Breast cancer is an umbrella term referring to a group of biologically and molecularly heterogeneous diseases originating from the breast. Globally, incidences of breast cancer has been increasing dramatically over the past decades. Analyses of multiple clinical “big data” can aid us in clarifying the means of preventing the disease. In addition, predisposing risk factors will be the most important issues if we can confirm their relevance. This study aims to provide an overview of the predisposing factors that contribute to a higher possibility of developing breast cancer and emphasize the signs that we ought to pay more attention to.This is a matched nested case-control study. The cohort focused on identifying the eligible risk factors in breast cancer development by data screening (2000-2013) from the Taiwan National Health Insurance Research Database (NHIRD) under approved protocol. A total of 486,069 females were enrolled from a nationwide sampled database, and 3281 females was elligible as breast cancer cohort, 478,574 females who had never diagnosed with breast cancer from 2000 to 2013 were eligible as non-breast cancer controls, and matched to breast cancer cases according to age using a 1:6 ratio.We analyzed 3281 breast cancer cases and 19,686 non-breast cancer controls after an age-matched procedure. The significant predisposing factors associated with breast cancer development including obesity, hyperlipidemia, thyroid cancer and liver cancer. As for patients under the age of 55, gastric cancer does seem to have an impact on the development of breast cancer; compared with their counterparts over the age of 55, endometrial cancer appears to exhibit an evocative effect.In this nationwide matched nested case-control study, we identified obesity, hyperlipidemia, previous cancers of the thyroid, stomach and liver as risk factors associated with breast cancer. However, the retrospective nature and limited case numbers of certain cancers still difficult to provide robust evidence. Further prospective studies are necessitated to corroborate this finding in order to nip the disease in the bud.The studies involving human participants were reviewed and approved by the China Medical University Hospital [CMUH104-REC2-115(AR-4)].The online version contains supplementary material available at 10.1186/s12885-022-09913-6. Over 2.1 million female  are diagnosed with breast cancer every year throughout the world . Written informed consent for participation was waived for this study in accordance with the national legislation and the institutional requirements.Since we want to conduct the comparative approach to the risk of breast cancer development in the fully enumerated cohort, we adopted the nested case-control study design to clarify their correlation. In order to verify the risk of pre-cancer, we set a backtracking period of five-years from the time of breast cancer diagnosis, and identified the diseases that were treated and meet the definition of ICD-9 code and identified at least three outpatient visits or one hospitalization. Of the 1 million samples, 486,069 females were enrolled, and 3281 females who was newly diagnosed with breast cancer (ICD-9-CM code 174) within 5 years after first observed date between 1 January 2005 and 31 December 2013, and obtained registry for catastrophic illness was eligible in breast cancer cohort. The first breast cancer diagnosis date was used as the index date for breast cancer cases. 478,574 females who had never diagnosed with breast cancer from 2000 to 2013 were eligible as non-breast cancer controls, and matched to breast cancer cases according to age using a 1:6 ratio. An index dates was set at the fifth year after the initial date of observation for non-breast cancer cohort. Hence, 19,686 matched controls were eligible in later analysis. The study flowchart was summarized in Fig.The baseline characteristics were age, gender, hypertension (ICD-9-CM codes 401-405), hyperlipidemia (ICD-9-CM codes 272.0-272.4), chronic liver disease (ICD-9-CM code 571), chronic kidney disease (ICD-9-CM code 585), diabetes (ICD-9-CM code 250), chronic obstructive pulmonary disease , autoimmune disease , cardiovascular disease (ICD-9-CM codes 410-414), stroke (ICD-9-CM codes 430-438), endometriosis (ICD-9-CM code 617), and obesity (ICD-9-CM code 278). Furthermore, we also obtained data of patients with cancers that may be related, such as colorectal cancer , lung cancer (ICD-9-CM code 162), thyroid cancer (ICD-9-CM code 193), liver cancer (ICD-9-CM code 155), cancer of the corpus uteri (ICD-9-CM code 182), ovary cancer (ICD-9-CM code 183), cervical cancer (ICD-9-CM code 180), skin cancer , and stomach cancer (ICD-9-CM code 151). The ICD-9-CM code for above mentioned disease were summarized in Supplementary Table SP values were two-sided and P < 0.05 was considered statistical significance. All statistics was performed using SPSS version 18.0 .The chi-squared test or Student’s t-test was used to compare the demographic characteristics of breast cancer cases and non-breast cancer controls as appropriate. Conditional logistic regression was used to estimate the risk of breast cancer development in different cancer types, the odds ratio (ORs) and confidence interval (CI) were computed. In addition, since breast cancer is related to hormonal regulation, we added the average age of menopause at 55 years of age as a boundary to further clarify whether the age factor can be found to be related to the development of breast cancer from other cancer survivors. All In this case-control study, 486,069 females were included. Of these, 3281 individuals were afflicted with breast cancer, the rest were those who were not, but still had other chronic diseases or other types of cancer. The risk of developing breast cancer was elevated among the disease of hyperlipidemia and obesity (Table P = 0.030). Obesity is confirmed by the outpatient physician who obtained the ICD-9-CM codes as 278, which is generally a stricter definition. Although the number of breast cancer patients who meet obesity standards is 30, there are still obvious differences in risk compared with non-breast cancer patients. Hyperlipidemia also has a significant influence on the development of breast cancer (P = 0.002).According to the study findings shown in Table P = 0.034). After adjusted by conditional logistic regression, the estimated OR of thyroid cancer was 1.82 (95% CI = 1.02-3.25), still remained significant higher risk in breast cancer development. In addition, liver cancer also showed significant higher risk in the future development of breast cancer, and the estimated OR was 1.78 . As for the age adjusted subgroup analysis (Table P = 0.048). For the opposing group consisting of those aged younger than 55, stomach cancer victims were reported to have a slightly significant higher risk of getting breast cancer with an OR of 7.45 . Of notes, although a great odds of high incidence risk of breast cancer have been estimated for the stomach cancer victims, a conservative used of current results is suggested. To further clarify the potential effects varied by age, the conditional logistic regression subgroup analysis using an age cut-off value of 50 years old were summarized in Supplementary Table SP = 0.003) was significant associated with the increasing risk of breast cancer development, which is consistent with the results found in age ≥ 55 years subgroup. In addition, although cancer of corpus uteri showed an potential increasing risk on breast cancer development, no statistical significance was estimated in age ≥ 55 years subgroup.According to the results of univariate analysis as shown in Table Obesity is a recognized risk factor for the development of breast cancer and its recurrence even when patients are treated appropriately . Excessip-value = 0.002). Nevertheless, further studies and literary reviews are needed to clarify the disparity in the findings in order to confirm the effect of cholesterol and its treatment on the etiology of breast cancer.Hyperlipidemia, high blood cholesterol, is a common comorbidity to obesity . There iCancer survivors can be affected by a number of health problems, but often their greatest concern is facing cancer again. Some cancer survivors may develop a new, unrelated cancer later on in life. We wanted to clarify which distinct cancers have connections to breast cancer, so we used the benefit of big data analyses to find the connection and discussed it further.Thyroid cancer starts when healthy cells in the gland mutate and grow out of control. Breast and thyroid cancers are two malignancies with the highest incidence in female. These cancers often occur metachronously which means the two cancers have a successive relationship and occur more than 6 months later from the first episode based on Moertel’s definitions . The risBased on our analysis, liver cancer survivors and secondary breast cancer had a significant correlation but has seldom been demonstrated before. The traceable reported case is a patient with hepatitis B who developed a tumor mass of the liver and was presented with right breast nodule at the same time . From thAs for primary liver cancer (PLC), there is an unfavorable increasing trend observed in most developed countries, obesity and buildup of fat in the liver due to western dietary habits is the major reason of this tendency . In otheBRCA1/2 gene are five times more likely to develop breast cancer than someone without a mutation [BRCA1/2 mutations have been reported to increase the lifetime risk of developing stomach cancer by as much as 6 folds among first-degree relatives of BRCA1/2 mutation carriers [Stomach cancer is a genetically heterogeneous tumor with multifactorial etiologies, associated with environmental and genetic factors. We believe that if the two cancers share common genetic influence, there may be a positive correlation between the occurrence. BRCA1/2 and CDH1 (E-Cadherin) are genes that are evident in the literature review. First, females with a mutated mutation . Stomachcarriers . Second,carriers . Other rcarriers . If obesCancer of corpus uterine  begins in the layer of cells that from the lining of the uterus. The known risk factors are hormone related, such as early menarche or late menopause, nullipara, irregular menstrual periods and obesity. Exogenous hormones can increase the risk of developing endometrial cancer. A large retrospective meta-analysis in German and Swedish Cancer Registry discovered that elevated risks were present on second ovarian endometrial carcinoma and secondary kidney cancer for 3973 endometrial cancer survivors , nothingThe enrolled samples reviewed in this study have three potential limitations. The first relates to the size of some comparison groups, especially for cancer survivors. Since we set strict conditions for the continued development of cancer, some cancers have only single digits, such as cancer of corpus uteri, ovary cancer, skin cancer and stomach cancer. These samples were too small to precisely detect risk factors with low prevalence number. The second limitation is the background population, they were all restricted to the same race and a single country. It cannot be completely regard as the tendency of most people. The third limitation relates to self-reported data which can introduce a bias. Take obesity for example, its association with hormone related cancers has been accepted, but obesity is not commonly diagnosed as a disease, unless interventional treatment, such as surgery, is required. Therefore, the input of this ICD-9-CM code may be indirectly underestimated. The same incident may easily occur on the input of some chronic diseases. Moreover, the analysis data of current study were only retrospectively abstracted from the outpatient visits, emergency admission, and hospitalization records registered in Taiwan’s NHIRD, the individual information including genetic factors and family history for study cohort, and tumor characteristics for cancer patients are not available. Despite this, this study still provided a nationwide evidence to identify predisposing risk factor associated with breast cancer development, and carefully discussed the potential association between the predisposing factors and breast cancer development according to the our study findings.To sum up, this article has presented a retrospective nationwide matched nested case-control study based on the basic concept of “Big Data” integration, and further revealed several predisposing factors associated with breast cancer incidence risk. Breast cancer prevention requires raising awareness among those possible predisposing risk factors. However, the retrospective nature and limited case numbers of certain cancers still difficult to provide robust evidence. Therefore, further prospective research and investigation need to be carried out in order to achieve greater consensus.Additional file 1: Supplementary Table S1. The ICD-9-CM code for all analyzed diseases.Additional file 2: Supplementary Table S2. Conditional logistic regression subgroup analysis for predisposing risk factors of breast cancer development.


Indium lung is characterized by interstitial pneumonia and/or emphysema which occurs in indium-tin oxide (ITO) workers. Indium lung is now known to progress after stopping exposure to ITO, but the long-term influences of ITO remain unclear.Forty seven years old, a never-smoker, who had been engaged in an ITO manufacturing process for 8 years. Emphysema was indicated by the medical check-up for ex-ITO workers, and he was diagnosed with indium lung. He underwent partial lung resections for pneumothorax two times, and obstructive pulmonary dysfunction had progressed through the years. He underwent right single lung transplant 20 years after ITO exposure. Pathologically, his lung showed severe distal acinar emphysema and honeycomb change. Fibrosis and destruction of the lung tissue significantly progressed compared to the previous partial resections. Scanning electron microscopy combined with energy dispersive spectroscopy revealed that the deposited particles contained indium and tin. After the transplantation, his respiratory function was improved.In this case, ITO resided in the lung tissue for 20 years, and lung tissue destruction kept progressing. Careful medical follow-up is recommended for ITO-workers even if they are asymptomatic. Indium-tin oxide (ITO) is used as the transparent electrodes in flat-panel displays.The first reported case of indium lung was a 27-year-old man who had worked surface grinding of the ITO targets between the ages of 23 and 26 and died of interstitial pneumonia . The proThis patient had undergone partial resection of both lungs, separately at different time points, respectively, to treat refractory pneumothoraxes. The comparisons between the two sets of specimens should give us the important information on the chronological changes of the indium lung, especially on the pathogenesis of emphysema in indium lung.A 47-year-old man with no history of smoking underwent right single LTX. He was engaged in an ITO manufacturing process from the age of 18 to 26. He underwent video-assisted thoracoscopic surgery (VATS) for right apical pneumothorax in X-21(year), since then he was transferred to non-indium desk work. One of his colleagues died of severe interstitial pneumonia in X-20. Following this incident, a cross-sectional study was conducted for all the employees involved in the ITO processing. Although VC was maintained (VC of 4.89 L), FEV1 was decreased (FEV1 of 2.40 L). Serum indium concentration and Krebs von den lungen 6 (KL-6) were significantly elevated . High-resolution computerized tomography (HRCT) showed reticulo-nodular shadow, ground glass opacity (GGO), and mild to moderate low attenuation areas on HRCT, which suggest emphysema. Lung disease due to ITO was suspected based on the features described above. He underwent the second VATS for left pneumothorax in X-17. Although serum indium and KL-6 levels declined slowly  at the Center of Advanced Instrumental Analysis, Kyushu-University revealed that the deposited particles contained indium and tin  . In a reThe previous reports using animal models demonstrated that ITO particles resided and kept injuring the lung tissue for weeks or months, and only a little ITO was transferred to other organs , 19. TheWe herein firstly reported the histopathology of an indium lung without a smoking history, which progressed 20 years after cessation of exposure. The lung tissue showed severe subpleural destruction of lung tissue such as distal acinar emphysema and honeycomb changes. These histological findings might contribute to the histological evaluation of the severity of indium lung. Because of the progressive nature of indium lung, careful follow-up is recommended for workers exposed to ITO even if they are asymptomatic.


Coronavirus disease 2019 (COVID-19) is a current global pandemic associated with an increased mortality, particularly in patients with comorbidities. Patients with chronic liver disease (CLD) and liver transplant (LT) recipients are at higher risk of morbidity and mortality after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Many liver societies have recommended that these patients should receive COVID-19 vaccinations, although there are limited studies assessing risks and benefits in this population. In addition, two doses of mRNA vaccines may not provide sufficient immune response, and booster dose(s) may be necessary, especially in LT recipients. Notably, variants of concern have recently emerged, and it remains unclear whether currently available vaccines provide adequate and durable protective immunity against these novel variants. This review focuses on the role of COVID-19 vaccinations in CLD and LT recipients. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that was first reported to cause a pneumonia outbreak in Wuhan, China, in December 2019 . As of DWe searched the literature using PubMed and Scopus on 1 March 2022 with search terms “COVID-19 vaccine and cirrhosis or liver transplant”. A total of 248 titles and abstracts were retrieved and manual reviewed the abstracts to address the studies of COVID-19 vaccine in patients with CLD and LT recipients. Additional references were reviewed from the literature bibliography to identify the relevant recent data included in this narrative review.COVIDCirrhosis.org and COVID-Hep.net registries   and combgistries    and two P = 0.002)  , is a ri= 0.002) .The presentation of LT recipients with SARS-CoV-2 infection is distinct to that of cirrhotic patients, with fewer detrimental effects observed in LT recipients. Of note, LT recipients often share common demographic characteristics and comorbidities associated with known risk factors for unfavorable outcomes in SARS-CoV-2-infected patients. For instance, LT recipients are more likely to have renal impairment and diabetes compared to the general population. Hence, risk adjustments incorporating these factors are crucial when determining whether LT itself is a risk factor for higher mortality in patients with SARS-CoV-2 infection . The oveLT recipients are typically on immunosuppressive therapy, which may impact the course of disease in the case of SARS-CoV-2 infection. Patients on immunosuppressive agents may be more vulnerable to severe infection, and the management of immunosuppressive agents during the treatment of SARS-CoV-2 infection may be problematic. A recent systematic review and meta-analysis of 509 LT recipients with SARS-CoV-2 infection reported that the use of immunosuppressants was significantly more common in non-severe cases and in patients who survived from infection, with pooled ORs of 10.7 (95% CI: 3.11–36.94) and 16.0 (95% CI: 11.48–22.30), respectively . The resThe direct impact of SARS-CoV-2 infection in patients with hepatocellular carcinoma (HCC) with regard to disease severity and mortality are not well established. To date, there have only been two small reports of patients with HCC who were infected with SARS-CoV-2, comprising 21 and 22 patients with HCC, respectively. The mortality rates in these reports varied from 19 to 40% . The secIn different circumstances, the SARS-CoV-2 pandemic has indirectly impacted the HCC management cascade. Several studies have compared the management of HCC between 2020 and the same period in 2019 and reported a significant reduction in HCC surveillance completion rates and the number of new HCC cases , 36. In Vaccination is an effective measure to resolve a pandemic . AlthougWith regard to COVID-19 vaccines, the entire virus or components of the virus are used to design and construct the vaccines , 47. ImmAntibody responses are used as the main laboratory parameter for measuring immune responses pre- and post-vaccination , 54. HigCLD and cirrhotic patients typically present with impairments in immunological status  Figure . DespitePatients with CLD or cirrhosis and LT recipients are strongly recommended to receive vaccinations against SARS-CoV-2 to prevent severe COVID-19 and unfavorable consequences. Several SARS-CoV-2 vaccine platforms have been utilized among these populations. However, the immunogenicity, efficacy, and safety data are variable and inconsistent due to a limited number of CLD, cirrhosis, and LT patients included in phase III studies . Only 21A suboptimal immune response is of concern, because suboptimal immunogenicity following vaccination against other infections in such patients is well-established and has been reported in the literature. Crucially, LT recipients who must be maintained on immunosuppressants may still be vulnerable to infection even after vaccination , 81. FurThe effects of mRNA-based vaccines have been more widely evaluated in solid organ transplant (SOT) recipients. Two currently available mRNA vaccines that are widely utilized include the mRNA-1273 (Moderna) vaccine and BNT162b2 (BioNTech and Pfizer) vaccine.An immunogenicity study using two doses of the BNT162b2 mRNA vaccine in LT recipients reported significantly weaker immune responses (72%) than that in age-matched immunocompetent individuals (94%). The geometric mean of RBD IgG and NA titers were also significantly lower among LT recipients. A combination of immunosuppressive therapy and impaired renal function were identified as risk factors for poor immune responses. Although approximately half of the participants experienced some adverse events (AEs), all AEs were mild and were more frequently observed in male participants . A prospCurrently available adenovirus vector-based vaccines for COVID-19 include the ChAdOx1-nCoV-19 vaccine (AstraZeneca and University of Oxford), Ad26.COV2-S vaccine (Johnson & Johnson), and Sputnik V . Immunogenicity and safety data of adenovirus vector-based vaccines in SOT recipients are limited. A small case series of 12 SOT recipients who underwent Ad26.COV2-S vaccination reported a significantly lower rate of detectable anti-RBD antibodies (17%) compared to 59% obtained with the mRNA vaccine series, which is in accordance with the trends of titer magnitude . NonetheAlthough inactivated SARS-CoV-2 vaccines are considered safe for patients with CLD and LT recipients, results from phase III trials remain to be confirmed. Immunogenicity, efficacy, and safety data focusing on CLD and LT patients are thus limited. Among the different vaccine platforms, inactivated vaccines may offer long-term safety but with potential suboptimal immune responses. Studies on BBIBP-CoV (Sinopharm) in LT recipients are scarce. There had a cross-sectional study reported the seropositivity in kidney transplant recipients only 43% after receiving the second dose of Sinopharm vaccine . A prospData regarding immunogenicity after vaccination with protein subunit vaccines are limited, and further investigations are warranted.Unvaccinated CLD and LT patients are anticipated to experience greater severity and mortality due to severe COVID-19. Vaccination is an essential tool that may alleviate these events. The efficacies of mRNA vaccines and Ad26.COV2.S were reported to be greater than 95 and 66%, respectively, in phase III studies , 76, 82;Recently, the large propensity-match controls with patients with cirrhosis study indicated that COVID-19 vaccine could prevent the hospitalization as high as 100% after obtained mRNA vaccine at least 1 dose . In addiCurrent recommendations of renowned international liver societies indicate that patients with CLD and LT recipients should receive COVID-19 vaccines –16 Tabl.All patients with CLD and HCC are advised to receive COVID-19 vaccines. Patients should not discontinue their medications for underlying diseases including immunosuppressive agents in patients with autoimmune hepatitis (AIH). Interruption of immunosuppressants may be harmful, such as the occurrence of hepatitis flares that eventually lead to liver failure in patients with AIH. In patients with HCC who may undergo resection, locoregional treatments  and systemic therapy should not be delayed due to vaccination. In this regard, vaccinations should be administered as early as possible.LT recipients and living donors should also receive COVID-19 vaccines. During the pre-transplant period, patients on waiting lists for transplantation and living donors should be prioritized for vaccination , 16, andThe dose of immunosuppressants should not be reduced or discontinued during vaccination, as this may increase the risk of rejection. LT recipients with abnormal liver biochemistry tests should be assessed for acute graft rejection . Of noteA study of non-cirrhotic patients with NAFLD  who obtained two doses of inactivated vaccines reported that NA positivity in the serum of patients was 95.5% compared to 97.6% in the general population  in contrThree other prospective studies confirmed the poor antibody responses in patients with cirrhosis and even greater hyporesponsiveness in LT recipients , 101. A Immunity derived from COVID-19 vaccines decreases in parallel with the time elapsed after vaccination. Accordingly, the Centers for Disease Control and Prevention have suggested that individuals receive a booster shot at least 5 months after receiving two doses of mRNA vaccines or at least 2 months after receiving the Johnson & Johnson vaccine . NeverthBased on several studies that have reported weak immune responses after two standard doses of mRNA-based vaccines in SOT recipients maintained on immunosuppressants, the WHO has recommended the administration of an additional dose of COVID-19 vaccines for a primary series of immunocompromised patients, including SOT recipients . This waA recent case series of the fourth dose of mRNA-based vaccines in 37 SOT recipients, 4 of whom were LT recipients, has been reported. Participants with a weak response (14%) and no response (84%) after three doses of the BNT162b2 vaccine were vaccinated with a fourth dose and appeared to exhibit a slightly increased HMI response; however, these effects were only observed in participants with previously developed weak immune responses. Nevertheless, no improvements were noted among participants that lacked an initial response. Additionally, the NA titers and CMI responses of both groups were low . AnotherAdditional doses, including the third or fourth dose of the two vaccines in LT recipients, may improve vaccine immunogenicity. However, a significant proportion of patients may remain vulnerable to COVID-19. Therefore, compliance with hygiene measures and avoidance of disease exposure should be maintained. Furthermore, due to the relatively short follow-up period in previous studies, the occurrence of allograft rejection and other indirect AEs will need to be monitored in more long-term studies.The effectiveness of vaccines against the SARS-CoV-2 Delta variant has been examined for the mRNA-based vaccine (BNT162b2) produced by Pfizer Inc. and BioNTech SE and a replication-deficient simian adenovirus vector ChAdOx1 nCoV-19 (Vaxzevria) from Oxford University and AstraZeneca. The results revealed modest differences in effectiveness with the Delta variant as compared with the Alpha variant. The effectiveness of two doses of the BNT162b2 vaccine was 93.7% (95% CI: 91.6–95.3) while that of the ChAdOx1 nCoV-19 vaccine was 74.5% (95% CI: 68.4–79.4) . In addiRecent data indicate that levels of NAs against the novel Omicron variant are lower, especially in viral vector-vaccinated individuals . SeveralThe AEs post-vaccination usually were mild, self-limited and non-fatal including the local AEs such as pain at injection site and systemic events such as fever, fatigue, flu-like symptoms and myalgia –78. TherThere are scarce data regarding vaccine effectiveness and immune responses including humoral and cellular immunity following COVID-19 vaccination in CLD patients and LT recipients. Challenging issues that warrant further evaluation include the effective durability of vaccine protection against SARS-CoV-2 infection, need for booster vaccines (such as fourth doses particularly in LT recipients), requirement for serologic testing to guide the need for booster vaccines, and effectiveness and safety of heterologous vaccines. Recently, variants of concern, including Omicron, have emerged as pertinent challenges. Future research is needed to verify the immunity conferred by currently available vaccines in patients with CLD and LT recipients.Furthermore, as patients with CLD and LT recipients, considered one of the immunosuppressed populations, are at risk for developing COVID-19, the role of pre-exposure prophylaxis with monoclonal-antibody such as tixagevimab and cilgavimab in which the interim analysis showed promising results should be further investigated . In addiPatients with CLD and LT recipients constitute immunocompromised populations owing to CAID or administration of immunosuppressants. These patient populations are thus more prone to developing severe SARS-CoV-2 infection with high mortality rates when compared with the healthy population. A key preventative measure is COVID-19 vaccination, and several platforms are currently available. Several international liver societies have recommended that these patients receive vaccination owing to the greater benefits over the potential risks, despite limited studies to date. Studies have suggested that these patients are hyporesponsive to COVID-19 vaccines, and booster shots are required. In conclusion, large knowledge gaps remain regarding the effects of vaccination in patients with CLD and LT recipients, and future research is warranted. In addition to vaccination, cautionary measures such as social distancing, washing hands, and wearing masks should be practiced as part of standard lifestyle behaviors.AK contributed substantially to the conceptualization, drafting, and critical revision of the manuscript. All authors made a substantial contribution to the literature research and drafting of the manuscript and 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There may be a role for eHealth-delivered exercise for people with multiple myeloma (MM), as exercise tailoring and supervision are critical for successful outcomes due to the significant impacts/risks of myeloma-related side effects. The purpose of this study was to determine the safety, feasibility, and preliminary efficacy of a 12-week virtually supported eHealth exercise program.Participants with MM completed a 12-week virtually supported home exercise program involving virtually supervised group workouts, independent workouts, and aerobic exercise. Tailoring was facilitated by the functionality of HEAL-Me, a novel eHealth app. Participants completed virtual fitness assessments and questionnaires at baseline and week 12.Twenty-nine participants consented, 26 completed all follow-up testing (90%). Exercise adherence was 90% (group), 83% (independent), and 90% (aerobic). No serious adverse events (grade ≥3) occurred. Significant improvements were found for quality of life and physical fitness. There was a high level of program/app satisfaction: 96% of participants agreed or strongly agreed that the exercise program was beneficial, 93% found it enjoyable, 89% were satisfied or very satisfied with delivery through the HEAL-Me app, and 48% felt that the eHealth program helped them manage cancer-related symptoms and side-effects.An eHealth intervention that is individually tailored and includes virtual supervision and active support from the healthcare team is feasible and acceptable to people with MM. The findings from this study warrant investigation using a large-scale randomized controlled trial. Specifically, myeloma bone disease leads to lytic lesions, which in turn can lead to fractures, pain, deformities, mobility issues, and neurological deficits.8 As such, myeloma bone disease poses a challenge for exercise delivery for two reasons: (1) exercise may be more likely to induce long bone fractures in this population compared to healthy individuals; (2) individuals may be hesitant to exercise due to a psychological fear of exercise triggering a fracture.9 In MM specifically, there is a paucity of exercise trials,10 with some studies showing promise in physical functioning,1114 and others reporting non-significance.1519 More research is required to determine what exercise volumes/types are appropriate for people with MM.Exercise can improve the lived experience of people living with cancer.20 but flexibility is another important consideration.21 Home programs offer flexibility but lack supervision and support while in-person programs at hospitals or fitness centers can be logistically challenging for participants, leading to adherence and completion issues.20 eHealth programming could leverage the benefits of in-person programming (supervision and tailoring) and home programming (flexibility). Indeed, eHealth interventions are being increasingly researched in the field of exercise oncology.22 Recent trials have found eHealth interventions to be feasible and acceptable in older adults with cancer,24 individuals with thoracoabdominal malignancies,25 and individuals with metastatic prostate cancer.26 Other trials identify the promise of eHealth interventions for outcomes such as fatigue, strength, pain, and functional capacity in various cancer populations.28Tailoring and supervision may be key program characteristics to ensure successful exercise programming for people with MM,The purpose of this study was to determine the safety, feasibility, and preliminary efficacy of a 12-week virtually supported home exercise program. The program progressed the activity of people with MM as recommended in the 2019 Exercise Guidelines for Cancer Survivors. We hypothesized that the 12-week program would prove safe and feasible for people with MM and would demonstrate preliminary efficacy with key physical function and quality of life outcomes achieving minimally important differences.www.clinicaltrials.gov (NCT04484714). Participants provided informed written consent prior to enrollment. This article follows the CONSORT Statement extension for randomized pilot and feasibility trials.29 Although this study is not randomized, many of the CONSORT principles from this extension still apply.30 The target sample size was 25.31The Myeloma Progressive Resistance and Aerobic Exercise Study (MY PROGRESS) was a single group pre-post feasibility study. The study received ethics approval from the Health Research Ethics Board of Alberta: Cancer Committee on 26 August 2020 (HREBA.CC-20-0201) and was registered at 32Using convenience sampling, participants meeting the following criteria were recruited: ≥18 years old; MM diagnosis; in one of three categories: (i) transplant ineligible, first-line treatment, (ii) transplant eligible, >3 months post-transplantation, and (iii) relapsed/recurrent myeloma with ≥1 prior line of treatment; ability to provide informed written consent in English. Recruitment occurred through (i) outpatient appointments at local cancer centers (oncology staff provided information to eligible patients), (ii) study presentations for the local myeloma patient support society, and (iii) eligible former participants of the Alberta Cancer Exercise program (ACE).33 and a cancer-specific intake form  by an exercise physiologist and approved by their physician prior to enrollment. Baseline physical activity level was determined using the Godin-Shephard Leisure-Time Physical Activity Questionnaire.34 Bone disease was considered but was not exclusionary, to capture a sample reflective of the real-world MM population. Physician approval was contingent on the stability of symptoms and reasonable optimization of pain control. At approval, the physician shared the participant's history and/or location of bony lesions with the exercise team. Exclusion criteria included: physician-determined inability to exercise safely at home based on clinical judgment; diagnosis of amyloid light-chain amyloidosis, solitary plasmacytoma, or Waldenstrom macroglobulinemia; too frail to partake in home programming .Participants were screened using the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+)7 The goal was to progress participants to moderate-intensity resistance training ≥2 times/week and moderate-intensity aerobic exercise ≥90 min/week by study completion.Programming was delivered by a kinesiologist with >3 years of exercise oncology experience with oversight from an exercise physiologist and physiotherapist. Participants received a 12-week tailored exercise program based on the 2019 Exercise Guidelines for Cancer Survivors.35 HEAL-Me is an online non-commercial application (app) developed by a University of Alberta research team led by a MY PROGRESS investigator (PT). HEAL-Me offers flexible, tailored home exercise programming using: (i) virtually supervised group workouts; (ii) independent home workouts; and (iii) independent aerobic exercise. See The program was delivered through HEAL-Me, an e-Health technology.Resistance exercise. The resistance exercise component involved 60-min virtually supervised group workouts as well as assigned independent workouts on the app. Participants progressed in exercise frequency and intensity over the 12-week program . Specifically, principles of exercise prescription included avoidance of exercises with high fall risk, extremes of spinal movements , and rapid and/or weight-loaded end-range movements that could potentially impact the location of lytic lesions.38 Each workout had a secondary circuit that followed the initial one, which alternated between (1) a core exercise sequence: two sets of two core exercises, (2) an 8-min balance sequence, and (3) additional stretching. Independent workouts were assembled from a bank of >150 exercises on the HEAL-Me app. At the program start, participants were matched to one of four program start-points based on their fitness  while exercising40 and recorded their aerobic exercise using the app's activity tracking portal, which includes a box for recording duration and a slider scale for rating of perceived exertion. Additional aerobic exercise program details are available in exercise . Partici Adherence was tracked directly in HEAL-Me. Reasons for missed sessions, adaptations to individual programs, and reasons for adaptations were recorded. Virtual one-on-one sessions were conducted on a regular basis  to discuss program design, adaptations, and techniques, and to explore the challenges and successes of participants.The primary outcome of this study was the protocol's feasibility. Feasibility was determined by uptake (≥21 participants consenting to the study over a 7-month recruitment period), completion (≥80% of consenting participants completing the 12-week assessment), safety , and adherence (completion of ≥75% of the exercise prescription). Adverse events were tracked and recorded as per the Common Terminology Criteria for Adverse Events (CTCAE version 5.0).41 Physical assessments were completed virtually using the latest version of Zoom Meetings . The study's kinesiologist completed baseline assessments, and an independent kinesiologist completed post-intervention assessments. Physical assessments were used to determine aerobic exercise capacity (2-min step test),42 lower body muscle strength (30-s sit-to-stand test),43 core endurance (plank endurance test), and balance (one-legged stance).44 Upper body flexibility was assessed by active shoulder flexion range of motion using a goniometer.45 Lower body flexibility was assessed using the modified sit-and-reach test.46 Height and weight were abstracted from medical records. Questionnaires assessed the quality of life -MM),47 fatigue -Fatigue),49 and symptom burden ).51 Bone pain was assessed using the FACT-bone pain (BP).52 Neuropathy was assessed using the FACT/Gynecologic Oncology Group-Neurotoxicity 4 (GOG-NTX4).53 The physical, social, emotional, and functional subscales of the FACT are also reported. Finally, physical symptom burden and psychological symptom burden were assessed using the subscales from the ESAS.51Questionnaires and virtual physical assessments were completed pre- and post-intervention (12 weeks) to evaluate secondary outcomes. Questionnaires were administered online using REDCap electronic data capture tools hosted and supported by the Women and Children's Health Research Institute at the University of Alberta.Demographics and feasibility measures are presented using descriptive statistics (mean ± SD or median (range) for continuous variables, frequency (percentage) for nominal variables). The normality of secondary outcomes was tested using the Skewness–Kurtosis test in Stata/MP. Data were analyzed using 95% confidence intervals (CIs) if normally distributed. Data were analyzed using asymmetric CIs and are presented as median along with the 25th and 75th quartiles and 5th and 95th percentiles if non-normally distributed. Analyses were conducted using Stata/MP 13.0 .n = 8), myeloma support society (n = 15), former ACE participants (n = 3), and Myeloma Canada (n = 3). Twenty-eight participants completed baseline testing and began the 12-week program . The mean age of participants was 65 ± 8.4 years , apprehension to spinal flexion (n = 1)) and 6 participants were unable to complete the plank test , inability to get onto the floor (n = 1)).Recruitment occurred over 7 months: September 2020 to March 2021. Thirty-one participants initially expressed interest in the study and were screened for eligibility. One participant decided not to participate after discussing the study with the research team because they were starting a new clinical trial drug. A second participant had stage 4 colon cancer and was no longer being followed for MM, so was referred to a different exercise program delivered by our research lab that was more appropriate. As such, 29 participants consented (uptake: 4.1 participants/month). Consenting participants were recruited by oncology staff referral (n = 4) and unrelated (n = 3) to the intervention were identified. Two cases of mild back pain (grade 1) occurred, one during a seated version of bridging (lumbar pain) and one during a low-impact jumping jack exercise (thoracic pain). Both cases were resolved within a few days and did not impact adherence. One case of moderate back pain (grade 2) occurred following a bridging exercise, resulting in a 6-day pause from exercise. One case of moderate-to-severe back pain occurred following a hip flexor stretch, resulting in a 7-day pause. This event fell into the category of grade 2 to 3 pain acutely but did not limit the participant's self-care activities of daily living in the days following, was not life-threatening, and did not require hospitalization. Thus, the event did not constitute a serious adverse event, given it did not meet full CTCAE criteria for a grade 3 back pain event.Adverse events related  unrelated to the exercise intervention occurred when a participant had a fall in their bathroom. The participant discontinued exercise for the remainder of the program (2 weeks). One case of moderate back pain (grade 2) unrelated to the intervention occurred when a participant slipped on ice outdoors, resulting in a 4-day pause. Finally, one case of grade 2 arrhythmia unrelated to the exercise intervention occurred in a participant with a history of previous cardiac intervention, resulting in a 10-day pause while undergoing cardiology testing/clearance.n = 20), comorbid medical issues (n = 20), and competing priorities (n = 15) (n = 33), decreased level of difficulty (n = 28), and custom routine (n = 24) (n = 27), limited range of motion (n = 19), and history of fracture/lytic lesion in the area (n = 10) .Participants completed 82.9% of independent home workouts, 89.9% of group workouts, and 89.7% of aerobic exercise. For aerobic exercise, 16 participants progressed from 40 min/week to 90 min/week, 5 participants maintained 90 min/week for 12 weeks, 3 participants progressed from 90 min/week to 150 min/week, and 4 participants maintained 150 min/week for 12 weeks. Reasons for missed exercise included: fatigue ((n = 15) . Exercis(n = 24) . Exercis(n = 10) . A compln = 26) and enjoyable  and felt the service provided by the program staff was excellent . Participants were satisfied with the HEAL-Me app, disagreeing or strongly disagreeing that the app was burdensome . While 48% of participants (n = 13) felt that the program helped them manage cancer-related symptoms and side effects, 48% of participants felt neutral about the program's benefits for symptoms and side effects.There was a high level of program satisfaction . Most paA summary of secondary outcome results is available in The mean difference in pre- versus post-intervention quality of life (FACT-MM) was +7.3 (95% CI: 0.6–14.0). The mean difference in pre- versus post-intervention fatigue  was +1.7 (95% CI: −1.4 to 4.8). The median difference in pre- versus post-intervention total symptom burden  was +1 (25th and 75th quartiles: −9 and +11).Findings from this study indicate that: (1) the program was feasible in terms of recruitment and completion rates, safety, and exercise adherence, (2) participants were satisfied with the program, program staff, and mobile app, and (3) secondary outcome results may indicate promise and warrant further investigation.54 Further, adherence to the program was high (82.9%–89.9%). Taken together, these results support the program's feasibility. This suggests that, consistent with the findings of other malignancy groups,2326 an eHealth intervention is a feasible way to deliver an exercise intervention to individuals with MM. This program included three key elements which likely bolstered the program's feasibility: (1) tailoring, (2) virtual supervision/active support, and (3) trained personnel.56All feasibility study targets were met. The low attrition rate compares favorably to previously observed rates of 15% to 42%.57 In the absence of purposeful adaptations accommodating these symptoms, this program may not be tolerable. Tailoring was facilitated by the functionality of the novel eHealth app, HEAL-Me. HEAL-Me allowed the kinesiologist to easily assign disease-specific template routines to participants, switch out exercises from ≥150 alternatives in seconds, and track when/why adaptations were needed. Given this functionality, the kinesiologist could provide tailored programming with minimal barriers.This study is the first to systematically document how programming was tailored to people with MM. Participants required daily/weekly adaptations to keep programming appropriate. Adaptations varied from small adjustments  to developing completely new routines. Importantly, myeloma-related pain and a history of fracture/lytic lesions were two primary reasons for program adaptations. These symptoms represent significant barriers to people with MM.20 Indeed, a recent review on eHealth interventions in cancer proposed videoconferencing as a way to deliver accessible, virtually supervised interventions.22 In the current study, supervision involved weekly virtually supervised workouts in small group settings and regular participant/specialist check-ins using videoconferencing through HEAL-Me. This allowed for live feedback on exercise form/technique and facilitated discussions that informed exercise adaptations and tailored education/advice.Supervision has been proposed to enhance the appropriateness of programming for people with MM.38 Participants valued this delivery model, identifying staff as knowledgeable, supportive, and comforting. We recommend that future studies in MM carefully consider the need for skilled personnel and interdisciplinary oversight to ensure sufficient safety checks are in place, while keeping program delivery feasible.An appropriately trained and diverse exercise team is likely needed to deliver safe, effective exercise programming in MM. In this study, a kinesiologist with >3 years of experience working with this population delivered the exercise program. The kinesiologist was supported by a physiotherapist with >20 years of experience in cancer rehabilitation who provided program oversight for this and many other programs at our center, a cancer-specific exercise physiologist who completed participant pre-screening, and an oncologist who approved participants for participation. This model aligns with recommendations from the International Bone Metastases Exercise Working Group.14 as well as previous studies that reported no adverse events.18 It is not clear why the rate of minor musculoskeletal events was higher in the current study compared to previous studies. In-person exercise is sometimes regarded as safer because it allows for both closer monitoring of exercise responses and hands-on assistance with exercise movement or technique.58 However, virtually supervised programming has emerged as a feasible and effective alternative for individuals with cancer.59 Another possible explanation is that the current study contained a higher proportion of individuals with bone disease, who may be at higher risk of experiencing events, compared to previous studies.17 In individuals with bone disease, staff must be aware of the potential benefits and risks of exercise, and participants need to make an informed decision on the level of risk that is acceptable to them, given the exercise dose needed to optimize their fitness and function.38 Further investigation is warranted to better elucidate the appropriate dosing of exercise in MM in order to deliver both a safe and effective program. In the absence of an established optimal exercise dose in MM, tailoring is likely key in ensuring exercise safety.20 Researchers should aim to minimize the likelihood and severity of events by ensuring programming is individually tailored, assisted by active support, and delivered by qualified personnel.56No serious life-threatening adverse events or events requiring hospitalization related to the intervention were observed. However, the rate of minor musculoskeletal events was higher compared to a recent exercise trial in MM,61 supporting previous findings in MM12 and with eHealth interventions in other cancer populations.28 Prolonged corticosteroid use decreases proximal muscle strength.37 Lower extremity muscle weakness may increase fall risk,62 and therefore, fracture risk63 within the MM population. Reducing fall risk through balance exercises and leg/hip muscle strengthening is therefore recommended for future exercise programming for MM.Secondary outcome results may indicate promise and warrant further investigation. The mean change in leg strength (30-s sit-to-stand score) was above the established minimally importance difference (MID) of >2 for older adults and clinical populations,17 Core and back extensor strengthening helps to improve dynamic balance64 and posture, reduce axial deformity and back pain,66 and prevent vertebral fractures in osteoporosis.67 The potential benefits of core exercises for improving back pain, posture, and fracture risk, as seen in osteoporosis research, support their inclusion within a myeloma-specific exercise program. However, these exercises should be individually tailored, focus on positioning, and minimize forces on the spine to lower the risk of adverse events and back pain exacerbations,38 as observed in this study.Although no MID is established for core endurance, the observed mean difference in pre- versus post-intervention plank duration of 41.6 s is promising. Core exercises are often neglected in exercise trials in MM.68 In the current study, a pre- versus post-intervention mean difference of +7.3 points was seen in FACT-MM, with the mean change in the emotional subscale achieving the established MID of 2 to 3.69 Total symptom burden did not improve in this study, but the program did not exacerbate symptoms. This is important because the control/maintenance of symptoms is a key exercise goal amongst those with advanced cancer.70 Symptoms of fatigue, bone pain, and neuropathy were measured in this study. The pre- versus post-intervention change in fatigue was below the MID threshold of 3.71 Improved fatigue has been observed in single group studies in MM72 but not in randomized control trials.18 To our knowledge, bone pain and neuropathy have not been outcomes in previous MM exercise trials. There is insufficient evidence on the effects of exercise on neuropathy and pain in cancer.7 Further research is warranted to discern the true effects of eHealth programming on overall symptom burden and the burden of specific symptoms/side effects  in people with MM.The MM population has a relatively low quality of life and high symptom burden.This study is not without limitations. First, without a control group, it is not possible to distinguish between the effect of the treatment and confounders. A single group design was chosen as the focus of this study was feasibility, given the novelty of the virtual delivery. Program effectiveness should be confirmed using a randomized controlled trial. Secondly, gold standard measures of physical function were not used. Valid/reliable virtual assessments were used instead to reach rural/remote participants and follow local COVID-19 public health measures. Thirdly, the sampling method employed in this study introduces referral/selection bias which impacts the generalizability of the results, as participants were likely motivated to exercise at enrollment. Finally, a strength of the program was the use of the HEAL-Me eHealth application to deliver the tailored exercise program. Leveraging the benefits of eHealth could improve access to specialist care for individuals with MM in lower-resource areas, including rural/remote communities.The 12-week virtually supported home exercise program was feasible for people with MM but associated with a higher than expected rate of musculoskeletal events, which may be due to the virtual nature of the program or the high proportion of individuals with bone disease included in the study. Programming should be individually tailored, and include supervision, active support, and well-trained personnel in order to manage the possibility of both serious and non-serious adverse events. A randomized controlled trial, with quality of life as a primary outcome, is warranted to determine the effects of the current exercise program. Additional clinically important outcomes including symptom burden, aerobic capacity, leg strength, core strength, and balance should also be explored.Click here for additional data file.Supplemental material, sj-docx-1-dhj-10.1177_20552076221129066 for Feasibility of a tailored and virtually supported home exercise program for people with multiple myeloma using a novel eHealth application by Graeme M. Purdy, Chris P. Venner, Puneeta Tandon and Margaret L. McNeely in Digital Health


Though motoric cognitive risk syndrome (MCR) share risk factors with disability, whether it predict disability remains understudied.This study aims to examine the association between MCR and incident disability.Longitudinal study.MCR was defined as subjective cognitive complaints and objective slow gait speed. Two subtypes of MCR were defined by whether memory impairment (MI) was also present, MCR-MI and MCR-non-MI. Incident activities of daily living (ADL) disability and instrumental activities of daily living (IADL) disability were outcome measures. Multiple logistic regression analysis was used to assess the independent effect of MCR at baseline on the odds of ADL/IADL disability at a 7 year follow-up.Among the subjects who were not disabled at baseline and followed for 7 years, 34.66% reported incident ADL disability, and 31.64% reported incident IADL disability. Compared with participants without MCR at baseline, those with MCR had 58% increased odds of incident ADL disability  and 46% increased odds of incident IADL disability  after 7 years. MCR-non-MI was associated with a 56.63% increased risk of ADL disability and a 34.73% increased risk of IADL disability. MCR-MI was associated with an even higher risk of IADL disability .MCR is an independent risk factor for both incident ADL and IADL disability. MCR-MI predicts a higher risk for disability than MCR-non-MI. Early identification of MCR among older adult is recommended and may decrease future risk of disability. MCR share risk factors with disability.MCR is an independent risk factor for both incident ADL and IADL disability.MCR participants are characterized as MCR-MI if having memory impairment or MCR-non-MI if there was no memory impairment.MCR-MI predicts a higher risk for IADL disability than MCR-non-MI.The unprecedented upward shift in life expectancy has increased the aging-related challenges faced by middle-income countries  and their spouses in China. The national baseline survey for CHARLS was conducted between June 2011 and March 2012, and samples were chosen through multi-stage stratified probability proportional to size (PPS) sampling ensuring that the baseline sample closely matched the 2010 census in terms of demographics. The final sample of 150 counties fell within 28 provinces. A total of 17,705 respondents were interviewed at the baseline survey in 2011 and were followed up every 2 years afterward using a face-to-face, computer-assisted personal interview (CAPI) technique. A more detailed description of CHARLS survey design can be found elsewhere  were younger than 60 years old; (2) lacked ADL data in 2011/2018 or had difficulty in ADL at baseline; (3) lacked IADL data in 2011/2018 or had difficulty in IADL at baseline; or (4) lacked MCR data at baseline. A total of 5,345 participants aged ≥ 60 years completed the follow-up survey in 2018: 1,832 participants lacking baseline MCR data were first excluded, and 1,759 participants diagnosed with ADL disability and 1,008 participants diagnosed with IADL disability at baseline were further excluded. Finally, 1,754 participants were included in the analysis for ADL disability, and 2,505 were included in the analysis for IADL disability. All participants provided written informed consent, and the ethics panel of the Ethical Review Committee approved this study. Disability was derived from the participants' reports of any difficulty in ADLs and IADLs and scaled. The ADL and IADL scales are the most commonly used disability assessment measures. The ADL scale used in CHARLS covers dressing, bathing, eating, getting in/out of bed, using the toilet, and controlling urination or defecation  if there was MI or MCR-non-MI if there was no MI . Information on chronic diseases, including any history of hypertension, diabetes, coronary heart disease, and stroke was self-reported.CHARLS questionnaire asked respondents about their participation in 11 social activities in the past month. If any of the options were selected, respondents were considered to have participated in social activities; otherwise, they were considered to not have participated in social activities. We constructed the variable of physical activity (PA) scores based on the International Physical Activity Questionnaire (IPAQ), including activities for exercise, entertainment, job demand, and other purposes. General questions about PA use in CHARLS questionnaire included the amount of time a person spent on different types of PA  in a usual week. According to the responses, we indexed the amount of physical activity in 1 day as 1 (<0.5 h); 2 (0.5–2 h); 3 (2–4 h); and 4 (>4 h). The score was calculated by multiplying the number of days and the daily PA duration index for each activity. Finally, we generated the variable of PA score using metabolic equivalent (MET) multipliers as follows: PA score = 8.0 × total vigorous activity weekly duration score + 4.0 × total moderate activity weekly duration score + 3.3 × total walking weekly duration score .The Wilcoxon rank-sum test for continuous variables and a chi-squared test for categorical variables were used as appropriate to assess when participants' baseline characteristics did and did not meet the criteria for each MCR subtype. Multiple logistic regression analysis was used to assess the independent effect of MCR at baseline on the odds of ADL/IADL disability at a 7 years follow-up in the sample population after adjustment for socioeconomic status, marital status, urban residence, educational level, baseline self-reported chronic diseases, and current smoking/drinking status. In addition, we repeated the analyses for MCR-MI and MCR-non-MI participants. We reported multivariate ORs from the logistical model along with the 95% confidence interval (CI). All reported p < 0.05): mean age (participants with MCR-MI were older compared to those with MCR-non-MI or without MCR), education , history of hypertension (a higher proportion of participants with MCR-MI had a history of hypertension), history of stroke (a higher proportion of participants with MCR-MI had a history of stroke), social participation , episodic memory scores (a lower mean scores of participants with MCR-MI than other subgroups) and gait speed .p < 0.05): mean age (participants with MCR-MI were older than those with MCR-non-MI or without MCR), education , depressive symptoms (a higher proportion of participants with MCR-MI had depressive symptoms), social participation , episodic memory scores (a lower mean scores of participants with MCR-MI than other subgroups) and gait speed .We found that MCR was significantly associated with an increased risk of ADL disability in the total population. MCR at baseline was associated with 58% increased odds of incident ADL disability  and 46% increased odds of incident IADL disability . We further analyzed the associations between subtypes of MCR with incident ADL/IADL disability and found that compared with healthy controls, participants with MCR-non-MI were associated with a 52.7% increased risk of ADL disability and with a 35.8% increased risk of IADL disability. Participants with MCR-MI were not significantly associated incident ADL disability, while associated with even higher incidence of IADL disability  compared with healthy controls.In this large, nationally representative sample of older Chinese adults, our study provided strong evidence that MCR could predict incident ADL/IADL disability in a non-disabled population. In addition, we found that MCR-MI was associated with a higher risk of future IADL disability than MCR-non-MI. Our results indicated that MCR could be used as a useful screening tool to identify individuals at high risk of incident disability.The disability prevalence on ADL/IADL shows associations with aging . They also reported that the co-occurrence of MCI and slow gait was related to a higher risk of disability compared with MCI or slow gait in another study .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


P. aeruginosa (MDRPA) has compromised the selection of appropriate treatment in critically ill patients. Recent investigations have shown the existence of MDRPA global clones that have been disseminated in hospitals worldwide. We aimed to describe the molecular epidemiology and genetic diversity of the MDRPA acquired by Intensive Care Units (ICU) patients in our hospital. We used phenotypic methods to define the MDRPA and molecular methods were used to illustrate the presence of carbapenemase encoding genes. To characterize the MDRPA isolates, we used MALDI-TOF biomarker peaks, O-antigen serotyping, and multi-locus sequence typing analyses. Our data show that the most widely distributed MDRPA clone in our ICU unit was the ST175 strain. These isolates were further investigated by the whole-genome sequencing technique to determine the resistome profile and phylogenetic relationships, which showed, as previously described, that the MDR profile was due to the intrinsic resistance mechanisms and not the carbapenemase encoding genes. In addition, this study suggests that the combination of environmental focus and cross-transmission are responsible for the spread of MDRPA clones within our ICU unit. Serotyping and MALDI-TOF analyses are useful tools for the early detection of the most prevalent MDRPA clones in our hospital. Using these methods, semi-directed treatments can be introduced at earlier stages and healthcare professionals can actively search for environmental foci as possible sources of outbreaks.The increasing number of infections from multidrug-resistant  Pseudomonas aeruginosa is a frequent source of hospital-acquired infections. These non-fermenting, gram-negative bacteria can cause severe infections in immunocompromised patients  and patients in Intensive Care Units (ICU) that may be associated with high rates of mortality. Given hospital environments, especially those with high rates of humidity, can act as a reservoir for P. aeruginosa [ruginosa ,2. TheseP. aeruginosa (MDRPA) has compromised the selection of appropriate treatments in critically ill patients, increasing morbidity and mortality in these patients. P. aeruginosa has a non-clonal population structure with a small number of widespread selected clones [Increasing amounts of infections from multidrug-resistant d clones . These cd clones . The detP. aeruginosa strains and to identify these HRCs. Pulse field gel electrophoresis (PFGE) is a method that represents the “gold standard”; it is a method with great technical complexity that requires a specialized technical staff. In the last few years, highly discriminatory and replicable molecular typing methods have been developed as a method for multi-locus sequence typing (MLST) [A variety of molecular methods have been used to type g (MLST) . HoweverRecently, a method using MALDI-TOF has been developed to identify HRCs in an accurate and quick manner . This meOver the recent years, whole-genome sequencing (WGS) has become an increasingly prevalent and cost-effective tool in microbiology laboratories. With new sequencing technologies and new bioinformatics analysis platforms, it has become feasible to perform WGS techniques and interpret their results with the help of less specialized personnel than had been previously required. WGS techniques provide great advantages in the molecular characterization of MDRPA by providing information about the resistome, molecular typing, and population structure.We aimed to describe the strain characterization of MDRPA that was acquired by ICU patients in our hospital by using different methods to develop specific control strategies and to help guide early antimicrobial therapy. Moreover, we used WGS techniques to perform an epidemiological analysis of a cohort of ST175 MDRPA that was isolated in our ICU unit. Additionally, we reported an MDRPA-presumed outbreak during this study, which we aimed to further investigate.The study was performed from January to December 2019. Patients that were admitted into the ICU in the Hospital Universitario de Navarra (HUN) during this period had perianal culture samples obtained at the time of ICU admission and once per week during their hospitalization. The samples were obtained as part of a Zero Resistance surveillance program, which attempts to look for multidrug-resistant microorganism carriers.We classified two patient types: (a) admission-positive patients that had positive cultures at the time of ICU admission for MDRPA; and (b) acquisition-positive patients that had negative cultures at the time of ICU admission but a subsequent positive culture for MDRPA.In response to an MDRPA outbreak in the ICU, we initiated a study in which swab samples from the ICU tap drains were additionally collected for the detection of MDRPA and carbapenemase-producing isolates.®CARBA SMART, bioMérieux, Marcy-l’Étoile, France; and CHROMID® ESBL, bioMérieux, Marcy-l’Étoile, France). Isolates suggestive of P. aeruginosa were identified with a MALDI-TOF analysis . Antimicrobial susceptibility tests were performed by disk diffusion tests according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines ). P. aeruginosa isolates were classified into non-resistant and multidrug-resistant (MDR) according to their antimicrobial susceptibility pattern and according to previously described criteria [Perianal surveillance swabs and tap drain samples were grown on selected chromogenic media  -The MLST method, as described previously in We characterized the MDRPA isolates by two typing methods:In all of the MDRPA isolates, we investigated the presence of 6911 and 7359 m/z peaks in the MALDI-TOF spectra. These two biomarker peaks can detect early ST175 HRCs as previously described in Cabrolier et al. (2015) and Mulet et al. (2019) [® CS, Version 1 . The application is based on reference-free approach with automated workflow (https://www.biomerieux-episeq.com/cs-how-it-works). In brief terms, it checks the quality of sequencing data and uses the open-source algorithm SPAdes for genome assembly [P. aeruginosa). We performed a wgMLST-based epidemiological analysis of the sequenced ST175 MDRPA using EPISEQ® CS application [® CS application constructs the matrix using both a similarity coefficient  between the samples and a clustering algorithm  [The MDRPA strain were identified as an ST175 clone and were analysed by the WGS technique, performed using the NEBNext Ultra II FS DNA Library Prep Kit  in an iSeq 100 instrument . The sequencing data were analysed with the easy-to-use, fully integrated web-based software application EPISEQassembly . Specieslication . We consgorithm) . We estaThe MDRPA isolated from perianal surveillance swabs and ICU tap drains that were suggestive of belonging to an outbreak and were epidemiologically related were sent to the National Microbiology Center  for further investigation by the PFGE and MLST techniques. All isolates were grown in Mueller–Hinton agar overnight. Once the PFGE-agarose blocks were performed, they were digested with BcuI, and the resulting fragments were separated by using electrophoresis in 1% agarose gels with the CHEF-DR II device  for 21 h, with switch times ranging from 5 s to 40 s in a Tris-borate ethylenediaminetetraacetic acid (TBE) buffer. Photographic images of the gels were digitally saved with the Geldoc EQ system . The DNA macrorestriction patterns were compared in order to determine band similarity, and they were interpreted according to the criteria established by Tenover et al.  for defiWe determined the acquisition route for patients who acquired an MDRPA strain based on the PFGE strain type and epidemiological relatedness.A representative isolate of each cluster was subjected to further investigation by the MLST and molecular methods to determine the presence of carbapenemase encoding genes.P. aeruginosa, of which 64 (25%) were MDRPA. From these MDRPAs, we randomly chose 30 isolates from 28 patients and studied them in further detail. The patients were categorized as follows: 3 patients (10.7%) that had positive cultures at the time of ICU admission and were classified as admission-positive patients; and 25 patients (89.3%) that we had obtained negative perianal cultures for MDRPA at the time of ICU admission, but a subsequent weekly culture that was positive for MDRPA; such patients were defined as acquisition-positive patients. The average number of days for the acquisition of MDRPA in our unit was 26.5 ± 5.55 days (a range of 7–78 days).Our cohort consisted of 1867 swabs with 255 isolated cases of In acquisition-positive patients, 27 MDRPA strains were isolated and characterized. Fifteen (55.6%) isolates were identified to be ST175 on the MLST test. All of them were of serogroup O4, had 6911 and 7359 m/z MALDI-TOF biomarkers peaks, and were not carbapenemase producers, despite their carbapenem-resistant phenotype. Two (7.4%) isolates were identified to be CC235 and showed positive agglutination with the O11 antisera. These isolates were carbapenem-resistant, but non-carbapenemase producers. Three (11.1%) isolates were identified to be ST253; they were VIM-2 carbapenemase producers and did not show agglutination with the O1, O4, O11, or O12 antisera. Seven (25.9%) isolates were genetically heterogeneous non-carbapenemase producers and did not agglutinate with the antisera .Eighth out of the fifteen ST175 MDRPA strains were further analysed by the WGS technique. We performed the MLST technique, resistome profiling, and epidemiological analysis. The WGS analysis confirmed MLST for ST175 in five isolates. The minimum spanning tree based on the allelic differences  showed tThe dendrogram reflected one cluster comprising four isolates that were probably related (Cluster 1 dendrogram), two isolates that were possibly related, and two isolates that were probably not related .The resistome analysis showed that isolates that were probably related presented the same resistome . No horiIn the context of a suspected ICU MDRPA outbreak, we sent 12 strains to the National Microbiology Center for PFGE testing: 8 strains were isolated from 7 ICU patients and 4 strains were isolated from ICU tap drains. The PFGE band patterns showed an epidemiologically complex situation. Cluster 1 comprised a predominant/major clone compound by four strains that were isolated from four patients and were non-carbapenemase producers, the ST175 strain and O4 serogroup. Cluster 2 was a minor-clone, and comprised VIM-2 carbapenemase ST253 strains isolated from two patients (two strains) and from one tap drain (one strain). Another minor-clone formed Cluster 3, and was formed by VIM-2 carbapenemase ST253 strains that were isolated from one patient (one strain) and from three tap drains (three strains). One MDRPA strain from a patient was a non-carbapenemase producer and genetically heterogeneous, therefore not genetically related and unable to be classified inside a PFGE cluster.P. aeruginosa in critically ill patients. None of the ST175 MDRPA isolates in this study were carbapenemase producers despite their carbapenem-resistant phenotype. No genes associated with carbapenemase production were detected by the in-house PCR tests. This finding was validated by the WGS analysis. The multidrug-resistant phenotype associated with the ST175 strain is mainly mutational [This study showed the strain characterization of MDRPA acquired by patients admitted to the ICU unit. Nearly 55% of the ICU MDRPA acquired were of the ST175 strain and showed positive agglutination with the O4 antigen. Our data are in agreement with a national Spanish multicentre study , which stational ,8, repreAccording to our data, 11.1% of MDRPA isolates belonged to the ST253 strain and were VIM-2 carbapenemase producers. The ST253 strain has a worldwide distribution, but it is not particularly associated with any resistance mechanism and it is therefore not considered one of the main HRCs. However, it has been acquiring resistance determinants, including metallo-beta-lactamases (MBL) in some hospitals; for instance, in Catalonia it is indeed associated with VIM-1 carbapenemase ,15. Our The ST235 strain is the most widely distributed HRC worldwide . The ST2P. aeruginosa were acquired during ICU hospitalization [Within this cohort, over 80% of the MDRPA isolated from patients admitted to our ICU unit was acquired intra-ICU. A previous study showed that almost 50% of the imipenem-resistant lization . Althouglization ,20,21,22In conclusion, due to the high prevalence of the ST175 MDRPA isolates in our local media, it is important to actively monitor for this HRC. O-antigen serotyping and MALDI-TOF are useful methods for the early detection of this clone. Using these techniques, semi-directed treatment can be introduced early. WGS analyses are becoming increasingly important in Microbiology Laboratories. Their implementation and the interpretation of their results using new, web-based informatics pipelines have been made progressively feasible.


Extracellular vesicles (EVs) are present in numerous peripheral bodily fluids and function in critical biological processes, including cell-to-cell communication. Most relevant to the present study, EVs contain microRNAs (miRNAs), and initial evidence from the field indicates that miRNAs detected in circulating EVs have been previously associated with mental health disorders. Here, we conducted an exploratory longitudinal and cross-sectional analysis of miRNA expression in serum EVs from adolescent participants. We analyzed data from a larger ongoing cohort study, evaluating 116 adolescent participants at two time points (wave 1 and wave 2) separated by three years. Two separate data analyses were employed: A cross-sectional analysis compared individuals diagnosed with Major Depressive Disorder (MDD), Anxiety disorders (ANX) and Attention deficit/Hyperactivity disorder (ADHD) with individuals without psychiatric diagnosis at each time point. A longitudinal analysis assessed changes in miRNA expression over time between four groups showing different diagnostic trajectories . Total EVs were isolated, characterized by size distribution and membrane proteins, and miRNAs were isolated and sequenced. We then selected differentially expressed miRNAs for target prediction and pathway enrichment analysis. In the longitudinal analysis, we did not observe any statistically significant results. In the cross-sectional analysis: in the ADHD group, we observed an upregulation of miR-328-3p at wave 1 only; in the MDD group, we observed a downregulation of miR-4433b-5p, miR-584-5p, miR-625-3p, miR-432-5p and miR-409-3p at wave 2 only; and in the ANX group, we observed a downregulation of miR-432-5p, miR-151a-5p and miR-584-5p in ANX cases at wave 2 only. Our results identified previously observed and novel differentially expressed miRNAs and their relationship with three mental health disorders. These data are consistent with the notion that these miRNAs might regulate the expression of genes associated with these traits in genome-wide association studies. The findings support the promise of continued identification of miRNAs contained within peripheral EVs as biomarkers for mental health disorders. Mental health disorders are among the 10 main causes of disability-adjusted life years (DALYs) globally. Depressive and anxiety disorders rank in fourth and sixth place as leading causes of disease burden in the global population between the ages of 10–24 years, and sixth and fifteenth in the population between the ages of 25-49 years 8552424) . This ge8552424) . A downrIt is worth noting that not all of our results were consistent with previous findings: miR-4433b-5p was previously observed to be upregulated in MDD patients in comparison with controls , while oWe observed no previous associations of miR-151a-5p and mental health disorders in the literature. This miRNA was downregulated in ANX in our study, and has the potential to be a molecular indicator for ANX that should be validated and further explored in further studies.We observed no statistically significant results in the longitudinal comparison. This may be due to a lack of statistical power to detect differences in the longitudinal design. It is important to note that there is a gap in the literature for longitudinal studies that analyze these conditions in youth while assessing EV-miRNA expression, and the results presented here may be used in future meta-analysis studies or as priors for Bayesian analyses.We followed methodology and data reporting recommendations from the International Society for Extracellular Vesicles , allowinHere, we presented a miRNA profile from serum EVs of adolescent participants with mental health disorders. The results identified numerous miRNAs, some consistent with previous studies and others novel to this study, that were associated with the presence of MDD, ANX and ADHD. Our data are largely consistent with previous findings in the literature that these miRNAs regulate genes involved in biological processes and regulatory mechanisms that have been previously implicated in these disorders. This work is relevant for identifying peripheral miRNAs associated with the establishment of mental health disorders, focusing on individuals during adolescence, a critical period for disorder development , and theSupplementary FiguresSupplementary Tables S1-S25


The SARS-CoV-2 targets were evaluated for a set of FDA-approved drugs using a combination of drug repositioning and rigorous computational modeling methodologies such as molecular docking and molecular dynamics (MD) simulations followed by binding free energy calculations. Six FDA-approved drugs including, Ouabain, Digitoxin, Digoxin, Proscillaridin, Salinomycin and Niclosamide with promising anti-SARS-CoV-2 activity were screened in silico against four SARS-CoV-2 proteins—papain-like protease (PLpro), RNA-dependent RNA polymerase (RdRp), SARS-CoV-2 main protease (Mpro), and adaptor-associated kinase 1 (AAK1)—in an attempt to define their promising targets. The applied computational techniques suggest that all the tested drugs exhibited excellent binding patterns with higher scores and stable complexes compared to the native protein cocrystallized inhibitors. Ouabain was suggested to act as a dual inhibitor for both PLpro and Mpro enzymes, while Digitoxin bonded perfectly to RdRp. In addition, Salinomycin targeted PLpro. Particularly, Niclosamide was found to target AAK1 with greater affinity compared to the reference drug. Our study provides comprehensive molecular-level insights for identifying or designing novel anti-COVID-19 drugs. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the well-known coronavirus disease of 2019, COVID-19 . It has The global research and clinical communities have been under tremendous pressure to produce treatments to battle the ever-growing pandemic since the outbreak of the unique COVID-19 disease. However, drug development can take several years and there is no certainty that it will be completed successfully. Furthermore, with the existing drug production or application method, this cannot be done, and it takes several years for newly approved drugs to reach the market. Instead, SARS-CoV-2 infection could be treated with existing drugs. When it comes to developing new drugs/vaccines or repurposing approved ones, detailed information on the possible target(s) is essential . Since the start of the pandemic, scientists have been working on developing vaccinations against SARS-CoV-2. As of July 2021, the WHO had approved 14 vaccinations under the Emergency Use Listing (EUL), with many more on the waiting list. Although all the licensed vaccinations have proven to be rather effective up to this point, the emergence of new strains due to rapid virus mutations poses a significant imminent danger to vaccine efficacy. Various routes are being targeted to limit viral replication inside human cells, and studies are being conducted to understand the complexities of how the virus affects the human body .Potential anti-coronavirus drugs can be divided into two categories based on the target: One targets the human immune system or human cells, while the other targets the coronavirus itself. The innate immune system response is critical in suppressing coronavirus replication and infection in the human immune system, and interferon is believed to improve the immune response . FurtherBecause there is a pressing need to treat the disease, most research is focusing on repurposing already approved drugs rather than classical drug discovery. Remdesivir was the first of all the COVID-19 drugs to be approved for hospitalized patients by the US Food and Drug Administration (FDA). The concept of drug repositioning, also known as drug repurposing, drug reprofiling, and therapeutic switching, has gained considerable attention from pharmaceutical companies and researchers due to its potential to discover new uses for approved drugs . CompareSince the outbreak started, a flood of computational articles identifying potential antiviral drug repurposing candidates has appeared in peer-reviewed journals and preprint services, but most of them lack experimental confirmation ,21,22,23A public health emergency with regard to COVID-19 in all countries and efforts to develop an effective vaccine or drug for prevention or treatment are critical. New compound approval as a drug necessitates a lengthy investigation period and a considerable financial investment. So, the best starting point is repurposing already approved drugs when developing novel COVID-19 therapeutics. We virtually reprofiled drugs against multiple SARS-CoV-2 targets, including SARS-CoV-2 Mpro, PLpro, and RdRp, in addition to AAK1 as a human target.50 less than 2.5 μM) FDA-approved drugs that showed antiviral activity compared to the clinically applied drugs Chloroquine, Remdesivir, and Lopinavir . The current study tried to find the potential target for each drug against SARS-CoV-2 through virtual screening. The included drugs are currently on the market and some are in clinical trials against SARS-CoV-2 infections. The drugs that are currently in clinical studies were given special consideration. The drugs’ generic name, clinical use, and reported activity against SARS-CoV-2 (IC50 μM) are presented in Previously, Meehyun Ko et al. tested a total of 24 FDA-approved drugs against SARS-CoV-2 in Vero cells and Calu3 cells—a well-known human lung cell line—as potential antiviral candidates . For deeThe structures of four SARS-CoV-2 proteins (macromolecules) and antiviral drugs (ligands) were retrieved and optimized for the docking simulation to investigate the binding preference between the protein binding pocket residues and ligands. The molecular docking resulted in ten different docked poses for each drug. Each drug’s optimal pose was chosen based on how closely its binding pattern in the active pocket matched that of the original ligand, taking into consideration the binding energy. Accordingly, the drugs under investigation were scored, with the top scorers being those with the lowest binding energy. For each ligand, the complex with the best-predicted affinity energy (AE) was used for the MD simulations.In this research, the docking efficacy of six FDA-approved drugs previously tested against SARS-CoV-2  against The repositioned drug with the highest score for each investigated target was selected. Ouabain (OUB) showed the greatest affinity for SARS-CoV-2 Mpro and PLpro  contrasted to the enzyme native ligand X77 and GRM , respectively. DGX and DIG showed AEs comparable to RdRp with binding energy  compared to cocrystallized ligand Remdesivir (RDV) which revealed AE equal to −7.8 Kcal/mol. Salinomycin (SLM) showed binding affinity for PLpro  compared to cocrystallized ligand GRM . Niclosamide (NIS) showed excellent interaction and binding affinity  for the AAK1 system in comparison to its cocrystallized ligand LKB . Finally, Proscillaridin (PRO) showed optimum binding affinity for RdRp .Molecular docking is a powerful approach for evaluating binding affinity and investigating the binding pattern of ligands that bind to the active region of target proteins . The mosAlthough molecular docking may shed light on repurposing drug protocols , their uHere, MD simulation calculations were conducted to understand the structural stability of some favorable docking results. We can summarize it as (i) PLpro–GRM, PLpro–OUB, and PLpro–SLM systems; (ii) Mpro–X77 and Mpro–OUB systems; (iii) RdRp–RDV and RdRp–DIG systems; (iv) AAK1–LKB and AAK1–NIS systems. Initially, The RMSD analysis from the 200 ns of MD trajectories were explored to examine flexibility across the simulation periods.50 values of all the tested drugs.PLpro is an essential aspect of the replicase–transcriptase complex as a nonstructural protein 3 (NSP3). By releasing NSP1–3 from the viral polyprotein, which is required for viral replication, human proteases with a comparable cleavage selectivity can be known, and inhibitors of that enzyme are unlikely to be harmful . The comStreptomyces albus produces Salinomycin (SLM), a carboxylic polyether ionophore. Ionophores have a wide range of bioactivity, including antibacterial, antifungal, antiparasitic, antiviral, and, more recently, anti-tumor properties [50 compared to the control drugs. This activity may be attributed to the SLM binding affinity for PLpro, as manifested from the docking simulation. SLM is connected to key PLpro residues through three hydrogen bonds  and Mpro–OUB (repurposed system) were submitted to 200 ns production MD simulations. For the RMSD analysis A, the vaNatural cardiac glycosides, such as Digoxin, Digitoxin, and Proscillaridin, can be utilized to treat congestive heart failure and cardiac arrhythmia. The virtual screening of our selected drugs indicated the affinity of these drugs for SARS-CoV-2 RNA-dependent RNA polymerase (RdRp) (PDB code: 7BV2). The RdRp enzyme allows the viral genome to be transcribed into new RNA copies using the host cell’s machinery . RdRp isRecently, MD simulation studies for RdRp have been carried out using RDV as a bound inhibitor ,41. PartNiclosamide (NIS) is an antiparasitic drug that prevents the tapeworm from absorbing glucose, as well as preventing oxidative phosphorylation and anaerobic metabolism . In compThe structural analysis for the AAK1 systems by considering the RMSD and RMSF calculations for AAK1–LKB  and AAK1–NIS (repurposed) systems suggested that they were more structurally stable than the previous simulated systems. The RMSD values A for AAKMMPBSA.py [As described in the Material and Methods section, relative binding free energies for all simulated systems were computed using the MM/GBSA approach ,47,48 asMPBSA.py  and are 50 values in Vero and Calu cells  bind to the catalytic site of AKK1 with a similar binding affinity trend.https://pubchem.ncbi.nlm.nih.gov/ (accessed on 4 January 2022)) [The PubChem database (y 2022))   ,52, the Before docking, native ligands in the active region of the active domains were re-docked to verify the docking process, which resulted in a docking pose with certain RMSD values. For the SARS-CoV-2 Mpro, PLpro, RdRp, and AAK1, and their respective cocrystallized ligands, the computed RMSD values were 1.483, 0.665, 0.883, and 0.321 Å, respectively. The validated docking methodologies were then utilized to investigate the ligand–protein interactions of the tested drugs at the target active site to anticipate their binding mode. The measured RMSD values of the tested drugs indicated the efficiency and validity of the docking process.The molecular modeling simulations were performed using the Molecular Operating Environment  software. With the MMFF94x force field, all minimizations were carried out with MOE until an RMSD gradient of 0.05 Kcal/mol was reached, and the partial charges were calculated automatically. Three viral SARS-CoV-2 proteins: (i) The SARS-CoV-2 Mpro , (ii) PLpro  , (iii) RThe generated ligand conformations were docked using a validated docking methodology, and the Triangle Matcher placement method was used and scored based on London dG. The top best 50 poses were refined, and the energy was minimized in the binding site using the induced fit method and then reranked with the GBVI/WSA scoring function . In all As a powerful tool to avail in silico, the stability of the above-repurposed systems, classical molecular dynamics (MD) simulations were carried out by using the PMEMD module  of the AEach solvated system was energetically minimized to avoid bad atomic contacts using the PMEMD module. The minimization was carried out in four successive stages by applying 5000 steepest descent steps followed by 5000 steps of the conjugate gradient method, where restraints were removed during the process. After successful minimization, each system was slowly heated up to 300 K over 100 ps under constant volume, where the solute was restricted with the positional restraints of 50 Kcal/mol·Å2. Next, maintaining the same solute restraints, 200 ps of MD was performed at the NPT ensemble (p = 1 atm and T = 298 K). Then, the force constant of the restraints was slowly removed over the eight stages of equilibration; each stage was carried out for 100 ps under the NPT ensemble. Finally, a 200 ns unrestrained MD simulation (named “production stage”) was performed for each equilibrated system. The SHAKE algorithm  with theThe structural analysis of all the simulated systems was evaluated by computing the root mean square deviation (RMSD) and root mean square fluctuation (RMSF) of the backbone atoms . Particularly, the RMSD calculations for each ligand were computed by considering only their respective heavy atoms. The trajectories were aligned by the main-chain atoms of the average structures from production stages by using the CPPTRAJ module .MMPBSA.py module [The CPPTRAJ module  was usedy module  of Amberulations ,48. Furtulations . This meulations ,74,75,76A set of comprehensive docking approaches and molecular dynamics simulations were performed to find viable drugs for inhibiting SARS-CoV-2 targets. Accordingly, based on docking and the MD simulation results, Digitoxin was postulated as an effective RNA-dependent RNA polymerase inhibitor compared to Remdesivir as a known inhibitor. It was concluded that Salinomycin may act as a PLpro inhibitor, while Ouabain can share the activity with Salinomycin and Proscillaridin as a dual inhibitor of both PLpro and Mpro SARS-CoV-2, respectively. In addition, Niclosamide was proposed to be an inhibitor for adaptor-associated kinase 1. The insights provided by the present study may substantiate the valuable exploration and development of anti-SARS-CoV-2 therapeutic agents from FDA-approved drugs, to be used as leads for further drug development. Furthermore, drug repositioning can be considered an efficient tool as a source of new analogs to help defeat COVID-19.