Pleomorphic adenoma (PA) is the most common benign tumor of salivary glands. PAs have the potential for regional and distant metastases that preserve their benign phenotype; they also have the potential for malignant transformation. The molecular pathogenesis of malignant neoplasms has been studied extensively in recent years, unlike that of benign tumors, such as PA.In this case report, we identified the molecular signatures of a 57-year-old Japanese woman. Our patient presented with a swelling of the hard palate with an erosive appearance.The patient was diagnosed with a right hard palate tumor suspected to be a malignant neoplasm.Partial maxillary resection and reconstruction were performed.CHCHD7-PLAG1 fusion genes were detected. Moreover, gene expression profiling indicated the possibility of the activation of several cancer-related signaling pathways. Although the PLAG1 gene is predicted to play a crucial role in PA tumorigenesis, its over-expression is reported to mediate multiple downstream factors. In this case, various up- and downregulated RNA signaling pathways, including MAP kinase signaling, PI3K/AKT1/MTOR signaling, JAK/STAT signaling, and PD-L1 signaling, were revealed.There was no obstacle to swallowing or dysarthria after surgery. There was no sign of recurrent palatal tumor 4 years after the operation. Using next generation sequencing, 5 nonsynonymous mutations and These molecular profiles of PA may elucidate the mechanism of metastasis, preserving its benign phenotype and carcinoma ex PA. PA has clinical features, such as distant metastases and malignant transformation, which are inconsistent with the benign phenotype in local sites. However, the molecular mechanisms underlying these inconsistent clinical features have not been elucidated. In this case, we identified the molecular signatures of a patient with PA using next-generation sequencing and gene expression profiling.Recent progress in the molecular profiling of malignant neoplasms has improved our understanding of the molecular pathogenesis of many cancer types and also contributed to the development of novel treatment strategies. However, the elucidation of the molecular signatures of benign tumors, such as pleomorphic adenoma (PA), has been inadequate. PA is the most common benign type of salivary gland tumors, accounting for 60% of all salivary gland tumors. Fusion genes, such as 2 a study launched at Shizuoka Cancer Center to evaluate the biological characteristics of cancer and diathesis of each patient by multiomics-based analyses. Ethical approval was granted by the institutional review board (Authorization Number: 25–33). Written informed consent from the patient was obtained for the publication of this case report.This is a case that is enrolled in project high-tech omics-based patient evaluationA 57-year-old Japanese woman presented to a hospital with a 2-month-old (or possibly longer) indolent oral swelling. A previous clinical examination at another facility reported the presence of a submucosal mass on the right side of her hard palate. After the biopsy, the palatal swelling acquired an erosive appearance, and she was referred to our hospital. She had a medical history of hepatitis C infection. Since she was a non-smoker with occasional social alcohol consumption, the risk factors were minimal. Upon clinical examination, the lesion measured 21 mm × 20 mm with everted edges and had an ulcerative surface . No obstacle to swallowing or dysarthria was observed after surgery. No sign of recurrent palatal tumor 4 years after the operation was detected.The tumor was located between the oral squamous epithelia and minor salivary glands and surrounded with a thick fibrous capsule. At the oral mucosal site, the fibrous capsule had been destroyed by chronic inflammation; the tumor border was unclear and intermingled with granulation and fibrotic tissues. Histologically, the tumor was composed of a mixture of epithelial and fibromyxoid components. The epithelial components were glandular and composed of double-layered cells and frequent foci of squamous metaplasia. In the fibromyxoid components, spindle- or stellate-shaped myoepithelial cells were loosely present and intimately related to outer-layered cells of the epithelial components. The tumor showed slight cellular atypia with no necrosis and abnormal mitosis. No lymph node metastasis was detected. The tumor was finally diagnosed as an ulcerated PA Fig. . The nonsynonymous mutations included 1 frameshift mutation in the ARHGAP9 gene and 4 missense mutations in the USF3, SOHLH1, SALL3, and FAM109B genes  was detected in an Ion Proton system (Thermo Fisher Scientific) using an original targeted RNA-sequencing panel, which was designed to detect transcripts of 491 fusion genes based on the Ion AmpliSeq RNA Fusion workflow (Thermo Fisher Scientific), as described in a previous report.Whole exome sequencing to identify tumor-specific genetic alterations was performed on an Ion Proton system using an Ion Torrent AmpliSeq RDY Exome Kit  according to the manufacturer's instructions. The corresponding peripheral blood sample was used as a control. Tumor mutation burden (mutations/Mbase) was 0.34. A total of 11 mutations, including 5 nonsynonymous mutations, 2 synonymous mutations, and 4 mutations located in non-coding regions, were detected. All gene symbols are referred from the My Cancer Genome website.2 ratio of tumor to healthy tissue ≥ 2) and down-regulated  genes in tumor cells, compared with adjacent healthy tissues, were 1,064 and 829, respectively. Expression of PLAG1, which is a partner gene of the detected CHCHD7-PLAG1 fusion gene, was strongly upregulated in the tumor . To clarify the association between detected expression abnormalities and tumorigenesis, we focused on genes annotated in OncoKB and associated with solid cancer. Pathways were classified based on classifications in previous reports.,10,11 A total of 38 up- and 18 down-regulated genes in the tumor, compared with adjacent normal tissues, were included. Among the 18 down-regulated genes, 2 genes (EPCAM and TMPRSS2) not assigned to cancer-related pathways were excluded from analysis, and the remaining 54 genes listed in Table Gene expression profiling was performed using the SurePrint G3 Human Gene Expression 8 × 60K v2 Microarray (Agilent Technologies) according to the manufacturer's instructions. Up- , suggesting that anti-PD-1/PD-L1 therapy might be sufficient for this patient. Observed upregulation of the well-known angiogenetic factor, VEGFA,  might be caused by upregulation of upstream factors, such as HIF1A, which play roles as transcriptional regulators of VEGFA and some receptor tyrosine kinases (RTKs). Significant expression abnormalities were detected in many genes included in well-known several cancer-related pathways, such as RTKs, Mitogen-activated protein (MAP) kinase, Janus kinase (JAK)/signal transducer and activator of transcription (STAT), and PI3K/AKT/mTOR. This suggests the possibility that these observed phenomena might contribute to clinical characteristics of PA, such as distant metastases and malignant transformation, which are inconsistent with the benign phenotype in its local site.Gene expression pattern revealed a distinct expression signature consisting of various up- and downregulated transcripts. CD274 (PD-L1), exploited by tumors to attenuate anti-tumor immunity, was strongly upregulated in the tumor . In this tumor, expression of IGF-I was strongly downregulated . IGF-I and IGF-II are multifunctional regulatory peptides that primarily mediate proliferation, differentiation, and survival effects. In vivo, the WNT signaling pathway was previously shown to be activated in transgenic mice overexpressing PLAG1. As described above, PA is benign but has various expression changes, which may be a factor in the development of malignancy and metastasis.Overexpression of 4Although we obtained molecular data on PA in this case, the pathogenesis of PA remains mostly unclear. This data may serve as a theoretical framework for further research into the development of novel treatment strategies for surgically untreatable distant metastases or malignant transformations. More in-depth multiomics studies with large number of cases are required to further ascertain the tumorigenesis of PA. However, we believe that data from our patient highlight the possibility that targeted therapy could be developed to induce dormancy in PAs to prevent their distant metastases and malignant transformation.We thank the staff at Shizuoka Cancer Center Hospital for their invaluable help.Data curation: Takashi Nakajima, Koiku AsakuraInvestigation: Masakuni SerizawaProject administration: Ken Yamaguchi, Masatoshi KusuharaResources: Takashi Nakajima, Tomoyuki Kamijo,Supervision: Tetsuro OnitsukaWriting – original draft: Masakuni SerizawaWriting – review & editing: Yoshiyuki Iida


Despite the availability of evidence-based treatments for obsessive-compulsive disorder (OCD), not all patients experience sufficient benefit or are able to tolerate them. Tolcapone is a catechol-o-methyl-transferase (COMT) enzyme inhibitor that augments cortical dopaminergic transmission. Conduct a proof of concept study to examine whether a COMT inhibitor would reduce OCD symptoms to a greater extent than placebo.We conducted a randomized, placebo-controlled, double-blind cross-over trial in adults with OCD (N=20). Participants were assessed at baseline, after 2 weeks of tolcapone, and again after 2 weeks of placebo on measures of OCD symptom severity and psychosocial functioning. There was a one-week washout period between the two-week treatment phases.Two weeks of tolcapone was associated with significant improvement in OCD versus two weeks of placebo . The mean percentage decreases in the total YBOCS scores for the entire sample over the corresponding two-week periods were 16.4% for tolcapone and 3.6% for placebo.These data indicate that brain penetrant COMT inhibitors merit further investigation as a candidate new treatment for OCD. Obsessive-Compulsive Disorder (OCD) is characterized by repetitive intrusive thoughts (obsessions) and/or repetitive rituals undertaken in response to those thoughts, or according to rigid rules . OCD is Tolcapone, a catechol-O-methyl-transferase (COMT) inhibitor, is available in some geographical jurisdictions (including the UK and USA) as an add-on agent for the specialist management of Parkinson’s Disease. The enzyme COMT serves to break down free dopamine in the prefrontal cortex; by blocking this enzyme, tolcapone enhances dopamine signaling in the cortex. In the frontal cortex, optimal dopamine modulation of prefrontal cortical networks appears to be necessary for a variety of cognitive functions, including planning, inhibition, attention, and response flexibility . ImportaThe aim of the current study was to examine the efficacy of two-week treatment with tolcapone in adults with OCD. This was a randomized, double-blind, placebo-controlled crossover design with a one-week washout between treatment periods. We hypothesized that tolcapone would significantly improve symptoms of OCD compared to placebo.Participants were recruited via advertisements and referrals, and were adults, aged 18-65 with a primary current Diagnostic and Statistical Manual Version 5 (DSM-5) diagnosis of OCD. All participants were recruited at a single site. Inclusion criteria included a current diagnosis of OCD with a minimum YBOCS severity score of 18. Participants were included if they were currently taking psychotropic medications as long as the dose had been stable for at least 3 months . Exclusion criteria were: 1) Unstable medical illness, including liver disease, as determined by the investigator and liver function test; 2) History of seizures; 3) Clinically significant suicidality ; 4) Baseline score of ≥17 on the Hamilton Depression Rating Scale (17-item HDRS); 5) Lifetime history of bipolar disorder type I or II, schizophrenia, autism, any psychotic disorder, or any substance use disorder; 6) Initiation of psychotherapy or behavior therapy within 3 months prior to study baseline; 7) Previous treatment with tolcapone; 8) Any history of psychiatric hospitalization in the past year; and 9) Currently pregnant (confirmed by urine pregnancy test).Structured Clinical Interview for DSM-5       (the YBOle (SDS) ; anxiety (HAM-A)  and depr (HAM-D) .This was a fully counter-balanced, double-blind, placebo-controlled cross-over design in which participants received EITHER tolcapone 100mg twice daily for two weeks, followed by one-week washout, followed by placebo twice daily for two weeks; OR placebo twice daily for two-weeks, followed by one-week washout, followed by tolcapone 100mg twice daily for two weeks. The order of treatment was randomized. The washout period was intended top prevent possible carryover effects that might compromises the assessments and conclusions. The study had low risk of bias using the Cochrane criteria  were discontinued from the study.An external pharmacy independent of the research team conducted the sequence generation using randomized lists. Medication was also assigned by the external pharmacy independent of the research team. All medication and placebo were of identical appearance, and were supplied as such to the study team and participants. All participants and study personnel were fully blinded. Outcome assessment was fully blinded.Safety and tolerability were assessed using spontaneously reported adverse events data, Columbia–Suicide Severity Rating Scale (C-SSRS) , vital signs, and by evaluating premature termination. Safety assessments  were documented at each visit. Assessment of side effects was done at each visit. Adverse events were coded by system organ class and preferred term using the Medical Dictionary for Regulatory Activities (Med-DRA) Version 11.1. Liver function tests were performed at baseline and then at study endpoint until in-person office visits were not possible given the COVID19 pandemic. Due to the pandemic of COVID19, study participants were allowed to perform their baseline and follow-up visits online using encrypted videoconferencing with the clinician, instead of in person visits. Blood samples for assessment of liver function, therefore, were at the discretion of the study investigator, and where considered medically necessary, the participant had them drawn locally if possible and submitted to the study team.The analysis followed Intent-To-Treat principles, with Last-Observation-Carried-Forward for dropouts and missing data. The analytic approach was determined prior to data unlock. Changes in YBOCS total scores for placebo treatment and tolcapone treatment were compared using paired sample t-tests, which constituted the primary analysis. This method was appropriate because the design was fully counter-balanced and randomized. Changes in total depression and anxiety symptom scores, and disability, were examined, again using paired t-tests, as secondary analyses. Statistical significance was defined as p<0.05 two-tailed.A total of 28 participants signed informed consents and were enrolled. Of those, eight individuals chose not to proceed with the baseline assessment or were deemed ineligible due to exclusion criteria and were not included for analysis  years. Of the 20 participants, 16 (80%) reported some previous treatment for OCD (either psychotherapy or medication). Of the 20 participants, 5 (25%) were taking other psychotropic medications prescribed specifically for the person’s OCD: two were taking sertraline (both at 100mg/d), two were taking fluoxetine (one on 40mg/d and one on 60mg/d), and one was prescribed venlafaxine (150mg/d). The current doses of medications had been stable for at least three months for each participant before enrolling in the current study and remained unchanged for the duration of the study. No participant was currently undergoing psychotherapy.Of the 20 subjects, 9 (45%) had current psychiatric comorbidities based on the MINI. Five met criteria for major depressive disorder, two for panic disorder with agoraphobia; two met criteria for social anxiety disorder, two for post-traumatic stress disorder, two for generalized anxiety disorder, two for at least one substance use disorder, and one for antisocial personality disorder.When taking tolcapone, participants experienced a mean decrease in their total YBOCS scores of -4.24 (SD= 6.20), which differed significantly from the change observed under placebo treatment of -1.10 (SD= 4.71) . HAM-A scores changed by -1.90 (SD= 4.39) with active treatment and by -1.60 (SD= 4.07) with placebo; and HAM-D scores changed by -1.65 (3.67) with active treatment and by - 2.00 (4.42) with placebo. The changes between the treatment conditions were non-significant for these two measures . SDS total scores changed by -2.68 (SD =4.41) under active treatment and by -1.97 (SD= 6.62) under placebo conditions. The change between the treatment conditions on SDS was not significant . One person’s SDS data were missing at all time points (no data to carry forward).Three adverse events occurred during active treatment, and three adverse events occurred during placebo treatment. All were of minor severity. Reported adverse events during tolcapone treatment were as follows: Mild headache, one patient; increased frequency of bowel movements, one patient; and blood in stool, one patient (this was followed up and found to be haemorrhoids). Reported adverse events during placebo treatment were as follows (each experienced by one patient per adverse event): Less frequent bowel movements, fatigue, muscle aching, and joint stiffness; and sleep problems. No suicidality was detected during the study at any time point on the C-SSRS.This randomized, placebo-controlled cross-over trial indicated that two-week treatment using tolcapone (100mg twice daily) was associated with significant symptomatic improvement in OCD as compared to two-week administration of placebo. The likely mechanism is that tolcapone enhanced cortical dopamine transmission and therefore top-down executive control over habitual patterns of behavior. The finding of significant separation from placebo after two weeks may suggest that longer studies using tolcapone for OCD may be worthwhile to see if even greater benefit is possible. This finding of benefit after two weeks of medication is in fact not new to OCD. Early research on fluvoxamine found that although full response to medication took approximat5ely 8 weeks, the medication actually demonstrated statistically significant improvement compared to placebo after only two weeks of administration . The perLimitations of this study include that the study design (including the extremely short duration of treatment) and the nature of the sample  precluded more complex statistical modelling. Additionally, a major confound in the study is the fact that some patients were being treated with SRIs and some were not. Although numerically those on SRIs do not appear to have had a better or worse response to tolcapone based on change in total YBOCS scores, this variable represents a confounder in our anlaysis.These data indicate that tolcapone, a brain penetrant COMT inhibitor, merits further evaluation as candidate treatment for OCD, in clinical trials of greater sample size and duration than herein. The study may also raise questions about COMT inhibitors as a class of potential medications as they have a distinct neurochemical mode of action versus existing pharmacotherapies for OCD (e.g. SRIs), and may offer advantages in terms of enhancing top-down executive control .Consort Diagram


While no patient experienced more than one recurrence within 1000 postoperative days in the PDD-TURBT group, five out of 40 patients treated by WL-TURBT experienced repeated recurrence. The comparison of cumulative incidence per 10,000 person-days between the two groups revealed that PDD assistance decreased by 6.6 recurrences per 10,000 person-days . This is the first study addressing PDD assistance-induced risk reduction of repeated bladder recurrence using the person-time method. Our findings could support clinical decision making, especially on adjuvant therapy after TURBT.Clinical evidence regarding risk reduction of repeated bladder recurrence after initial photodynamic diagnosis (PDD)-assisted transurethral resection of bladder tumor (TURBT) is still limited in patients with non-muscle-invasive bladder cancer (NMIBC). We analyzed patients with primary NMIBC undergoing TURBT without any adjuvant treatment to compare the risk of cumulative recurrence between the conventional white-light (WL)-TURBT and PDD-TURBT. Out of 430 patients diagnosed with primary NMIBC from 2010 to 2019, 40 undergoing WL-TURBT and 60 undergoing PDD-TURBT were eligible. Multivariate Cox regression analysis for time to the first recurrence demonstrated that PDD assistance was an independent prognostic factor with better outcome ( Transurethral resection of bladder tumor (TURBT) is the mainstay of treatment and diagnosis in bladder cancer, especially in non-muscle-invasive bladder cancer (NMIBC), accounting for about 80% of bladder cancers .Although the bladder can be preserved in most patients with NMIBC, frequent and repeated intravesical recurrence after TURBT remains the biggest clinical problem. Our previous study demonstrated that smoothing of the recurrence hazard curve showed three peaks: a large first peak before 500 postoperative days, a small second peak at 500–1000 days, and another small peak around 1500 days . When thClinical Practice Guidelines for Bladder Cancer 2019 [Improving the quality of TURBT and increasing the rate of complete tumor resection is essential to reduce the risk of recurrence. Over the last couple of decades, 5-aminolevulinic acid (5-ALA) or hexaminolevulinate-induced fluorescence cystoscopy has been developed with the aim of detecting tiny and/or flat lesions ,5. RecenIt has been almost three years since the approval of the PDD-TURBT technique in Japan. However, the clinical evidence regarding oncological outcomes is still limited, especially in repeated recurrence after initial TURBT. Here, we analyzed patients with primary NMIBC undergoing TURBT without any adjuvant treatment to compare the risk of cumulative recurrence between WL-TURBT and PDD-TURBT.The Department of Urology, Nara Medical University, participated in investigator-initiated multicenter clinical trials  from February 2012 to December 2012 and a sponsor-initiated multicenter clinical trial  from May 2015 to March 2016. Our hospital provided the PDD-TUBT technique for patients with NMIBC as a framework of an advanced medical care system, namely ‘ALAB-O,’ from July 2010 to December 2013. The results have adequately proven the efficacy and safety of PDD-TURBT using oral 5-ALA in patients with NMIBC. Since the Pharmaceuticals and Medical Devices Agency (PMDA) approval in Japan (December 2017), we have started the PDD-TUBT for NMIBC as a medical practice covered by regular health insurance.We reviewed 430 patients with primary NMIBC undergoing WL-TURBT or PDD-TURBT from July 2010 to August 2019 at the Department of Urology, Nara Medical University hospital. The clinical characteristics of the patients included age, sex, performance status, past history of NMIBC, tumor multiplicity, tumor size, and second transurethral resection. Pathological diagnosis of the specimens was reassessed by an experienced uropathologist (T.F.) to determine T categories , tumor grades  classifications), presence of carcinoma in situ (CIS), and lymphovascular involvement.TM, KARL STORZ GmbH & Co. KG; Tuttlingen, Germany) (January 2018–August 2019). We switched imaging modes of white light and blue light frequently during the operation to set the resection margin. Resection of all the visible tumors accompanied with or without cold cup biopsy was performed according to the surgical method previously described.The preoperative process for administration of 5-ALA, anesthesia, resection device, and imaging device for WL-TURBT and PDD-TURBT have been previously described ,8,10. ApBasically, a second TUR was indicated if high-grade Ta or T1 was pathological detected or there was no adequate muscularis propria in the specimen. Whether or not a second TUR was performed depended on the judgment of the physician. Single immediate instillation of chemotherapeutic drugs (epirubicin or pirarubicin) and adjuvant therapy depended on the physician’s preference. Patients were followed up according to our institutional protocol as previously described. Briefly, WL cystoscopy with urine cytology was performed every three months for two years, every six months for the subsequent three years, and annually thereafter. Recurrence in the pelvis and upper urinary tract was checked using computed tomography every six or twelve months. Recurrence was defined as recurrent intravesical tumors of pathologically proven urothelial carcinoma (UC). Progression was defined as recurrent disease with the invasion of the muscularis propria (≥T2), positive regional lymph nodes, and/or distant metastases.p-values < 0.05 were considered statistically significant. After the patient selection, Fisher’s exact test or the Mann–Whitney U test was applied to compare the background between the WL-TURBT group and the PDD-TURBT group. The recurrence-free survival was estimated using Kaplan–Meier analysis and compared using the log-rank test or univariate Cox regression analysis between the two groups. Multivariate Cox proportional hazards regression analysis was used to identify independent prognostic variables. Variables that potentially affected prognosis on univariate analysis or that presented significant differences during the background comparison were included in the multivariate analysis.Prism software version 7.00  and SAS statistical software package version 9.4  were used for data visualization and statistical analyses. In this study, p-value under conditioning on the total number of cases, which follows a Poisson distribution [Incidence rates of bladder recurrence after initial TURBT were calculated by dividing the number of cumulative incidences by the total number of person-days at risk throughout the follow-up period. The incidence rates were compared between the WL-TURBT group and the PDD-TURBT group by calculating the normal approximation confidence interval, incidence rate ratio , and exact ribution ,12,13.We have accumulated experience with 5ALA-mediated PDD-TURBT since 2004. The visually stunning endoscopic technique can enable surgeons to determine circumferential resection margin and often detects occult tumors that are easy to overlook under observation with WL mode A,B. Bladp = 0.04), there was no significant difference in other factors between the two groups.p = 0.023, hazard ratio = 0.35) and that large tumor size was the most likely to be a confounding factor  among other clinicopathologic variables. Multivariate analysis including other prognostic factors demonstrated that PDD-assisted surgery was an independent prognostic factor with better outcome . Among the 100 analyzed patients, only one patient had progression to muscle-invasive disease. The risks of progression and cancer-specific death were unable to be evaluated in this study.The median follow-up period was 402 days . Fifteen (38%) out of 40 patients treated by WL-TURBT and nine (15%) out of 60 patients treated by PDD-TURBT experienced at least one recurrence within 1000 days after initial TURBT. Recurrence-free survival was significantly longer in the PDD-TURBT group compared to the WL-TURBT group . Univarip = 0.011).While there was no patient who experienced more than one recurrence within 1000 postoperative days in the PDD-TURBT group, one (2.5%), two (5%), and two (5%) patients out of 40 patients treated by WL-TURBT experienced two, three, and four repeated recurrences within 1000 postoperative days. Single event times are mostly analyzed using the Kaplan–Meier method followed by the log-rank test or the Cox proportional hazards model. However, patients can suffer from repeated same events in some types of disease, such as cardiovascular events , biliary2 white-light source for patients with recurring, multifocal, Ta UC, or CIS and concluded that the procedure was clinically applicable [2) is administered to tumor cells during PDD-TURBT. Further basic research is warranted to confirm our hypothesis regarding the potential of PDT during PDD-TURBT.Our study demonstrated that the use of PDD assistance decreases not only the rate of the first recurrence but subsequent recurrences. The person-time method found a 63% reduction of recurrence . Regarding the associated medical cost, one recurrence requires approximately 4000 USD for hospitalization expenses, anesthesia, and TURBT in Japan. Moreover, psychological and physical stress is unfathomable in patients having recurrent tumors. Early recurrence within 1000 postoperative days is considered largely attributed to tiny lesions, which are overlooked by conventional WL TURBT ,3. PDD cplicable . At the Our previous study developed a risk stratification model for NMIBC, so-called J-NICE (the Japanese NIshinihon uro-onCology Extensive collaboration group) risk tables . The recTo the best of our knowledge, this is the first study addressing the PDD assistance-induced risk reduction of repeated bladder recurrence using the person-time method. We believe that our findings could support clinical decision making, especially on adjuvant therapy after TURBT. Further large-scale retrospective studies using background adjustment method, such as propensity score matching, and subsequent prospective trials are needed in order to better define the real clinical value of PDD-TURBT.


This randomized clinical trial assesses the comparative effectiveness of the Healthy Choices intervention when delivered in a clinic- vs home-based setting on medication adherence and alcohol use among youths and young adults living with HIV. Is the Healthy Choices intervention program more effective if delivered in an HIV clinic vs remotely?In this randomized clinical trial, 183 HIV-positive youths and young adults underwent four 30-minute sessions with community health workers targeting medication adherence and alcohol use; those randomized to the clinic setting had greater improvement in viral load during 1-year follow-up than those randomized to remote (home-based) delivery. Clinic, but not home, delivery was also associated with a trajectory of decreasing alcohol use severity during follow-up.These findings suggest that Healthy Choices sessions provided in the clinic have greater long-term effects on viral load than sessions delivered at home. Youth living with HIV make up one-quarter of new infections and have high rates of risk behaviors but are significantly understudied. Effectiveness trials in real-world settings are needed to inform program delivery.To compare the effectiveness of the Healthy Choices intervention delivered in a home or community setting vs a medical clinic.This randomized clinical trial was conducted from November 1, 2014, to January 31, 2018, with 52 weeks of follow-up. Participants, recruited from 5 adolescent HIV clinics in the United States, were youths and young adults living with HIV aged 16 to 24 years who were fluent in English, were currently prescribed HIV medication, had a detectable viral load, and had used alcohol in the past 12 weeks. Individuals with an active psychosis that resulted in an inability to complete questionnaires were excluded. Data were analyzed from May to December, 2019.Participants were randomized to receive the Healthy Choices intervention in either a home or clinic setting. Four 30-minute individual sessions based on motivational interviewing to improve (1) medication adherence and (2) drinking behavior were delivered during 10 weeks by trained community health workers. In session 1, participants chose which behavior to discuss first. Using motivational interviewing strategies, the community health worker elicited motivational language, guided the development of an individualized change plan while supporting autonomy, delivered feedback, and addressed knowledge gaps. Session 2 focused on the second target behavior. In subsequent sessions, community health workers reviewed the individualized change plan, monitored progress, guided problem solving, and helped maintain changes made.Primary outcomes were viral load and alcohol use change trajectories during 52 weeks of follow-up. Alcohol use severity and frequency were measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)  and number of drinks consumed each day over a 30-day period, with timeline followback.P = .02). A similar pattern was observed in ASSIST scores during follow-up, with reduced ASSIST scores in the clinic group .A total of 183 young people living with HIV  were randomized to the home setting (n = 90) or clinical setting (n = 93). Using growth-curve analysis, both groups showed declines in viral load after the intervention: among participants with available viral load information, in the home group, 12 participants (21%) had an undetectable viral load at 16 weeks, 12 (22%) at 28 weeks, and 10 (20%) at 52 weeks; in the clinic group, 16 participants (24%) had an undetectable viral load at 16 weeks, 20 (39%) at 28 weeks, and 18 (35%) at 52 weeks. However, the clinic group maintained gains, whereas those counseled at home had a significantly different and increasing trajectory during follow-up (unstandardized β = −0.07; 95% CI,−0.14 to −0.01; In this trial, the Healthy Choices intervention resulted in improvements in viral load and alcohol use over 12 months. Unexpectedly, the clinic setting outperformed home-based delivery for viral suppression. Although cross-sectional differences in ASSIST scores were nonsignificant, clinic delivery did improve the trajectory of ASSIST scores during follow-up. Thus, clinics may be the more effective site for interventions aimed at viral load reduction for young people living with HIV.NCT01969461ClinicalTrials.gov Identifier:  Alcohol consumption among persons with HIV exacerbates health problems and accelerates HIV disease progression.6 Optimal adherence to antiretroviral treatment (ART) decreases morbidity and mortality,9 the potential for the development of drug-resistant strains of HIV,12 and HIV infectiousness.16 Healthy Choices, a 4-session, 10-week intervention based on motivational interviewing,17 is the only intervention (to our knowledge) to demonstrate improvements in viral load and alcohol trajectories in youths living with HIV in a full-scale, multisite randomized trial when delivered by members of the research team.19 Thus, testing the intervention in a real world clinical setting when delivered by members of the HIV clinical care team, such as community health workers (CHWs) and local supervisors, can provide evidence to inform practitioners on clinically effective and cost-effective treatments that are available prior to dissemination on a wider scale.24 Such effectiveness trials are the next stage on the translational science spectrum.25Youth living with HIV make up more than one-fourth of new infections in the United States26 It is possible that short-term viral load improvements may have been sustained if participants received a full exposure of treatment. Many researchers have suggested home-based service delivery to increase access to and engagement in behavioral health services, especially when delivered by CHWs, but this remains untested in youths living with HIV.28 Thus, this comparative effectiveness trial compared Healthy Choices in a home-based vs clinic-based setting, delivered by CHWs and supervised by members of the clinical care teams, on primary outcomes of viral load and alcohol use. We hypothesized that home-based delivery would result in greater improvements in viral load and alcohol use compared with clinic-based services by decreasing barriers to participation and by delivering treatments in the youth’s natural ecology.In the original Healthy Choices trial, although most youths attended at least 1 session, less than half completed all 4 sessions.Participants were recruited from 5 adolescent HIV clinics in Chicago, Illinois; Detroit, Michigan; Memphis, Tennessee; Los Angeles, California; and Philadelphia, Pennsylvania. Inclusion criteria included positive HIV status, age of 16 to 24 years, ability to complete questionnaires in English (96.7% of participants spoke English at home), currently prescribed ART, detectable viral load within the last 4 weeks, and alcohol use in the past 12 weeks. Exclusion criteria included having an active psychosis that resulted in an inability to complete questionnaires. Participants were randomized to intervention delivery in the clinic (n = 93) or at home (n = 90).CONSORT) reporting guideline for randomized clinical trials  followed the same format but focused on the second target behavior. In the subsequent 2 sessions (weeks 6 and 10), the CHW reviewed the individualized change plan, continued to monitor and encourage progress, and guided the youth to problem-solve barriers and maintain any changes made. Based on randomization, the intervention was delivered in a private room in the clinic or in the home or a community-based location of the youth’s choice. Participants received no monetary incentives for attending the intervention sessions.The 4-session intervention was identical for the clinic and home locations and has been previously described.30 A trainer then observed 6 coaching sessions and provided feedback to local supervisors on coaching and feedback strategies. During the trial, supervisors provided 30 minutes of weekly coaching to CHWs. Supervisors were required to review at least 1 audio-recorded session conducted by the CHW per month. Supervisors also participated in a monthly group call with trainers, during which supervisors at all active sites discussed issues that emerged in sessions and effective coaching strategies. A review and coding of 25% of session recordings was conducted to assure motivational interviewing was being administered with fidelity. Supervision sessions were also recorded and coded for motivational interviewing fidelity. When either supervision sessions or participant sessions fell below the threshold, a trainer contacted the site supervisor for remediation.Community health workers participated in a 2.5-day training by members of the Motivational Interviewing Network of Trainers. Supervisors attended the 2.5-day training and an additional half day of supervision training. The CHWs and supervisors each submitted 4 audio-recorded roleplays for clearance using the “beginning proficiency” threshold on the Motivational Interviewing Treatment Integrity codes.Baseline assessment data were collected in the clinic. The alcohol use timeline followback questions were recorded on paper by an interviewer, and all other data points were collected using audio-computer-assisted self-interviewing. The same measures were completed at baseline and at 16, 28, and 52 weeks. Participants were paid $50 for each data collection.Age, race/ethnicity, biological sex, gender identity, and sexual identity were assessed using audio-computer-assisted self-interviewing. Blood for quantitative plasma HIV RNA assays was collected within a 2-week window surrounding the data collection time point. Viral load values reported as below the level of detection were set to 20 copies per milliliter. All viral load values were transformed to log10 for the statistical analyses.31 This test yields a summary score for severity of alcohol use ranging from 0 to 33, with higher scores indicating greater severity. Number of drinks per day was measured using the timeline followback procedure.32 The interviewer asked the participant to use a calendar to identify the number of standard drinks consumed each day over a 30-day period. The number of drinks consumed in the participants’ heaviest drinking week in the 30-day period was used as the measure of drinks per week as in the original Healthy Choices trial.18We measured 2 dimensions of alcohol use: severity of problems and number of drinks per week. Severity of problems was measured using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), a brief screening tool to assess the individual’s level of alcohol use and problems related to use.35 because it considers change over time in terms of an underlying, latent, unobserved process, which is what we aim to affect with behavioral interventions. The LGCA results are often quite similar to findings observed using multilevel modeling with fixed and random effects.37 However, they have the advantage of being able to capture unique trajectories that may be of interest to the researcher, and they can avoid potential aggregation bias because trajectory changes are captured at the level of the individual. The drawback of using LGCA is that it is based on structural equation models, which are less well known to clinicians, and that LGCA model fitting is complex and requires detailed documentation  and 1 indicator of antiretroviral medication adherence . Outcomes from behavioral interventions are often characterized by an early large response that attenuates over time. This curvilinear response can be identified for each individual, and the statistical differences in the mean response curves can be assessed for groups using latent growth curve analysis (LGCA) This statistical approach is commonly used in studies of behavioral health interventions2 tests and ANOVA to investigate the equivalence of possible confounders across each condition at baseline. Specifically, we examined proportional differences across demographic characteristics  and mean differences across age and baseline outcome values .The planned overall sample size was 500 patients, with 100 patients per site for 5 sites. Assuming that participant observations were independent, if the setting accounted for at least 1% of the unique variance in the alcohol outcome measures, we would have 80% power to detect a significant difference in the alcohol measures. The slow accrual of these very high-risk subjects limited our actual sample size to 183. Post hoc power analysis and details from our original power estimation are provided in the eAppendix in 2 analyses to test for differential attrition by study arm at each follow-up. We also tested for differential attrition at each follow-up across site, as well as several demographic characteristics . Finally, we conducted a series of point-biserial correlations to examine attrition at each follow-up point by age and baseline outcome values .We conducted analyses to test for the presence of differential attrition between conditions . In these instances, slopes can be specified that quantify each component of the trajectory. Due to the need to correct for baseline differences in ASSIST scores when calculating follow-up values, we utilized an alternative growth modeling procedure.38 This analysis modeled only postintervention points corrected for baseline ASSIST values.A piece-wise LGCA approach,39 For each outcome, a model was estimated that included 3 latent growth components. These included an intercept  and 2 slopes. Factor loadings for slopes were scaled in constant 4-week units of time. Slope 1 captured pre- to postintervention change. Loadings were set to zero at baseline and 4 at the 16- week follow-up and then held constant at 4 thereafter. Slope 2 estimated the linear change over the postintervention follow-up period. Factor loadings for this slope were set to zero for baseline and 16-week follow-up, 7 for the 28-week follow-up, and 13 for the 52-week follow-up. The model included condition (home vs clinic) as a variable in the latent growth factors and a fixed effect for site. All models were estimated using full-information maximum likelihood estimation. For model fit criteria and details of sequential model building see the eAppendix in Models were estimated using Mplus, and examples of the general coding approach is available through their website.t181 = −2.29). In subsequent analyses of primary outcomes, demographic covariates were excluded from the growth curve models. Models for ASSIST scores included baseline scores as a covariate in the estimation of latent growth factors to adjust for baseline differences between delivery condition. χ2 Analyses did not reveal differential attrition based on condition. When examining demographic characteristics, we did find differential attrition based on gender identity at 52 weeks . Specifically, transgender women were less likely to be retained in the 52-week follow-up compared with cisgender male and cisgender female participants. t Tests provided no evidence of differential attrition by age or baseline outcome values . With respect to intervention dose receipt, 35.5% of the sample completed 0 sessions, 26.8% completed at least 2 sessions, and 25.1% completed all 4 sessions. There were no differences between groups in dose received .Demographic data for the total sample are presented in slope2 = −0.07; 95% CI, −0.14 to −0.01; P = .02)  .P = .92) between conditions. Furthermore, at the 28-week follow-up, there was no significant difference in log viral loads . However, we saw a significant mean difference at 52 weeks  for log viral loads between the clinic and home conditions. The observed means provide a direct illustration of the clinical significance of this difference. Those who received the intervention in the clinic had, on average, approximately 355 fewer viral copies per milliliter compared with those who received home delivery. As a result of divergent trajectories, significant differences between intervention conditions emerged over time postintervention. We did not observe a significant mean difference in log viral loads at the 16-week follow-up , representing a return to near-baseline levels, the clinic-condition slope was significantly smaller  in P = .14), 28-week , and 52-week  follow-up points; however, the direction of nonsignificant differences reversed owing to differences in trajectory, with lower scores indicated among youths who received the intervention in a clinic. The standard deviation of baseline-adjusted ASSIST scores at the 52-week follow-up was approximately 7.10. The cross-sectional difference between conditions would therefore correspond to a Cohen d = 0.25, indicating a small effect size.In models of alcohol severity (ASSIST), when correcting for baseline values, the condition was significantly associated with trajectory over time postintervention. Specifically, whereas the home-based condition had a nonsignificant trend over the follow-up period (unstandardized βP = .39). At the 16-week assessment period, we observed a between-group difference . Estimates indicated that these differences persisted at 28 weeks . Differences attenuated at 52 weeks . The clinical significance of between-group differences is illustrated by an examination of group means. The observed differences between groups are largest at the 16-week follow-up (4.03 drinks in the heaviest drinking week) and attenuate to a mean difference of 2.5 drinks at 52 weeks. Given that responses ranged from 0 to 39 drinks, these differences are modest in magnitude relative to the variability in drinking.For alcohol use frequency , there w40 Furthermore, because home- and community-based delivery did not result in increased session attendance, other modes of delivery, such as videoconferencing and mobile apps, should be considered to increase session attendance.In this randomized clinical trial, Healthy Choices resulted in improvements in viral load and alcohol use (severity and frequency) during 12 months of follow-up when delivered by CHWs to a primarily racial/ethnic-minority sample of youth living with HIV in the clinic or at home or in the community. Unlike in the original Healthy Choices trial, viral load improvements were sustained over time, possibly owing to the improved regimens in the current trial compared with the state of antiretroviral therapy in the original trial a decade ago. Contrary to our hypothesis, the clinic-delivered intervention outperformed the home- or community-based delivery with regard to viral suppression and alcohol severity; it may also be less costly and easier to implement. However, most youth did not receive a full dose of treatment, and intent-to-treat analysis suggested improvements even with small doses of intervention. Future studies could consider an adaptive design to test the effect of a single session, with additional sessions offered to nonresponders.41 may be faced with many more psychosocial barriers than youths who struggled with viral suppression a decade ago. Thus, improving viral suppression in one-quarter to one-third of such a high-risk group has significant public health implications. While brief interventions may be more easily implemented in clinic settings, a more intensive intervention may be needed to sufficiently halt viral replication among youths at highest risk.43 Some youths may benefit from motivational interviewing alone, and some may benefit more from motivational interviewing combined with cognitive-behavioral skills-building interventions.44More than half of participants did not achieve viral suppression, regardless of condition. However, youths who still have unsuppressed viral load in the current era of simplified regimens and effectiveness of antiretroviral therapy, even with less-than-perfect adherence,Limitations include lower-than-optimal study retention, although this is not unusual for a real-world effectiveness trial. In addition, generalizability of the sample, recruited from academic medical settings, may be limited.This randomized clinical trial found that the Healthy Choices intervention resulted in greater improvements in viral load and alcohol use when delivered in a clinic vs a home setting. Given these findings, in addition to considering designs to develop an adaptive intervention and technology-based delivery, future directions may include conducting a cost-effectiveness analysis of clinic vs community-based delivery.


Global health is facing the most dangerous situation regarding the novel severe acute respiratory syndrome called coronavirus 2 (SARS-CoV-2), which is widely known as the abbreviated COVID-19 pandemic. This is due to the highly infectious nature of the disease and its possibility to cause pneumonia induced death in approximately 6.89% of infected individuals (data until 27 April 2020). The pathogen causing COVID-19 is called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which is believed to be originated from the Wuhan Province in China. Unfortunately, an effective and approved vaccine for SARS-CoV-2 virus is still not available, making the situation more dangerous and currently available medical care futile. This unmet medical need thus requires significant and very urgent research attention to develop an effective vaccine to address the SARS-CoV-2 virus. In this review, the state-of-the-art drug design strategies against the virus are critically summarized including exploitations of novel drugs and potentials of repurposed drugs. The applications of nanochemistry and general nanotechnology was also discussed to give the status of nanodiagnostic systems for COVID-19. As from the beginning of 2020, the global health sector is passing through a perilous situation owing to the ongoing outburst of a novel severe acute respiratory syndrome called coronavirus 2 (SARS-CoV-2) . This paIn the past 18 years, several viral diseases have been reported, such as severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 to 2003, and H1N1 influenza in 2009. In 2012, Middle East respiratory syndrome coronavirus (MERS-CoV) was reported for the first time in Saudi Arabia ,8. In thAs we know, genetic information is usually carried by DNA, however, for many viruses including HIV and the influenza virus, RNA is used as their basic genetic material. The corona viruses also belongs to the RNA virus family and it consists of a single, 30,000-base-long RNA . A largeAt present there are no vaccines, monoclonal antibodies (mAbs), or drugs available for COVID-19. However, a sturdy research effort is presently under way to develop a vaccine against COVID-19 and some may be available in a short time . CurrentKampf et al. conducted a systematic review on the analysis of literature regarding different human corona viruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus, or endemic human coronaviruses (HCoV). The authors concluded that these viruses can persist on inanimate surfaces such as metal, glass, or plastic for up to 9 days. Further they can be effectively eliminated by using surface disinfection procedures with 62% to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 min .This article summarizes the state-of-the-art drug design strategies against the COVID-19 virus including exploitations of novel drugs and potentials of repurposed drugs. The applications of nanochemistry and generally nanotechnology were also discussed to give the status of nanodiagnostic systems for COVID-19.The World Health Organization (WHO) announced “COVID-19” as the official name for the 2019 novel CoV, a CoV variety that infected and distressed the lower respiratory tract of patients with pneumonia in Wuhan, China. Additionally, it has been provided with reference names such as SARS-CoV-2. In the fall 2019, a group of patients were reported with pneumonia of indefinite cause with association to a native Huanan South China Seafood Market in Wuhan, Hubei Province, China, after which it has spread globally ,19,20. ATo date, complete and comprehensive clinical expression for COVID-19 or SARS-COV-2 is not distinct and clear, as the reported and observed symptoms and indications in infected patients ranges from mild to severe, even resulting in death for some . MedicalAs far as the reports have showed, no specific and exact antiviral treatment has been established yet for the effective treatment or management of COVID-19. Concerning the COVID-19 infected patients, it has been suggested to follow suitable symptomatic management and supportive cautions ,24. MoreThe treatment with established antiviral drugs and general corticosteroids used for general clinical practice including neuraminidase inhibitors , acyclovir, ganciclovir and ribavirin, as well as methylprednisolone for influenza virus, have found to be inacceptable for the prevention and treatment of COVID-19 and also are not recommended . MoreoveOn the other hand, recent publications have disclosed that chloroquine (CQ) can potentially inhibit the in vitro replication of some CoVs. So, the experts hypothetically suggested that CQ can progress the clinical consequences of the COVID-19 infected patients. However, the molecular mechanisms by which CQ could accomplish such outcomes remains to be further examined and explored. Since, COVID-19 was established a few days ago, to utilize the similar cell surface receptor ACE2 against SARS-CoV-1 ,29, it mARDS (acute respiratory distress syndromes) are distressing conditions of prodigious pulmonary inflammations and hypoxemic circumstances, leading to severe illness and mortalities. The key therapeutic approaches have been concentrated over various strategies that could efficiently inhibit extreme inflammations or managing the subsequent physiological imbalance, triggering respiratory lapse . There aCoronavirus possesses a positive-sense single-stranded-RNA genome. The angiotensin responsible in converting enzyme 2 (ACE2) has been recognized as the host cellular receptor for SARS-CoV2 envelope spike glycoprotein . The typUntil now (unfortunately) there is no any effective recipe for drug synthesis or use for SARS-CoV-2 infection; the latter results in fatal inflammatory responses and acute lung injury. Effective and suitable drug candidates have to be designed to resolve this due to this urgent and unmet medical need. SARS-CoV-2 Mpro protease constitutes one of the most attractive antiviral drug targets, especially in the design and development of SARS drugs.Rut et al. provided a structural framework for the design of inhibitors as antiviral agents or diagnostic tests by preparing a combinatorial library of fluorogenic substrates with glutamine in the P1 position . The autTon et al. developed a novel deep learning platform called “deep docking” (abbreviated as DD) and conducted docking studies on 1.3 billion compounds from ZINC15 library and identified the top 1000 potential ligands for SARS-CoV-2 Mpro protein . These sOn the other hand, controversial inference which indicates the lack of suitability of SARS-CoV-2 Mpro as the protein target was also reported. Molecular dynamics investigations on Mpro with a highly similar SARS protein was also reported . This stPark et al. attempted an investigation to identify neutralizing antibodies that can bind to SARS-CoV-2 Spike (S) protein and interfere with the interaction between viral S protein and a host receptor by bioinformatics tools . The seqEscherichia coli K-12 system. Future experimental validations in this direction can give valuable results in vaccine development.Qamar et al. conducted an effective multi-epitope vaccine (MEV) against SARS-CoV-2 by taking seven antigenic proteins as target and epitopes  . DockingKo et al. reported 54 molecular hits with a therapeutic index (TI) greater than 6 by screening 5406 molecules including US Food and Drug Administration (FDA) approved drugs and bioactive compounds . This stZhang et al. suggested the potential of Chinese medicine to develop a drug against COVID-19 by in silico screening and network pharmacology of Chinese herbal medicines . Zhu et Some other receptors were also reported as the therapeutic target for designing drugs against COVID-19. Zhang et al. reported angiotensin converting enzyme 2 (ACE2) receptor as a potential target . It is bThe concept of drug repurposing deserves significant attention in managing COVID-19 treatment owing to its extremely high infectious rate and urgency for the unmet medical need. Repurposed drugs are very beneficial since they can bypass the preclinical trials associated with drug research and can give quick benefit to patients . Guo hav50 value = 1.13 μmol/L; CC50 > 100 μmol/L, SI > 88.50) and RDV  potently blocked virus infection at low-micromolar concentration and showed high selectivity index. RDV is already proved to be active against several viruses and currently under clinical trials to evaluate its efficacy against Ebola virus infections. This study gives additional insights on the use of this adenosine analogue prodrug against COVID-19 infections. On the other hand, CQ is already well known for its action against malarial parasite infections and anti-inflammatory properties [Wang et al. evaluated FDA approved drugs including ribavirin, penciclovir, nitazoxanide, nafamostat, chloroquine (CQ) and two well-known broad-spectrum antiviral drugs remdesivir RDV, GS-5734) and favipiravir (T-705) against a clinical isolate of 2019-nCoV in a cell culture infection model . The aut34 and faoperties .Further CQ has been approved for the clinical treatment of autoimmune diseases such as lupus erythematosus and rheumatoid arthriti . RecentlGao et al. reported that Chloroquine phosphate was very effective and safe for COVID-19 associated pneumonia in multicenter clinical trials conducted in China . The hydGautret et al. successfully demonstrated the synergistic effect of hydroxychoroquine and azithromycin in 20 COVID-19 cases and observed efficient viral elimination . SimilarControversial results are indicated by Cao et al; lopinavir-ritonavir treatment did not resulted in any benefit beyond standard care .Wang et Favalli et al. provides an indication for using antirheumatoid arthritis drugs for COVID-19 with their pros and cons by correlating with the pathophysiology of COVID infection . The autLiu et al. observed that an anticoagulant agent dipyridamole (DIP) suppressed HCoV-19 replication at an EC50 of 100 nM as evident from in vitro studies . The autSang et al. verified the assumption of using HIV-1 protease inhibitors as anti-SARS drugs by targeting SARS-Co-V 3CLpro . The autChen et al. did virtual screening using 3CL (pro) molecular model and observed that antivirals ledipasvir or velpatasvir are particularly attractive as therapeutics acting through dual inhibitory actions on two viral enzymes with minimal side effects . PhytochAdvancements in nanoscience regarding viruses causing respiratory diseases can be found. Although there is not any literature available regarding drastic and successful therapeutic strategies of nanotechnology against COVID-19, the following data can guide the upcoming research works for developing both a successful and effective nanomedicine against SARS-CoV-2 and “give an obstacle” of related pulmonary disorders associated with these viral infections.The advantages of using nanomedicine for the management of respiratory viruses were reviewed in literature . The gatNovel NPs were reported, which can improve the performance in the treatment of respiratory diseases through different mechanism of action which are (i) the development of polymers with faster mucus penetration and do not remain stuck, overcoming this barrier, (ii) the creation of biodegradable NPs with the stability to overcome the cell membrane and act in the lung with minimal levels of toxicity, causing no lesions during treatment, (iii) modification of the chemical structure of NPs by adding surface capping agents such as polyethylene glycol (PEG).2) nanocarriers that targeted the 3′non-coding area of influenza a virus. These NPs entered cells without the aid of transfection agents and strongly inhibited influenza A in vitro [Influenza virus: Genomic mutations and antigenic shifts between various influenza species yields a high degree of variance that leads to the inception of novel influenza viral strains as well as unnecessary drug resistance . A polymin vitro .Human papillomavirus: These viruses target the epithelial cells and yield a lot of symptoms, which include common warts, cervical carcinoma, and cancer. More than 100 types of HPV have been identified and classified to be highly risky STP909 (CervisilR), a nano drug candidate, is loaded with siRNA to combat HPV16 and HPV18, which account for 70% of cervical cancer. In vitro studies show that from the E7 genes of HPV16 and HPV18, mRNA duplexes were formed, while tests in rabbits demonstrated that the NPs result in a knock-down of E7 gene. Many other gene silencing experiments that target E7 gene in mice models, mammalian cells, as well as vaccine studies, have been investigated in vaccine formulations ,89.Respiratory syncytial virus (RSV): A siRNA loaded lipid based nanocarrier, ALN-RSV01, combats the nucleocapsid “N” gene which is a key viral protein of RSV. It was the first RNAi-based treatment authorized for clinical studies and has now reached phase II, which indicate very safe and successful antiviral consequences ,91.Human parainfluenza 3 (HPIV-3): The latest research revealed suppression of HPIV-3 replication, possibly due to a blocking function of the cell-virus leveraging AgNPs. The findings of this analysis indicate that the inhibitory behavior depends on both the NPs size and zeta potential .Although, till date, no specific targeted delivery systems have been developed or explored for the management SARS-CoV, SARS-CoV-2 (COVID-19) and other CoV strains, it is expected that nanotechnology-based treatment approaches including monoclonal antibodies or vaccines, can find a way for efficient and rapid diagnosis.Disease caused by respiratory syncytial virus (RSV) was reported to be eliminated in mice by using virus-like NPs carrying RSV fusion proteins (F VLP). The advantage of using FVLP is that they act against RSV by inducing natural killer cells, activated IFN-γ(+), and IFN-γ(+) tumor necrosis factor (TNF)-α(+) CD8(+) T-cells in the lung and bronchiolar airways during the infection stage but not forming harmful lung plasmacytoid dendritic cells (DCs) and effector T-cells . RSV wasMajor NPs reported for acting against respiratory viruses are three categories given below .Polymeric NPs: They possess exciting properties such as tunable properties, feasible synthetic protocols, and good biocompatibility, which makes them interesting candidates for biomedical applications. Poly (lactic-co-glycolic acid) (PLGA) is one of the well-known member of this category which is approved by FDA for application in human body. This is due to the excellent biocompatibility and biodegradability in the human body . Other eSelf-assembling proteins NPs: These are prepared through the oligomerization of monomeric proteins, which were found suitable for biomedical applications .Inorganic NPs: Extensive literature is available regarding the biological effects of inorganic NPs such as metal oxide NPs, which showed good results in antibacterial and antifungal studies . FeaturePeptide-based NPs: Earlier studies have showed applications of peptide inhibitors (short-sequenced) and mutations of amino acids could potentially act against the infections associated with SARS-CoV . As repoThe reported NPs against different respiratory viruses through nasal administration are summarized in There exists a huge urgency for developing a successful nanovaccine in order to reduce mortality and hospitality currently faced by most of the countries. “LIF nano”, which is a special class of mesenchymal stem cells, are also reported to improve patient’s biological resistance to COVID-19 using stem cells . These tNPs-based biosensors are vital tools that contribute to the detection of individuals affected with pathogens. Theragnostic aspects of nanosystems as quantum dots were reviewed in recent literature . SensoryZhu et al. reported a NPs-based biosensor system for COVID-19 which works via a “one step and single tube” reaction pathway . This se5 copies of SARS-CoV-2 pseudovirus particles. These results are very promising since it reduces operational requirements in current molecular diagnosis of COVID-19, which assist early clinical diagnosis of the affected individuals.Zhao et al. demonstrates a promising alternative to this approach by using poly (amino ester) with carboxyl groups (PC)-coated magnetic NPs (pcMNPs) . The autWang et al. reported a rapid and simultaneous detection system for both SARS-CoV-2 and other respiratory viruses using nanopore target sequencing (NTS) . The autYu et al. also employed the NTS method to detect the alterations of gut microbiota homeostasis in COVID-19-affected individuals . There iThe NPs-based delivery approaches have exhibited significant potential applications, however, studies have showed that these approaches could cause severe damages in respiratory sites and even could impair lung function. The four major patho-biological aspects, including oxidative stress, genotoxicity, inflammation, and fibrosis must be considered with the context of NPs and associated approaches. 2-NPs) in the lungs of mice after a 90-day successive intra-tracheal administration of TiO2 NPs. The TiO2-NPs expressively enhanced the accumulation of ROS level, inflammation, lipid peroxidation level, and also reduced the antioxidants competency in the lungs. The NPs could produce ROS followed by oxidation of antioxidant moieties, and thus could influence the respiratory system and associated patho-biological activities including pulmonary inflammation and genotoxicity [The oxidative stress typically arises due to disparity amongst the reactive oxygen species (ROS) production and the capability of a biological system to voluntarily eradicate the reactive moieties. Sometimes, it could be caused directly due to generation of ROS within the cell or indirectly disturbing the mitochondria respiration  or reductoxicity .In some cases, it has been observed that the NPs, administered through nasal route, caused chronic or acute inflammation-mediated processes such as inclusion of inflammatory cells and proclamation of cytokines ,135. In Genotoxicity, either primary or secondary, is a major concern associated with NPs-mediated delivery systems. The genotoxic moieties or NPs affect directly by binding with the DNA structures or constituent of the cellular division such as microtubule spindle or centromeres . The carFibrosis is considered as an indicator of accumulation of inhaled NPs in the pulmonary sites and causes uncommon modes of pulmonary inflammation such as eosinophilia . In one Currently, various enormous and significant efforts are going on to develop a scientific risk management research structures. The United States National Nanotechnology Initiative/Environmental, Health, and Safety Research Strategy is one of the structures that majorly focusses over the establishment of measuring tools which could efficiently determine the physico-chemical properties of nanotechnology-based delivery systems or nanomedicines . Thus, iIn spite of the global efforts to apprehend the causes and treatment approaches for COVID-19, many concerns still remain indistinct. Among these concerns, the first concern is that one of the report that has disclosed the presence of COVID-19 in the patient’s stool . AlthougTo summarize, these days a dramatic situation on the planet exists. The invisible enemy with the abbreviated name “COVID-19 pandemic” threatens the global health, causing pneumonia induced death in approximately 7% of infected individuals . The pathogen causing COVID-19 is SARS-CoV-2, which is believed to be originated from the Wuhan Province in China. Until now, there is no drastic, effective, or successfully applied recipe to face SARS-CoV-2 virus. However, in the last days, there has been a strong effort of R&D of many pharmaceutical industries to discover the appropriate anti-virus cocktail of the already discovered drugs or find a new one. In the whole situation, the impact of nanoscience  is significant, but only few scientists worldwide have published their research findings. The latter was due to some preliminary few tests and results exported from animals and in further fewer test in the hospitalized infected patients. It is considered that the first  vaccine can be shared in market during the next year, but until then, all efforts must be done to discover a drastic drug so as to face this invisible enemy, COVID-19.The most promising statement of the few last days has come from Chinese scientists who claimed to have developed a new weapon to combat COVID-19. They say that they have found a nanomaterial that can absorb and deactivate the virus with 96.5% to 99.9% efficiency .Global health is facing the most dangerous situation regarding the novel severe acute respiratory syndrome called coronavirus 2 (SARS-CoV-2), which is widely known as the abbreviated COVID-19 pandemic. In this review, the state-of-the-art drug design strategies against the virus are critically summarized including exploitations of novel drugs and potentials of repurposed drugs. The applications of nanochemistry can be summarized in the use of some specific nanomaterials as (i) polymeric, (ii) self-assembling proteins, (iii) inorganic, (iv) peptide-based. Also, special attention is given to NPs-based biosensors, which are vital tools that contribute to the detection of individuals affected with pathogens. Conventional detection methods rely on nucleic acid detection and have various demerits, which are (i) low sensitivity and laborious experimental procedures, (ii) large time duration between sample collection and results interpretation, (iii) high false negative rates, and (iv) lack of specificity which results in misdiagnosis in patients having other viral infections. Some studies have showed that these approaches of nanotechnology could cause severe damages in respiratory sites and even could impair lung function. The four major patho-biological aspects, including oxidative stress, genotoxicity, inflammation, and fibrosis, must be considered with the context of NPs and associated approaches. So, the basic conclusion is that COVID-19 is a new pandemic, and can be initially faced with some already known nanomaterials, which have been applied to the previous SARS-CoV or similar viruses. This knowledge will be a significant tool the fight for this new virus.


The psychological impact of the COronaVIrus Disease 2019 (COVID-19) outbreak and lockdown measures on the Italian population are unknown. The current study assesses rates of mental health outcomes in the Italian general population three to 4 weeks into lockdown measures and explores the impact of COVID-19 related potential risk factors.th and April 6th 2020. Eighteen thousand one hundred forty-seven individuals completed the questionnaire, 79.6% women. Selected outcomes were post-traumatic stress symptoms (PTSS), depression, anxiety, insomnia, perceived stress, and adjustment disorder symptoms (ADS). Seemingly unrelated logistic regression analysis was performed to identify COVID-19 related risk factors.A web-based survey spread throughout the internet between March 27Endorsement rates for PTSS were 6,604 (37%), 3,084 (17.3%) for depression, 3,700 (20.8%) for anxiety, 1,301 (7.3%) for insomnia, 3,895 (21.8%) for high perceived stress and 4,092 (22.9%) for adjustment disorder. Being woman and younger age were associated with all of the selected outcomes. Quarantine was associated with PTSS, anxiety and ADS. Any recent COVID-related stressful life event was associated with all the selected outcomes. Discontinued working activity due to the COVID-19 was associated with all the selected outcomes, except for ADS; working more than usual was associated with PTSS, Perceived stress and ADS. Having a loved one deceased by COVID-19 was associated with PTSS, depression, perceived stress, and insomnia.We found high rates of negative mental health outcomes in the Italian general population 3 weeks into the COVID-19 lockdown measures and different COVID-19 related risk factors. These findings warrant further monitoring on the Italian population’s mental health. Lockdown measures included travel restrictions, the mandatory closure of schools, nonessential commercial activities and industries. People were asked to stay at home and socially isolate themselves to prevent being infected.The psychological impact of the COronaVIrus Disease 2019 (COVID-19) outbreak and related lockdown measures among the Italian population are unknown. The COVID-19 pandemic is a global health emergency that could potentially have a serious impact on public health, including mental health information on social media and elsewhere . At the Concerning the COVID-19 pandemic, a study on 1210 respondents in China found rates of 30% of anxiety and 17% of depression .Together, these findings strongly suggest the need to accurately and timely assess the magnitude of mental health outcomes in the general population exposed to COVID-19 pandemic, with particular regard to the implementation of preventive and early interventions strategies for those at higher risk. However, no study to date has investigated mental health outcomes and associated risk factors in the Italian population. This could be of additional relevance considering the implementation of the strict lockdown and social distancing measures imposed on the entire national territory.The aim of the current study was to assess rates of mental health outcomes in the Italian general population three to 4 weeks into lockdown measures and to explore the impact of COVID-19 related potential risk factors. This study aims at providing evidence that could potentially inform subsequent research strategies and mental health delivery in Italy and Europe. Our hypothesis is that specific COVID-19 related risk factors could show a relevant association with mental health in the general population.A cross-sectional web-based survey design was adopted. Approval for this study was obtained from the local IRB at University of L’Aquila. On-line consent was obtained from the participants. Participants were allowed to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured.th and April 6th 2020 using an on-line questionnaire spread throughout the internet, using sponsored social network advertisement together with a snowball recruiting technique. Questionnaires were evenly distributed across the national territory. The investigated timeframe corresponds to the contagion peak in Italy, according to epidemiological data confirmed by the World Health Organization  women, median age was 38 (IQR=23). Because of the web-based design, no response rate could be estimated as it was not possible to estimate how many persons were reached by social network advertisement.Post-Traumatic Stress Symptoms (PTSS), depression symptoms, anxiety symptoms, insomnia, perceived stress and adjustment disorder symptoms (ADS) were assessed using the Italian versions of the following instruments and cut-offs or scoring:The Global Psychotrauma Screen, post-traumatic stress symptoms subscale (GPS-PTSS) : PTSS wethe 9-item Patient Health Questionnaire (PHQ-9) , using tthe 7-item Generalized Anxiety Disorder scale (GAD-7) , using tthe 7-item Insomnia Severity Index (ISI) , using tthe 10-item Perceived Stress Scale (PSS) , using athe International Adjustment Disorder Questionnaire (IADQ) , using tStandardized age, gender, and region of residence  were inserted as independent variables. Region of residence was inserted in order to account for the different incidence of COVID-19 among Italian regions. COVID-19 related independent variables were:being under quarantine either because infected or in close proximity to infected people;any changes in working activity compared to “working as usual” ;having a loved one infected, hospitalized or deceased due to COVID-19;any stressful events comprised in the IDAQ checklist, purposely modified in order to capture only stressful events due to COVID-19. The IADQ checklist comprises eight questions about any potential stressful life event occurred in the recent past, with a yes/no response, including financial, working, educational, housing, relationship, own or loved one’s health and caregiving problems. In order to separate COVID-19 related stressful life events from non-COVID-19 related events, responses to the checklist were modified as follows: “no”; “yes”; “yes, due to COVID-19”. Responses were collapsed in a binary variable where 1=“any stressful life evet only if due to COVID-19” and 0=“no stressful life events or presence of a stressful life event not due to COVID-19”.A history of childhood trauma and any previous mental illness, as assessed by the dedicated GPS module; education level, occupation  and being in a relationship.Frequency analysis were performed in order to ascertain the prevalence of each outcome, separately for Northern, Central, and Southern Italy.A seemingly-unrelated multivariate logistic regression model was fitted in order to explore the impact of the proposed covariates and confounders on the selected outcomes. Seemingly unrelated regression models are systems of equations that allow to jointly model several outcomes, assuming correlation among their errors. Because of the very low missing data rates (<3%), missing data were treated with listwise deletion in regression analysis.® (StataCorp). Seemingly unrelated logistic regression was performed using the -suest- postestimation command after running a panel of logistic regressions.Data analysis was performed using Stata v. 16th percentile was 31, with 3,933 (21.9%) respondents scoring above this threshold; 4,129 (23.0%) respondents reported a IADQ scoring compatible with the suspect of a presence of an adjustment disorder.Socio-demographic characteristics of the sample, along with rates of mental health outcomes, are reported in Seemingly unrelated logistic regression analyses are reported in In this study, we report for the first time on the mental health outcomes related to COVID-19 outbreak and related lockdown measures on the general population in Italy. To the best of our knowledge, this is the first study to report on mental health outcomes related to the COVID-19 outbreak in Europe on such a large sample size. This study shows relatively high rates of PTSS, Depression symptoms, Anxiety symptoms, Insomnia, Perceived stress and ADS, with young women having higher odds of endorsing a mental health outcome. These outcomes were associated with a number of COVID-19-related risk factors, including being under quarantine, having a loved one deceased by COVID-19, working activity discontinued due to lockdown measures, or experiencing other stressful events  due to the pandemic or lockdown measures. These findings were adjusted for previous psychiatric illness and a history of childhood trauma, suggesting that the COVID-19 pandemic is exerting an independent effect on the population mental health.vs. self-report) and sampling strategy. Furthermore, our study uses screening tools that may only suggest the presence of a mental disorders. To the best of our knowledge, no large epidemiological study has ever been conducted in Italy on stress-related disorders, so no comparison with pre-covid evidence can be proposed.Compared to previous reports on common mental disorders in the Italian population, our data suggest in increase in rates of common mental disorders such as depression symptoms and anxiety symptoms . HoweverCompared to an early report on the mental health outcomes related to COVID-19 in China on 1210 respondents . AnotherCoherently with previous reports from China, female gender , 13, 21 Monitoring populations’ mental health is critical during a pandemic, as generalized fear and fear-induced over-reactive behaviour among the public could impede infection control . FurtherThis study has some important limitations due to the sampling technique. Relying on social networks voluntary recruitment and re-sharing could have introduced an important selection bias, firstly excluding people not on social networks, and secondly introducing a self-selection bias, as suggested by the highly unbalanced gender ratio observed. This latter bias could have affected also two other large web-based surveys in China, that reported on samples with a 64.7% and 67.3% proportion of woman , 13. ForThis study has also several strengths, including a very large sample size and the sampling timeframe that corresponded to the pandemic peak in Italy.Future studies will need to monitor the trajectory of mental health outcomes, in order to define mental health interventions at a population level.Moreover, these results suggests that appropriate mental health care delivery should be at the centre of future re-organization healthcare management, anticipating the needs, planning, and delivering much needed mental health protection of the whole community as well as in special populations .We found high rates of negative mental health outcomes in the Italian general population three to 4 weeks into the COVID-19 pandemic and lockdown measures. COVID-19 related factors were associated with these outcomes independently from previous mental illness or childhood trauma. These findings warrant further monitoring on the Italian population’s mental health and could serve to inform structured interventions in order to mitigate the impact on mental health of the outbreak.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 Internal review board, University of L’Aquila. The patients/participants provided their written informed consent to participate in this study.Conceptualization: RR, VS, FP, GL. Methodology: RR. Formal Analysis: RR. Data Curation: RR, SM, GL. Writing—Original Draft: RR, VS. Writing—Review and Editing: RR, VS, DT, AM, FP, SM, CN, AR, AS, GL.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.