% posttest probability of being diagnosed with moderate to severe OSA and should be investigated more urgently. The implications of our findings are that the STOP-Bang questionnaire is a helpful tool when triaging patients who were referred to sleep clinics.2 as well as population-specific anatomic and phenotypic features that influence OSA development and severity. Although OSA is prevalent globally, certain regions report higher prevalences, ie, China, the United States, Brazil, and India.2 These differences influence prevalence-dependent variables, such as pretest and posttest probabilities. We have addressed this by organizing studies based on geography to accurately represent OSA prevalence in each global region. Moreover, DOR values, which are independent of prevalence, were comparable across groups for moderate-to-severe OSA, ranging from 1.62  in South America to 2.24  in the Middle Eastern group.Groups were organized relative to country and geographic proximity. Asian countries were separated into East Asia and South or Southeast Asia to minimize external factors that influence OSA prevalence The North American group showed a high sensitivity of 94%  and AUC of 0.89  to detect moderate to severe OSA with lower specificities. Similar results were found for the South American, European, and the Middle Eastern groups. Asian groups showed lower sensitivity and AUC values at the same AHI cutoff, ie, 93%  and 0.52  in the East Asian group; 89%  and 0.70  in the South or Southeast Asian group; both groups had higher specificities.67 In Asian populations, higher body fat percentages and visceral fat are associated with a lower BMI.69 This fat distribution pattern is associated with increased tongue size and lower lung volumes that may contribute to nocturnal upper airway collapse,70 such that Asians present with OSA at lower BMIs and are more sensitive to BMI increases.71 Changing the STOP-Bang BMI cutoff to 30, closer to the obesity cutoff for Asian populations, has shown increases in sensitivity without compromising specificity for OSA detection.61Variation in the STOP-Bang questionnaire performance among these geographic groups may be explained by obesity and craniofacial characteristics. Obesity prevalence and patterns of adiposity vary among ethnic groups. In European, North American, South American, and Asian populations, AHI increases with BMI; however, BMI is most associated with OSA severity in the latter 2 regions.72 Differences are found between ethnic groups, such that Asian populations have more craniofacial restriction,73 while European groups have larger upper airway soft tissues 73 with smaller airway dimensions.14 Similarly, North American and South American populations also showed increased neck circumference, which is associated with greater odds of a higher Mallampati class, indicative of oropharyngeal crowding, while Asian groups do not.66 This may explain the excellent clinical utility seen in each regional group other than the East Asian population. Further research is necessary to investigate the contribution of ethnic and genetic factors to OSA prevalence and severity.The craniofacial features are important in OSA pathogenesis and are unique depending on location. Chinese individuals have a smaller, narrower retropalatal airway and soft tissues with greater susceptibility to pharyngeal collapse.Ideally, a diagnostic test has high sensitivity with sufficient specificity, is inexpensive, and allows for early disease identification. High sensitivity is helpful to rule out OSA and/or to prioritize patients referred to sleep clinics; however, it is an incomplete study estimate, especially in the presence of study heterogeneity and bias. False-negativity is a component of sensitivity that provides a robust summary estimate and may be considered independent of prevalence. In our meta-analysis, the false-negative rate was 8% (6%-11%). Considering specificity may improve accuracy. A moderate to low specificity at a STOP-Bang score of at least 3 may subject patients to false-positive results, increasing unnecessary costs and caseloads at sleep clinics. Nevertheless, with the goal of diagnosing and preventing mortality and morbidity associated with OSA as well as the low risk of investigating potential OSA, false-positives are of secondary importance.This study has limitations. First, included studies used various laboratory PSG and HSAT devices to diagnose OSA. Although often comparable, some inconsistences may exist. Second, risk of bias for internal validity was occasionally unclear, specifically whether PSG and STOP-Bang results were masked and interpreted independent of clinical information. Third, metaregression analysis showed positive confounders contributing to differences between groups, thus enhancing combined estimates of our results. Some confounders were related to components of the STOP-Bang questionnaire , while others were not (OSA definition). Next, although the STOP-Bang questionnaire had high NPVs for moderate to severe and severe OSA, it is possible to miss patients with OSA who have lower AHIs because of lower NPVs in patients with mild OSA. Additionally, our results are unique to the sleep clinic and do not apply to other populations owing to inflated OSA prevalence, given that patients were screened before referral for further OSA investigation. Furthermore, moderate-to-high heterogeneity exists. This may be attributed to methodological heterogeneity and variability in study location; however, all studies were grouped with efforts to unify populations. A random-effects model for meta-analysis was performed because of the suspicion of high heterogeneity. Despite these limitations, our study provides an interpretation of the available literature on the STOP-Bang questionnaire as an OSA screening tool among different global populations in the sleep clinic setting.In this study, the STOP-Bang questionnaire showed high sensitivity and NPVs at all AHI cutoffs. These findings indicate that it is a useful OSA screening tool for triaging patients in sleep clinics in various global regions.


Background: The impact of the ongoing COVID-19 pandemic on vulnerable groups like patients suffering from substance use disorders is expected to be tremendous, and corresponding concerns were raised early on by many experts around the world. Psychosocial distress, financial insecurities and physiological problems associated with the COVID-19 crisis could be especially challenging for this group of patients.Methods: In the current study data was collected from a clinical sample of patients with alcohol use disorder  during the initial stage of the pandemic. The impact of various COVID-19 related factors  on patients' personal life was evaluated. Alcohol consumption, craving, and potential posttraumatic stress disorder (PTSD) symptoms were assessed using different scales and their associations were analyzed. Furthermore, differences regarding these variables between comparably sized groups of patients who remained abstinent (N = 37), relapsed (N = 41), or reported unaltered drinking behavior  were investigated. The impact of sociodemographic and COVID-19 factors on relapse (in comparison to abstinence) was evaluated using binary logistic regression analysis.Results: Our results confirmed the expected positive associations between alcohol consumption, craving, and PTSD symptoms, respectively, among patients with AUD. Furthermore, group differences indicate significantly lower levels on all three scales for abstinent patients. Although generally low PTSD scores were observed, 8% of our participants were found to be at risk of PTSD. Results of a binary logistic regression analysis indicated the presence of psychosocial COVID-19 factors  as well as living alone as two major risk factors for relapse.Discussion: Our findings based on actual patient data support the anticipated negative consequences of the pandemic on persons with AUD. Crucially, our results regarding relapse emphasized psychosocial COVID-19 factors and isolation as especially challenging circumstances for persons with AUD, whereas economic and physiological health aspects seemed of minor impact on relapse. Our results reflect the initial stage of the pandemic, whereas long-term developments should be closely monitored. Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on February 11, 2020 , and its worldwide spreading is extensively impacting on the global physical and mental health. At the end of 2019, a cluster of atypical cases of pneumonia was observed in Wuhan, Hubei Province, China  (N = 446) scored above the cutoff score on the Impact of Event-Scale – Revised (IES-R)  implicate higher levels of stress and psychological distress among SARS survivors during and even 1 year after the outbreak . In thisUnsurprisingly, the COVID-19 pandemic can alter pre-existing or trigger new addictive behaviors. In this context, an increased prevalence (4.3%) of severe Internet use disorder, as well as rising numbers of relapse in alcohol (19%) and smoking abuse 25%) were reported . These t% were reThe COVID-19 crisis might affect vulnerable persons particularly hard . PhysiolIn respect to alcohol use disorder (AUD), alcohol consumption leads to a significantly higher risk for contracting bacterial and viral lung infections (including COVID-19) . PsychosCombining these aspects, deterioration of preexisting conditions such as AUD and associated relapse were anticipated . In geneA recent study on the impact of the COVID-19 pandemic on various addictive disorders in Italy found relatively high rates of depression, anxiety, irritability, and posttraumatic stress symptoms among a clinical sample of patients suffering from different SUDs . Furthermore, the authors evaluated quality of life and craving in this context . CravingIncidents of confirmed COVID-19 cases in Austria  between March and June 2020 are displayed in Concerns about the multifaceted consequences of the pandemic on patients with SUDs were raised early in this pandemic , 32. HowFirst, associations between current alcohol consumption , subjective craving and PTSD-symptoms were assessed. Second, differences regarding these aspects between groups of patients who remained abstinent, relapsed, or showed unaltered alcohol consumption behavior  after the onset of COVID-19 in Austria were evaluated. Third, the impact of different sociodemographic and COVID-19 related factors on relapse (vs. abstinence) during the beginning of the pandemic were investigated.N = 127) at our inpatient and outpatient facilities as part of routine anamneses. This study includes a retrospective data analysis and was conducted in accordance to the Declaration of Helsinki and approved by the local ethics committee. Data was processed and analyzed anonymously. All patients seeking help at our facilities between the beginning of April and mid-June 2020, who were diagnosed with AUD and consented to provide their responses were included in this study. From our total sample 41.7% were treated at our inpatient facilities. Outpatients were assessed either in face-to-face consultations (24.4%) or via telephone (33.9%).Data was collected from patients diagnosed with AUD (N = 37), patients suffering relapse since mid-March (N = 41) and those still consuming . Descriptive summary statistics of sociodemographic variables of the total sample and the three subgroups are shown in According to their current state of alcohol consumption with respect to the beginning of the COVID-19 pandemic in Austria, participants were classified into three subgroups: persons remaining abstinent   . The AUDAUDIT-C)  is a widPrimary Care PTSD screen for DSM5    was usedThe impact and burden of COVID-19 related factors on patients' personal life was evaluated. To that end, patients were asked to determine the presence or absence of different aspects in regard to the COVID-19 pandemic that resulted in personal worries or problems. The corresponding answers were categorized into four different COVID-19 factors. Physiological aspects included all health problems, as well as access to health care in relationship to the COVID-19 pandemic. Economic factors ranged from financial problems, economic uncertainty to job loss due to the pandemic. Psychosocial aspects included negative emotions such as depression, fear, anxiety, and worries about others, as well as a reported psychological burden as a result of isolation during this initial stage and lockdown. A reported lack of access to alcohol, as well as closing of bars were summarized as other factors. Each of these four COVID-19 factors was registered as either absent or present for each participant.p-values indicate possible associations between the variables. Detailed information on the applied analyses can be found in the Results section below.Data was analyzed using IBM SPSS Statistics for Windows (Version 25.0) . DescripDescriptive statistics for COVID-19 factors, as well as alcohol consumption (AUDIT-C), craving, and PTSD symptoms (PC-PTSD5) are displayed for the total sample and the three subgroups  in In the total sample , psychosocial COVID-19 factors were reported by the majority of patients (53.5%), whereas burden by physiological, economic and other factors were indicated less frequently (between 21.3 and 24.4%).N = 10) of the sample were indicated at risk of PTSD due to the pandemic (with a recommended PC-PTSD5 cut-off score of 3 or more) (Alcohol consumption measured by AUDIT-C scores (range 0–12) were high in the relapsed (median = 11) and consuming (median = 10) subgroups of patients. Craving scores (range 0–4) were also highest among those who relapsed (median = 3) at the initial stage of the pandemic. Regarding PTSD symptoms due to COVID-19, only a third of our patients (31.7%) reported one or more symptoms, resulting in medians of zero for the total sample and the three subgroups. Importantly, 7.9% (or more) . Half ofp < 0.001) and AUDIT-C and PC-PTSD5 scores , respectively. Craving and PC-PTSD5 scores showed a weak to moderate positive correlation . These results suggest a positive association between all three variables, indicating higher levels of alcohol consumption (AUDIT-C score) with higher levels of stress (PC-PTSD scores) and craving. Bubble plots of the different combinations of scales, and for the three subgroups are depicted in Spearman rank correlations between alcohol consumption (AUDIT-C) and craving and PTSD symptoms (PC-PTSD5) were calculated for the total sample.  Significant positive correlations between all three factors were found, with moderate correlations for AUDIT-C and craving  = 82.1, p < 0.001, dCOHEN = 2.7. Post-hoc Dunn-Bonferroni groupwise tests showed significant differences between the abstinent group and both relapsed (p < 0.001) as well as consuming patients (p < 0.001), respectively. Note that all patients in the abstinent group scored zero on the AUDIT-C. This finding therefore indicates the obviously higher alcohol consumption scores for the two other subgroups. Relapsed and consuming patients did not differ with respect to AUDIT-C scores.A significant difference between the three groups was found for AUDIT-C scores, H(2) = 19.4, p < 0.001, dCOHEN = 0.81. Post-hoc Dunn-Bonferroni groupwise comparisons revealed significant differences for the abstinent group compared to both relapsed (p < 0.001) and consuming patients , respectively. These findings indicate lower subjective craving for the abstinent compared to the other patients  = 8.6, p = 0.013, dCOHEN = 0.47. Post-hoc performed Dunn-Bonferroni tests revealed a significant difference only between abstinent and relapsed patients (p = 0.01), but not between the other groups . These results suggest higher subjective stress (corresponding to higher PTSD scores) for relapsed patients compared to the abstinent group  of patients being abstinent before the beginning of the pandemic, and either remained abstinent (N = 37) or relapsed (N = 41) throughout the initial stage of COVID-19. The model allows to evaluate the effects of sociodemographic factors  and COVID-19 impact  on the probability of relapse. A backward variable selection procedure  was performed using a cutoff value of 0.53 . Results of this regression analysis are presented in Binary logistic regression analysis was performed for the subsample  and specificity (0.62). Patients with psychosocial COVID-19 factors have an increased risk  of relapsing compared to patients not reporting psychosocial impact of COVID-19. Living alone also leads to a higher risk of relapsing  compared to those living with others, and age showed a small negative non-significant effect .The model with the highest correct classification rate (step 6 of 7: 70.5%) was selected as the final logistic regression model. 2 = 14.3, The current study investigated different aspects of COVID-19 in a clinical sample of persons with AUD, who sought help at our inpatient and outpatient facilities during the initial stage of the pandemic. Furthermore, although the impact of the COVID-19 crisis might differ between individuals, we aimed to identify general risk factors regarding relapse of persons with AUD. Current alcohol consumption, subjectively perceived craving, and PTSD symptoms were assessed as relevant factors for AUD with respect to COVID-19. A general increase regarding addictive behavior due to COVID-19 was anticipated and already confirmed for a Chinese population . SpecifiIn line with our first aim, anticipated associations between the three variables alcohol consumption, craving and posttraumatic stress symptoms were confirmed. It is not surprising that increased craving—irrespective of its cause—leads to increased alcohol consumption . On the Our clinical sample consisted of three subgroups of patients who remained abstinent, relapsed, or were consuming before and after the onset of the pandemic. The second aim of this study was to further investigate group differences regarding the various scores. Naturally, lower alcohol consumption  was reported among abstinent persons compared to the other subgroups. Craving was also significantly lower for abstinent compared to both, relapsed and consuming patients. One can only speculate about the causal relationships. However, an increase in craving scores has already been described by other authors to be associated with an elevated risk for relapse . We founOur final aim was to investigate different sociodemographic and COVID-19 factors as potential risk factors for relapse among persons with AUD. Recent literature discussed the potential harming effects of various relevant aspects of life due to COVID-19. Physiological factors involve the elevated risk of a severe outcome of COVID-19 among persons with AUD . Most prBased on our current findings, abstinent persons suffering from AUD, who are living alone and report the presence of psychosocial distress due to COVID-19 should be in special focus of health care providers with respect to potential relapse. Complementary measures to support this group through the pandemic could be telemedicine services for diagnostic purposes as well as counseling . Our resOur findings involve some limitations, and have to be interpreted with caution. First, the current study investigated individual-level characteristics, whereas area-level correlates   were notIn conclusion, our data suggests that the current situation and specially periods of COVID-19 caused lockdowns overstrain the capacity of stress management and relapse prevention as a substantial part of this vulnerable group suffering from AUD. Without quick and specific help by health care services many of them would use alcohol as means of short-termed stress management. Conceiving psychosocial stressors and PTSD symptoms should be part of every inpatient or outpatient contact and depending on their incidence the medical care should be intensified. But also the health care system as a whole should lay particular attention on SUD, since this group needs extra support due to the crisis on hand. In case of further lockdowns people suffering from SUD need unhindered and low-threshold access to treatment. However, our data only depicts the first phase of the COVID-19 pandemic including the first lockdown stage. More research is needed to capture long-term effects and to develop long-acting strategies for the support of persons with SUDs during this ongoing and future pandemic.The 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 Ethics Commission of the Medical Faculty of the Johannes Kepler University Linz. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.KY: supervision and resources. IF-L: formal analysis and methodology. JR and NG: data curation. All authors contributed to the conceptualization of the study and writing of the original draft, and have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Coronavirus disease 2019 (COVID-19) has rapidly emerged as a threatening pandemic. Clinical features of this pandemic involve a wide range of manifestations and are not completely known. Here, we present six cases of thrombotic events in patients with COVID-19.In this case series, we present six patients with confirmed COVID-19, according to real-time polymerase chain reaction, who were referred to our emergency department and were found to have thrombotic events. Pulmonary thromboembolism was diagnosed in three patients by computed tomography (CT) angiography. One patient was found to have deep vein thrombosis in Doppler ultrasonography. Another patient who presented with loss of consciousness was finally diagnosed with a cerebrovascular accident using brain CT. One of the patients had developed a myocardial infarction evident on the electrocardiogram.It is ostensible that COVID-19 puts the patients at an increased risk for developing thrombotic conditions, possibly through formation of hyper-inflammatory and hyper-coagulative states. However, further prospective studies are recommended to confirm these findings. In December 2019, a novel coronavirus emerged in Wuhan City, Hubei province, China . AlthougHerein, we describe six cases of COVID-19 who presented to our emergency department (ED) and were found to have thrombotic events during clinical assessments. Case 1: The case was a 70-year-old woman who referred to the ED with the sole complaint of dyspnea. The patient did not mention any history of thrombotic events or significant diseases, except for diabetes. Laboratory assessments showed a white blood cell (WBC) count of 9000 per ml with 17.4% lymphocytes and C-reactive protein (CRP) of 193 mg/L. The patient underwent lung computed tomography (CT) that revealed bilateral ground glass opacities (GGO) (es (GGO) .Reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal swab samples yielded a positive result for COVID-19. On physical examination during the hospitalization period, the patient showed asymmetry in size of her forelegs’ circumference and thus underwent lower limb sonography. Doppler ultrasound exam was consistent with deep vein thrombosis (DVT) in the right femoral and popliteal veins. Subsequent D-dimer and troponin I (TPI) measurements revealed high levels of 700 ng/mL and 12 ng/mL respectively, which confirmed the diagnosis of DVT.The patient underwent anticoagulation treatment for the diagnosed DVT. Heparin infusion was immediately commenced at a dose of 5000 U, followed by a maintenance dose of 1000 U/h for the first four days. Then, the patient was put on rivaroxaban 15 mg every 12 hours for 3 weeks, which was reduced to 20 mg daily afterwards. The symptoms was resolved completely after three months of follow-up and the patient was in good condition.Case 2: Our second case was a 38-year-old man without any significant medical history who presented to the ED complaining of dyspnea and cough. With a clinical suspicion of pulmonary thromboembolism (PTE), the patient underwent CT angiography of the lungs, which showed right pulmonary artery thromboembolism along with bilateral crazy paving pattern in the lung parenchyma  for his PTE and was discharged in good condition with no further complications in a three-month follow-up.Case 3: The third case was a 74-year-old man with a history of chronic obstructive pulmonary disease (COPD) who presented with chest pain and dyspnea. Upon admission, a blood sample was taken from him and tested for TPI, which revealed a level of 35866 ng/mL. His electrocardiography (ECG) showed an extensive anterior myocardial infarction (MI). The patient was admitted with an impression of MI. Blood analysis during hospital stay indicated a WBC count of 8200 per ml with 19.8% lymphocytes and a CRP level of 33 mg/L. As the patient had a persistent dyspnea with low O2 saturations, he underwent lung CT scan, which showed a bilateral GGO pattern  and CRP (164 mg/L). Lung CT images showed an organizing pneumonia pattern and the swab sample from nasopharyngeal mucosa was assessed with RT-PCR and tested positive for COVID-19. General condition of the patient deteriorated during the course of hospitalization and he developed respiratory distress. Therefore, the patient underwent CT angiography of the lungs with a high clinical suspicion of PTE, which confirmed the diagnosis of bilateral PTE in main pulmonary arteries (arteries . The patCase 6: The case was a 56-year-old male who referred to the ED with fever, dyspnea, and cough. He was severely ill upon admission and thus was immediately transferred to ICU. Laboratory tests showed a WBC count of 7.4 per ml with 19.4% lymphocytes and a CRP level of 217 mg/L. Chest CT scan showed a bilateral GGO pattern ( pattern  and the  pattern . D-dimerWith the advent of COVID-19, clinicians primarily recognized it as a respiratory infection that often presents as an atypical pneumonia. However, as few months have passed and the body of evidence has grown larger, we have attained a more comprehensive knowledge of COVID-19 and its potential manifestations. The disease may present itself through involvement of different organs, which can lead to single or multiple organ failures .Although several studies have shown thrombocytopenia in COVID-19 patients, it may also present with coagulopathy in some patients . On the D-dimer has also been suggested as a prognostic marker in patients with COVID-19 infection . Some evIt is believed that COVID-19 causes massive fibrin formation that may precipitate in different tissues and subsequently produce high levels of D-dimer as the fibrosis resolves. The precipitated fibrin in alveolar spaces and interstitial tissue of the lung along with thromboses in small vessels result in adverse events such as respiratory failure that eventually requires intubation , 14.Zhang et al.  reportedDavoodi et al.  reportedIn conclusion, it seems that COVID-19 infection predisposes patients to coagulopathies and various thrombotic events. Some patients may even present with these findings as their primary manifestation. These thrombotic events seem to occur regardless of traditional risk factors, as some patients showed no predisposing factor in their history. It seems that the hyperinflammatory and hypercoagulative states are responsible for the presence of thrombotic events. However, this association should be further assessed in prospective studies.


Neurospora crassa, genes unpaired during meiosis are silenced by a process known as meiotic silencing by unpaired DNA (MSUD). MSUD utilizes common RNA interference (RNAi) proteins, such as Dicer and Argonaute, to target homologous mRNAs for silencing. Previously, we demonstrated that nuclear cap-binding proteins NCBP1 and NCBP2 are involved in MSUD. We report here that SAD-8, a protein similar to human NCBP3, also mediates silencing. Although SAD-8 is not essential for either vegetative or sexual development, it is required for MSUD. SAD-8 localizes predominantly in the nucleus and interacts with both NCBP1 and NCBP2. Similar to NCBP1 and NCBP2, SAD-8 interacts with a component (Argonaute) of the perinuclear meiotic silencing complex (MSC), further implicating the involvement of cap-binding proteins in silencing.In the filamentous fungus  Neurospora crassa, one such defense mechanism is known as meiotic silencing by unpaired DNA (MSUD) , which contains a host of RNAi-related proteins  . In our proteins . SAD-3, Neurospora.In addition to the aforementioned silencing components, the nuclear cap-binding complex (CBC) has also been shown to play a role in MSUD . CBC conNeurospora protocol guide (http://www.fgsc.net/Neurospora/NeurosporaProtocolGuide.htm). Genotypes of strains used in this study are listed in Standard fungal techniques were used according to the Neurospora knockout library was as described (Identification of MSUD suppressors from the sad-8 (ncu01310-t26_1) are available from FungiDB (https://www.ncbi.nlm.nih.gov/taxonomy). A comprehensive fungal tree of life can be seen in the work of Chromosomal location, gene model, and other information for Neurospora vegetative  and sexual (SRR957218) RNA-seq datasets were obtained from the European Bioinformatics Institute (EBI)’s European Nucleotide Archive (ENA)  when its nonfluorescing halves are brought within proximity by two interacting proteins  were taken using an M205 FA stereomicroscope and a DFC345 FX camera from Leica. For photography of perithecia (fruiting bodies) and asci (spore sacs), an Apple iPhone 5 with a Magnifi photoadapter  and a Vanguard 1231CM microscope were employed. For fluorescent microscopy, Zeiss LSM710 and Olympus BX61 were used. Preparation and visualization of asci were carried out as previously described  and 18315 (A)] that appear to be MSUD-deficient. These strains refer to deletion mutants of ncu01310, in opposite mating types. To verify that ncu01310 is truly important for silencing, we put it through a quantitative MSUD suppression assay.To discover new MSUD players, we have developed a high-throughput reverse genetics screen to isolate silencing mutants from the Neurospora typically yields black American football-shaped ascospores . However, if only one Round spore copy is present in a cross , it will be unpaired and silenced, leading to the production of mainly round ascospores . This negative feedback scheme is known as “silencing the silencer”. Genes other than Round spore have been used as reporting markers for MSUD activity. These include actin (act+), β-tubulin (Rbml), and Ascospore maturation-1 (asm-1+), whose unpairings result in the production of lollipop asci, wavy asci, and white ascospores, respectively. As seen in ncu01310 acts as a semidominant suppressor of MSUD, suggesting that this gene is important for the silencing process. Accordingly, ncu01310 is referred to as sad-8 hereafter.sad-8 gene is located on the right arm of linkage group V. Its translated polypeptide consists of 484 amino acids and has a molecular weight of 54.9 kD. According to the NCBI’s conserved domain database, the N-terminal quarter of SAD-8 contains an NCBP3 (pfam10309) domain, which is a type of RNA recognition motif (RRM) (sad-8 gene is the only open reading frame in the Neurospora genome encoding an NCBP3 domain.The if (RRM) . NCBP3 iif (RRM) . In humae.g., Aspergillus fumigatus), Saccharomycotina , and Taphrinomycotina . Neurospora belongs to Pezizomycotina, and SAD-8 homologs are represented in several classes of this subphylum . Most MSUD genes that are not known to affect quelling (vegetative silencing), such as sad-1 to sad-5, have relatively low vegetative expression  , it is unlikely to be a crucial factor in growth and development, as the corresponding deletion strain is proficient in linear growth and conidial production.Thus far, none of the known MSUD proteins are essential for cell viability . However, since for MSUD .The first few reported MSUD proteins localize in the perinuclear region, the epicenter of meiotic silencing activity . These pNeurospora, we utilized BiFC to investigate the interactions among the corresponding proteins. As expected, Neurospora CBP80 interacts with both CBP20 and SAD-8  forms a complex  with NCBP2 (CBP20) and another complex  with NCBP3 (SAD-8 homolog)  to interact with NCBP1  and plays a role in MSUD . In Pezizomycotina, the subphylum to which Neurospora belongs, five classes do not have an NCBP3 homolog (Homo sapiens may keep an NCBP3 protein for spliced mRNA biogenesis and N. crassa may keep another for silencing, S. cerevisiae may not need any as it possesses very few introns and has lost its ability to conduct RNAi (Neurospora tetrasperma and Fusarium graminearum, two fungi that are MSUD-capable (SAD-8 is similar to NCBP3, which binds NCBP1 and forms an alternative CBC in mammals . While t homolog . Gebhardsad-8 does not appear to affect either somatic growth or asexual spore production under standard laboratory conditions, although its expression profile suggests that it may play a role in the asexual stage. In HeLa cells, NCBP3 depletion causes an almost 100-fold increase in viral growth (sad-8 mutation may show an adverse effect under stressful conditions.Unlike the first few reported MSUD components, SAD-8 joins a growing list of silencing factors that are not absolutely required for sexual spore production. Deletion of l growth . It is psad-8 is not required for sexual development, it is possible to fully assess its silencing role in a homozygous deletion cross. Interestingly, while a cross devoid of CBC still maintains roughly four-fifths of its MSUD activity (sad-8 leads to a near-complete silencing deficiency. These suggest that while CBC plays an auxiliary role in MSUD, SAD-8 is a critical silencing component.Since Neurospora asci, SAD-8 behaves similarly as it localizes predominantly in the nucleus but can also be seen in the perinuclear region (in vitro and proposed a model for its biological relevance. While other models of complex assembly are possible, a straightforward interpretation of our results is that CBP20, CBP80, and SAD-8 form a trimer in Neurospora. Like CBC, SAD-8 has interaction with the SMS-2 Argonaute, a component of MSC. This observation solidifies the connection of Neurospora nuclear cap-binding proteins to RNAi and supports the notion that they mediate MSUD through their interactions with the perinuclear silencing complex.Like other RNA export proteins, human NCBP3 is predominantly nuclear but can also be found in the cytoplasm (r region . In mammr region . HoweverAccording to our MSUD model, an unpaired gene initiates the production of aRNAs, which are exported to the perinuclear region and processed into siRNAs. These siRNAs can then guide MSC to target complementary mRNA transcripts. An mRNA is typically bound by CBC, which mediates its export to the cytoplasm. One possibility is that the CBC-SAD-8 complex helps deliver an exiting mRNA to MSC. In this scenario, the contact between SAD-8 and MSC is essential for the mRNA transfer, and CBC enhances their interaction. In the absence of CBC, a SAD-8-bound mRNA can still be exported to the perinuclear region and interact with MSC, even though it does not have the optimal configuration for the silencing machinery. While this is a conceivable explanation for our observations, other possibilities abound. For example, CBC and/or SAD-8 may have a stimulatory effect on the silencing machinery directly or indirectly (