The risk of EV progression was strongly correlated with the presence of baseline EV (p < 0.001). To the best of our knowledge, this is the first study to demonstrate that DAA-induced SVR is associated with decreased risk of de novo EV occurrence and progression in the real world.The real-world benefits of direct-acting antiviral (DAA)-induced sustained virologic response (SVR) on the de novo occurrence and progression of esophageal varices (EV) remain unclear in patients with hepatitis C virus (HCV)-related liver cirrhosis (LC). This is a retrospective cohort study evaluating all patients with Child-Pugh class A HCV-related LC during 2013 to 2020 in the Chang Gung Medical System. A total of 215 patients fit the inclusion criteria and were enrolled. Of them, 132 (61.4%) patients achieved DAA induced-SVR and 83 (38.6%) did not receive anti-viral treatment. During a median follow-up of 18.4  months, the 2-year incidence of de novo EV occurrence was 8 (7.0%) in the SVR group and 7 (12.7%) in the treatment-naïve group. Compared to the treatment-naïve group, the SVR group was associated with a significantly lower incidence of EV occurrence (adjusted hazard ratio [aHR]: 0.47,  The natural history of patients with hepatitis C virus (HCV)-related compensated liver cirrhosis is now well characterized . About 2Predicting the development, bleeding, and mortality of EV in patients with cirrhosis is a key concern in clinical practice. It is well established that sustained virologic response (SVR) after interferon (IFN)-based anti-HCV treatment can prevent de novo EV development in patients with HCV-induced cirrhosis . Since 2The present retrospective cohort study, from January 2013 to December 2020, consists of a subgroup analysis based on electronic medical records obtained from the Chang Gung Research Database (CGRD), which is a de-identified and anonymous database . The infA total of 5606 patients with HCV-related liver cirrhosis were enrolled. We excluded patients with confounding factors, including 567 patients with HBV co-infection, 50 patients with HIV co-infection, 447 patients with alcoholism, 1542 patients with a history of HCC/CCC, and 196 patients who underwent previous EVL/EIS treatment. We also excluded 2483 patients without a record of esophago-gastro-duodenoscopy (EGD) prior to inclusion, 54 patients with enlarged EV, 521 patients without follow-up data to evaluate de novo occurrence and progression of EV, 84 patients without a complete MELD score, and 11 patients without SVR in the DAA group .The present study only considered patients who had undergone endoscopy prior to the time of enrollment (within 6 months) and were found to be EV-free or display a F1 degree of severity (grade 1 EV). Patients with EV severity of F2 or worse were excluded. Endoscopic procedures for EV assessment were performed by skilled endoscopists, and EV size was determined via medium insufflation and classified according to the North Italian Endoscopic Club score .Retrospective endoscopic observation for EV was logged according to the following definitions. EV occurrence was defined as the development of EV in previously EV-free (F0) patients. EV progression was defined as the occurrence of F1~F3 EV in previously F0 patients, the occurrence of F2~F3 EV in previously F1 patients, or the onset of portal hypertension (PHT)-related bleeding episodes.Designation of patients in the DAA group to receive anti-HCV treatment was determined at the discretion of the treating physician on the basis of the labels approved by the Taiwan Food and Drug Administration and in compliance with the standard of care recommended by international guidelines for HCV infection . SVR is We considered inverse probability of treatment weighting (IPTW) with propensity score to estimate treatment efficacy in this study . The IPTp-values are two-sided with p < 0.05 taken as statistically significant. All analyses were performed using SAS version 9.4 .The incidence and progression of varices were visualized as Kaplan-Meier plots. Baseline demographic, clinical, and biochemical parameters, as well as ultrasonographic and endoscopic findings, were analyzed as possible predictors of study endpoints. Multivariate analyses were conducted using a Cox proportional hazards regression model. Results are presented as the adjusted hazard ratio (aHR) with the accompanying 95% confidence interval (CI) after adjustment for potential confounding factors. As demonstrated in p = 0.030), MELD score , and female gender  were significantly associated with the occurrence of EV (As shown in ce of EV . Neitherp = 0.033), baseline EV of grade F1 (vs. F0) , female gender , arterial hypertension , and diabetes  were significantly associated with EV progression (As shown in gression . Neitherp = 0.050).The cumulative probabilities of EV progression according to endoscopic findings at inclusion and the achievement of viral suppression (DAA induced SVR) are shown in This real-world multicenter retrospective study is based on a cohort of patients with HCV-related early cirrhosis who had received DAAs treatment or not. According to methods for comparative effectiveness, we used our observational data to emulate a hypothetical randomized trial by comparing DAA-exposed versus DAA-unexposed patients . Its resDAAs are accepted as the standard of HCV care by many clinicians . TherefoThe natural development and progression of EV are affected by many clinical factors such as the initial variceal status, EV ligation history, alcoholism, HBV or HIV coinfection, and hepatocellular carcinoma. We herein excluded these confounding factors to estimate causality due to treatment in this observational study. Other factors that may be involved in the development of EV, such as HCV genotype 1b , MELD scIn patients with pre-treatment cirrhosis, HCV eradication with SVR may stop progression or even induce regression of the fibrosis spontaneously, leading to improved portal hypertension and lower risk of variceal bleeding . Savino p = 0.006), but not with EV progression (p = 0.299).The baseline MELD score was also an independent predictor of EV, which was noted by Bruno et al.  SimilarlSanyal et al. reported that the risk of having varices increases with decreasing platelet counts . In our DAA-induced SVR reduced the risk of EV bleeding in HCV-related liver cirrhosis patients in one clinical study . Our stup = 0.010) and arterial hypertension  have significant correlation with EV progression, but not EV occurrence. Morbidities of other metabolic syndromes such as obesity and dyslipidemia had no significant correlation with EV occurrence or progression.Besides SVR, metabolic syndrome also affects the natural history of PHT in cirrhosis . In the p < 0.001) in this study. Khan et al. reported that women display a significantly different EV bleeding rate after particular treatment [Female gender correlated significantly with de novo EV occurrence and progression (reatment . The posreatment . Pregnanreatment .p = 0.051), which may be because patients with high-risk varices  tend to also receive NSBBs. Conversely, NSBBs can not only be used to prevent variceal bleeding, but also to treat arterial hypertension, angina, tremor, and migraine; therefore, they are not considered specific enough. Hence, the use of NSBBs may be a potential confounder.According to the 2016 practice guidance about portal hypertensive bleeding in cirrhosis by the American Association for the Study of Liver Diseases (AASLD) , there ip > 0.05). Third, each modality for evaluating liver cirrhosis has particular shortcomings.There are some limitations of this study. First, this is a study from Taiwan, where genotypes 4 and 5 are rare. Second, clinical data were not complete in this retrospective study and a majority of patients were therefore excluded. According to the flow chart , most ofDespite early cirrhosis, SVR after DAAs significantly reduced the de novo occurrence and progression of EV during the short-term 24-month period study. In clinical practice, frequent EGD observation may be avoided in SVR patients. This study provides further evidence supporting the real-world benefits of early DAA treatment in HCV-positive patients with cirrhosis of the liver.


Four-hydroxynonenal (4-HNE) exerts a central role in the pathophysiological process of pulmonary diseases. The aim of this project was to evaluate the correlations between serum 4-HNE with severity and prognosis in patients with community-acquired pneumonia (CAP) by a prospective cohort study.A total of 239 patients with CAP and healthy volunteers were recruited. Fasting blood was collected. Serum 4-HNE was measured with ELISA. Clinical characteristics and demographic information were obtained. The relationships between serum 4-HNE and clinical characteristics were evaluated through the Spearman or Pearson correlation coefficient. The associations of serum 4-HNE with severity and prognosis were estimated through logistic regression analysis.On admission, serum 4-HNE was upregulated in patients with CAP compared with healthy volunteers. Serum 4-HNE was gradually increased in line with CAP scores. Additionally, elderly patients with CAP were more prone to suffer from 4-HNE elevation. Moreover, serum 4-HNE was positively correlated with CAP severity scores. Meanwhile, the poor prognostic outcomes were tracked among patients with CAP. Higher serum 4-HNE on admission increased the risks of mechanical ventilation, vasoactive agent usage, and death in patients with CAP during hospitalization. The predictive powers for severity and death were increased in serum 4-HNE compared with CAP severity scores and inflammatory cytokines.Serum 4-HNE on admission is positively correlated with the severity and poor prognosis among patients with CAP, indicating that 4-HNE participates in the pathophysiology of CAP. Serum 4-HNE may be used as an earlier biomarker for diagnosis and prognosis in patients with CAP. Community-acquired pneumonia (CAP) is one of the most pervasive fatal infectious diseases. Epidemiological studies revealed that CAP has caused three million deaths across the world, one million deaths in Asia, and six hundred thousand hospitalizations of geriatric patients in the United States every year –4. PneumIt is widely realized that the excessive production of reactive oxygen species (ROS) can evoke oxidative stress and cellular damage , 11. ROSHowever, the function of 4-HNE in patients with CAP is unclear at present. In addition, the relationships of serum 4-HNE with severity scores and prognostic outcomes were not uncertain in patients with CAP. We conjectured that 4-HNE may exert a significant role in the process of CAP. Therefore, serum 4-HNE was detected in the different graded patients. The relationships of serum 4-HNE with the severity and prognosis were evaluated in patients with CAP through a prospective cohort study.9 L or less than 4 × 109L  a new patchy infiltrate, leaf or segment consolidation, ground-glass opacity, or interstitial change were observed through a chest radiograph; (II) all patients had CAP in the community rather than in the hospital; and (III) at least one of the following signs was observed in patients: coughing, sputum production, and dyspnea occurred; core body temperature was higher than 38.0°C; abnormal breath sounds and rales were observed on auscultation; and the number of white blood cells (WBCs) was greater than 10 × 104 × 109L . Additio4 × 109L . In addig/min and serum samples were obtained (via enzyme-linked immunosorbent assay (ELISA) as we have described previously  area under the curve (AUC). Statistical significance was regarded as p < 0.05.Statistical analyses were conducted In this study, baseline information was compared and analyzed. As shown in Serum 4-HNE was determined among all participators through ELISA. As shown in OR] of age was 1.057 , the OR of being a smoker was 1.102 , and the OR of systolic pressure was 1.016  among patients with CAP  , systolic pressure, diastolic pressure, diabetes, cerebral infarction, hypertension, bronchitis, and coronary heart disease on serum 4-HNE levels among patients with CAP was observed. The odds ratio [with CAP . Althoug, 1.389) .The relationships between serum 4-HNE and routine blood indicators were evaluated among patients with CAP. As shown in The relationships between serum 4-HNE and CAP severity scores were analyzed through linear regression. Age was adjusted in the different regression models. We found that serum 4-HNE was positively related to CURB-65, CRB-65, CURXO (severe), SMART-COP, and APACHE II in patients with CAP . For theThe effect of 4-HNE elevation on admission on the prognosis was evaluated in patients with CAP using logistic regression. As expressed in The predictive powers for severity were estimated between serum 4-HNE and different clinical characteristics among patients with CAP through the ROC AUC. As shown in This project estimated the relationships of serum 4-HNE with severity and prognosis among patients with CAP. This project mainly revealed that: (1) serum 4-HNE was upregulated in patients with CAP in comparison with healthy participants; (2) serum 4-HNE gradually increased in line with CAP scores; (3) elderly patients with CAP were more susceptible to suffering from serum 4-HNE elevation; (4) serum 4-HNE was positively associated with CAP severity scores; (5) higher serum 4-HNE at the early stage increased the risk of mechanical ventilation, vasoactive agent usage, and death during hospitalization; and (6) predictive capacities for severity and death were higher in serum 4-HNE compared with known CAP severity scores and inflammatory cytokines.Four-hydroxynonenal is one reactive breakdown product of the lipid peroxides , 13. PreMounting data have demonstrated that multiple organ injury is observed in the process of CAP , 34. In Former studies have demonstrated that the markers of oxidative stress have the predictive capacity of diseases’ prognosis. Excessive oxidative stress always indicates a bad prognosis in patients with cerebral malaria . 8-IsoprA ROC curve was analyzed to explore the application of detecting serum 4-HNE in CAP management. The results found that though there were similar predictive powers for severity between serum 4-HNE and CAP severity scores, the predictive capacities for severity and death were significantly increased compared with inflammatory cytokines among patients with CAP. In addition, the predictive capacities for death were higher in serum 4-HNE than those in many known CAP severity scores. Therefore, serum 4-HNE may be regarded as a diagnostic and prognostic biomarker for severity and prognosis in patients with CAP. On admission, when the concentration of serum 4-HNE was higher than 1,063.7 pg/ml, the risk of critically ill patients with CAP was remarkedly increased. Additionally, once the content of serum 4-HNE was more than 1,308.5 pg/ml, the risk of death was significantly increased during hospitalization. Consequently, serum 4-HNE detection can indicate partial CAP patients with higher serum 4-HNE need more medical attention, earlier therapy, and intervention. It is helpful to reduce the death risk of critically ill patients with CAP.In vivo and in vitro studies are favorable to clear up this confusion in patients with CAP.This study mainly assessed the relationships between serum 4-HNE on admission with severity and prognosis among patients with CAP. This research enhanced the understanding of 4-HNE in CAP. Nevertheless, there are several defects in this study. First, this research just had a modest sample size from one hospital in China. So, the generalizability of these conclusions may be limited. Second, only the circulatory level of 4-HNE was measured in patients with CAP. The local expression of 4-HNE in the lungs was unclear. Maybe, the level of pulmonary 4-HNE is more convincing and better in patients with CAP. Third, this was a longitudinal study. Therefore, the mechanism of 4-HNE elevation remained unknown in patients with CAP. Taken together, this research mainly found that serum 4-HNE is upregulated in patients with CAP. Elderly patients with CAP are more prone to suffer from 4-HNE elevation in serum. Serum 4-HNE is positively related to severity and poor prognosis among patients with CAP. The level of serum 4-HNE on admission has stronger predictive capacities for severity and death than those in many known CAP severity scores and inflammatory cytokines, demonstrating that 4-HNE exerts important roles in the pathophysiology of CAP. Our results provide evidence that serum 4-HNE may be used as an early biomarker for diagnosis and prognosis among patients with CAP.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of the Bozhou People’s Hospital (2021-10). The patients/participants provided their written informed consent to participate in this study.LF and HZ contributed to the design of the study, funding support, statistical analyses, and drafting of the manuscript. Y-LJ, M-MT, H-YL, and J-YC contributed to sample collection, data interpretation, recruiting patients, and obtaining their written informed consent. All authors have read carefully 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. The reviewer C-MF declared a shared affiliation with the authors to the handling editor at the time of review.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.


Gut microbiota-derived metabolites have recently attracted considerable attention due to their role in host-microbial crosstalk and their link with cardiovascular health. The MEDLINE-PubMed and Elsevier’s Scopus databases were searched up to June 2022 for studies evaluating the association of baseline circulating levels of trimethylamine N-oxide (TMAO), secondary bile acids, short-chain fatty acids (SCFAs), branched-chain amino acids (BCAAs), tryptophan and indole derivatives, with risk of cardiovascular disease (CVD). A total of twenty-one studies were included in the systematic review after evaluating 1210 non-duplicate records. There were nineteen of the twenty-one studies that were cohort studies and two studies had a nested case–control design. All of the included studies were of high quality according to the “Newcastle–Ottawa Scale”. TMAO was positively associated with adverse cardiovascular events and CVD/all-cause mortality in some, but not all of the included studies. Bile acids were associated with atrial fibrillation and CVD/all-cause mortality, but not with CVD. Positive associations were found between BCAAs and CVD, and between indole derivatives and major adverse cardiovascular events, while a negative association was reported between tryptophan and all-cause mortality. No studies examining the relationship between SCFAs and CVD risk were identified. Evidence from prospective studies included in the systematic review supports a role of microbial metabolites in CVD. Cardiovascular disease (CVD) remains a major public health issue . The proGut microbiota-derived metabolites like trimethylamine N-oxide (TMAO), secondary bile acids, short-chain fatty acids (SCFAs), branched-chain amino acids (BCAAs), tryptophan and indole derivatives have recently attracted considerable attention due to their role in host-microbial crosstalk ,6 and thGut microbiota-derived metabolites are produced from bacterial metabolism of dietary substrates, modification of host molecules, such as bile acids, or directly from bacteria . Summarihttp://www.prisma-statement.org/ (accessed on 2 February 2022) ) and coronary revascularization  .In the Wang et al. study, 136 patients with HF and 51 participants without HF were followed for a mean of 2.3 years and 35 of them had a composite event of death or HF-related re-hospitalization . In the Eleven of the included studies in this systematic review  examinedIn a very recent study by Amrein et al., higher TMAO concentrations were associated with all-cause mortality  but not CVD-mortality (HR 1.11 [95% CI 0.99–1.26]) .Significant associations were also reported lately in a large cohort of 5331 participants. During 13.2 years, 4791 deaths were recorded and after adjusting for many potential confounders increased plasma levels of TMAO were associated with an increased risk of all-cause mortality (HR 1.30 [95% CI 1.17–1.44]) .In the Winther et al. study after a median follow-up of 6.8 years and 6.5 years, 106 total deaths and 44 CVD deaths were reported, respectively . No signIn contrast, Ringel et al. investigated associations of plasma TMAO with short- (30 days) and long-term (9 years) all-cause mortality in three independent cohorts of 1666 patients with stable atherosclerotic CVD (449 patients with CVD in a cohort of 904 patients), acute MI (326 patients), cardiogenic shock (436 patients), and T2D  . After 1Finally, Roncal et al. determined TMAO in plasma using MS in 262 patients with symptomatic PAD who were followed for a mean period of 4 years . During Yu et al. analyzed 204 serum metabolites in 1887 African Americans from the ARIC Study using MS techniques . During Significant results were also obtained for the relationship between deoxycholic acid and all-cause mortality (HR 2.13 [95% CI 1.25–3.64]) in patients with chronic kidney disease .On the other hand, Huang et al. analyzed data from the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study Cohort of 620 men free of CVD, who were followed for 28 years. Of the 406 metabolites quantified in serum using MS techniques no significant associations of the ten secondary bile acids analyzed with CVD or all-cause mortality were observed .No significant associations between three secondary bile acids and all-cause mortality were also reported in an earlier study by Cheng et al. among 2327 participants free of CVD .Balasubramanian et al. used two datasets created from the Women’s Health Initiative study consisting of 943 subjects  and 1355 subjects  free of CVD . Of the This systematic review summarized the evidence of the associations between circulating microbial-related metabolite levels and risk of CVD. Associations of TMAO and subsequent risk of CV outcomes were supported by some ,20,22 buIn recent years, several systematic reviews of prospective studies have suggested that TMAO is an independent risk factor for CVD ,15,16,17Our updated systematic review included a total of 11 individual studies that examined the associations of TMAO with CV outcomes. Among them, four outcomes  were found to be positively associated with TMAO levels in some but not all of the included studies. In three previous meta-analyses of 19, , 11 12]12] and 1The findings of the present review confirm previous findings of a former systematic review on the strong positive prospective associations between BCAAs and CVD risk . In TobiPotential mechanisms explaining the relationship between elevated BCAAs levels and risk of CVD include activation of the mammalian target of rapamycin (mTOR) signaling, which leads to exacerbated cardiac dysfunction, and remodeling in myocardial infarction .To our knowledge, this is the first systematic review of secondary bile acids in relation to CVD risk. Inconsistent results were obtained for these relationships. No significant results were shown for total CVD ,34, wherIn our systematic review tryptophan was inversely associated with all-cause mortality  . TryptopOf indole derivatives, indoxyl sulfate is a protein-binding molecule that exhibits CV toxicity and in our systematic review was associated with risk of MACE in CKD patients . Some prAltered circulating SCFA profiles may be related to several metabolic conditions. SCFA are produced in the gut by the metabolic activity of the intestinal microbiota as catabolic end-products from the fermentation of undigested dietary components, mainly complex carbohydrates. Although studies have focused on different clinical conditions, evidence on the role of these mediators in CVD is lacking .To the best of our knowledge, this systematic review provided the most comprehensive evidence on the associations of microbial metabolites with risk of several CV outcomes. Focusing on prospective studies allowed us to limit the influence of reverse causality and selection bias, and all of the included studies were evaluated to be of high quality, as assessed with the “Newcastle–Ottawa Scale”.There are several limitations to be considered. First, the lack of studies on SCFAs limited conclusions about the role of main metabolites produced by intestinal bacteria in CVD and this is an area that needs development. Second, due to the observational nature of the studies included in the review, potential causal mechanisms underlying the above associations cannot be inferred. Third, confounder adjustment differed across the studies, which may have resulted in different associations between metabolites such as TMAO or bile acids and CV outcomes. Fourth, we were unable to conduct a meta-analysis, mainly because of the heterogeneity of the included articles. Differences in metabolite targets, characteristics of the study populations and differential reporting of associations could increase the possibility the results of the meta-analysis not to be useful and meaningful.In conclusion, our systematic review summarized the evidence on the associations of gut microbiota-derived metabolites with CV outcomes and showed inconsistent results for TMAO and bile acids but robust ones for the relationships between BCAAs and CVD. There are still a small number of longitudinal studies assessing the association of tryptophan and indole derivatives with the risk of CV outcomes. Further studies are needed to investigate whether circulating microbial metabolites could be an intervention target for CVD.


Middle-aged adults (40-65 years) report higher stress levels than most other age groups. There is a need to determine the feasibility of using a meditation app to reduce stress and improve stress-related outcomes in middle-aged adults with a focus on men, as previous meditation app–based studies have reported a low proportion of or even no male participants.This study aims to (1) determine the feasibility  of a consumer-based meditation app , to reduce stress among middle-aged adults reporting elevated stress levels, and (2) explore the preliminary effects of Calm on perceived stress, psychological outcomes , health behaviors , and COVID-19 perceptions.This feasibility randomized controlled trial evaluated an app-based meditation intervention in middle-aged adults (N=83) with elevated stress levels  and limited or no previous experience with meditation. Participants were randomized to the intervention group  or a control  group. Participants completed self-report assessments at baseline and postintervention (week 4). Feasibility was measured as acceptability and demand using Bowen framework. Feasibility and COVID-19 perceptions data were examined using descriptive statistics, and preliminary effects were evaluated using repeated measures analysis of variance.Participants were satisfied with Calm  and found it appropriate or useful . Most reported they would likely continue using the Calm app . More Calm users reported satisfaction, appropriateness or usefulness, and intent to continue app use than POD users. Calm users (n=33) completed a mean of 20 (SD 31.1) minutes of meditation on the days they meditated and 103 (SD 109.1) minutes of meditation per week. The average adherence rate to the prescribed meditation was 71% among Calm app users, compared to 62% among POD users. Recruitment rate of men was 35% (29/83). Of those randomized to Calm, 55% (15/29) were men, and retention among them was higher  than that among women . No significant within or between group differences were observed.A 4-week, app-based mindfulness meditation intervention  may be feasible for middle-aged adults and a useful stress-management tool. Calm users expressed satisfaction with the app and felt it was appropriate and useful. Significant improvements in perceived stress and psychological outcomes or stress-related health behaviors were not observed. Even though men spent less time in meditation than women did and completed fewer weekly sessions, they were more likely to adhere to the prescription. Further research is needed for improving stress and stress-related outcomes among middle-aged adults with emphasis on the effects of mindfulness meditation apps for men.ClinicalTrials.gov NCT04272138; https://clinicaltrials.gov/ct2/show/NCT04272138 Middle-aged adults 40-65 years)  report h years  rMeditation is the most prevalent nonpharmacological approach known to reduce stress ,9. MeditEngagement in health behaviors  and treatment preferences for stress reduction often differ between men and women . PreviouThe aims of this study were to (1) determine the feasibility  of a consumer-based meditation app , to reduce stress in middle-aged adults reporting elevated stress levels, and (2) explore the preliminary effects of Calm on perceived stress, psychological outcomes , health behaviors , and perceptions of COVID-19.ResearchMatch website , an, an27], α value <.05.Feasibility and COVID-19 perceptions data were examined using descriptive statistics. Preliminary effects on perceived stress, anxiety, depressive symptoms, mindfulness, coping, physical activity, and eating habits were examined using repeated measures analysis of variance. Data were analyzed in SPSS  and SAS . Results were considered significant at a 2-tailed In total, 83 middle-aged adults were consented and randomized, of which 60 (72%) were included in the analysis . DemograParticipants were satisfied with the meditation intervention  and found it appropriate or useful . Most participants reported that they were likely to continue using Calm in the future  completed a mean of 20 (SD 31.1) minutes of meditation on the days they meditated, and a mean of 103 (SD 109.1) minutes of meditation per week during the study . On averRecruitment rate of men into the study  was 35% (29/83). Of those randomized to the Calm app, 55% (15/29) were men. Retention among men was higher  than that among women .No significant within or between group differences in stress or psychological outcomes related to stress were observed, nor were significant differences observed in health behaviors related to stress .Most participants in Calm reported that the COVID-19 pandemic affected their stress levels , mental health , and physical health  .A 4-week, app-based mindfulness meditation intervention  may be feasible for use among middle-aged adults. Calm group participants expressed satisfaction with the intervention and felt it was appropriate and useful. However, significant improvements in perceived stress and psychological outcomes  or health behaviors related to stress  were not observed among these participants. The majority of participants reported that COVID-19 has negatively affected their stress, mental health, and physical health.We exceeded our benchmark (>75%) for acceptability rating of the Calm app among middle-aged adults experiencing stress. This finding was similar to that of other studies assessing the feasibility of Calm in patients with cancer and among college students . Our benOur benchmark was to recruit 40% men, and we recruited 35% men (29/83) in our study. We were able to recruit more men than other app-based meditation studies (5.7%-27%), including studies that focused on middle-aged adults ,25,43-46Significant changes in stress and related psychological outcomes or health behaviors were not observed. In another study testing the efficacy of meditation delivered via Calm, changes in stress and mindfulness in college students were observed after 8 weeks of participation. When taken together with these findings, the present data suggest that any significant changes in stress levels may take longer than 4 weeks to be noticeable .Few studies have tested the effects of app-based mindfulness meditation on health behaviors related to stress  and havePerceptions of COVID-19 could have had an important impact on stress in relation to the findings of this study. It is possible that meditation helped the study participants in the intervention group to maintain their stress and anxiety levels, as well as depressive symptoms (as opposed to elevated levels), during the COVID-19 pandemic . LikewisLimitations to this study include the following: (1) the majority of the sample comprised White participants, and generalizability of the findings may thus be limited; (2) the intervention was only 4 weeks long and did not include a follow-up; and (3) the COVID-19 pandemic may have had a notable impact on the findings of this study.This study supports the feasibility of a 4-week, mobile app–based mindfulness meditation intervention  in middle-aged men and women with specific application for the recruitment of men to inform future studies.


There have been several studies describing clinicoradiological features of the novel coronavirus SARS-CoV-2 infection. It seems that we still should know more about pathological features in the different stages of this infection.A 77 year-old man with cough and respiratory distress was admitted to the intensive care unit.  Real-time PCR on nasopharyngeal swab was done for him and it was positive for SARS-CoV-2.He was treated with oxygen therapy, hydroxychloroquine and antibiotic therapy and was discharged from the hospital with brief improvement of clinical symptoms. However, due to persistent dyspnea, the patient was admitted to the hospital again and throracotomy and wedge biopsy were performed for about 3 months from the onset of symptoms.Pathological examination revealed diffuse alveolar damage, fibroblastic hyperplasia, infiltration of inflammatory cells and hyaline membrane formation. Vaccination is one of the effective efforts of global scientific community to end the novel 2019 Novel coronavirus 2019 (COVID-19) pandemic. To date, the World Health Organization (WHO) has approved eight vaccines for emergency use: Pfizer/BioNTech, Moderna, AstraZeneca, Johnson and Johnson, Covishield, Sinovac, Sinopharm, and Bharat Biotech -6. Quire A 77-year old man was evaluated in our hospital because of severe respiratory distress and cough. He was an active smoker (about 1 pack year). There was a slight fine crackle on auscultation on the right lower lobe. Nasopharyngeal swab was done for him and it was positive for COVID-19 with cycle threshold (Ct) number 18. He was treated by assisted oxygenation, hydroxychloroquine and antibiotics. . His symptoms mildly decreased and recovered from the acute illness .Patient was not dependent on nasal oxygen and due to the time of peak of the SARS-CoV-2 infection and large number of critically ill patients in need of hospitalization; we decided to discharge our patient by symptomatic and conservative outpatient therapy at home, including famotidine, aspirin, atorvastatin. but he was admitted to the hospital again because of progressive orthopnea and desaturate on exercise. On clinical examination, he was suffering and dyspneic. His laboratory findings were: White blood cells (( WBC:7900/mm3) ;Hb:14/5 g/dl;platelets:165000/mm3; Lactic acid dehydrogenase ((LDH:754 unit/liter). CT scan was done and revealed bilateral and diffuse patchy ground glass opacity and lower lung bronchiectasis . BecausePatient outcome: his symptoms moderately improved but not completely, and he is still suffering from exercise dyspnea.th and 23rd after symptom onset. They declared non pathogonomonic findings such as alveolar damage with septa disruption, desquamation, edema, and proteinaceous exudates and alveolar congestion. Diffused peripheral vessels endothelial hyperplasia, muscular wall thickening, and intravascular hemorrhagic thrombosis were also declared as late histopathological findings of those two cases. Tian et al.  caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is RNA virus. It has high variable symptoms ranging from none to severe respiratory distress and other organs failure. The standard method of testing for the presence of SARS-CoV-2 is real-time reverse transcription polymerase chain reaction (rRT-PCR) which detects the presence of viral RNA fragments. The test is typically done on respiratory samples obtained by a nasopharyngeal swab. Lung biopsy has limited value for disease diagnosis, but better identification of histopathological features is necessary. Most of the patients experience long recovery including prolonged respiratory distress, desaturate on exercise and anorexia. So we evaluated a symptomatic covid 19 infected patient (that was proven by PCR test) because of his remaining respiratory symptoms for about 3 months. We analyzed his pathological specimens which revealed fibroblastic proliferation, fibrin and hyaline deposition, viral cytopathic effect and pneymocyte II hyperplasia. These findings are suggestive for diffuse alveolar damage in organizing phase. Aliofi et al. (Our findings revealed late lung histopathological findings of a symptomatic Covid-19 infected patient including diffuse alveolar damage in organizing phase. Now we are in global pandemic SARS-CoV-2 infection and many infected patients were not evaluated in the early phase of the disease, so we suggest that we should consider Covid-19 infection for every patient with unknown chronic lung disease especially the patients who has diffuse alveolar damage in lung biopsy. Further studies are needed on more infected patients with prolonged respiratory symptoms that could be beneficial for the better planning of patients’ follow-up and treatment.


Music performance anxiety is a common experience among elite and professional musicians and impedes performers from achieving flow state, or a state of focused, sustained engagement that promotes optimal performance.The aim of this study was to use heart rate variability (HRV) to determine the psychophysiological underpinnings of optimal music performance.We assessed HRV to study how autonomic-cardiac modulation was associated with flow during piano performance. Twenty-two pianists (15–22 years) with at least a Grade 8 Royal Conservatory of Music certification prepared two standardized pieces and a self-selected piece. Performer heart rate data were measured with a Polar 800 watch in 5-min periods immediately before performances, during performances and post-performance. HRV was employed to assess autonomic modulation of cardiac intervals. HRV indices of sympathetic and parasympathetic modulation of the heart were analyzed in 2.5-min segments to monitor short-term autonomic adjustments using the Kubios HRV Software. Flow state was measured using the 36-item Flow State Scale (FSS). Relationships were analyzed using zero-order correlations and multiple linear regressions.Our sample consisted of 22 RCM Grade 8 certified pianists. Participants achieved the highest level of flow during performance of the Bach piece. Decreased HRV was observed during performance, as indicated by a significant drop in total power. Flow state was positively associated with High Frequency (HF) power during the pre-performance phase, and inversely associated with Low Frequency (LF) power during performance.Inverse association of flow with LF-HRV during performance affirms the importance of vagal-HR modulation for achievement of flow state. Increased HF-HRV and reduced LF-HRV immediately prior to performance suggests that flow state may be shaped as much by physiological preparation during pre-performance as it is by physiologic responses during performance. Further research is required to validate the correlation between autonomic modulation of the heart and flow state. Evidence of this correlation between autonomic modulation of the heart and achievement of flow state may pave the way for further research on enhancing musical performance and targeting MPA through HRV-based interventions. HRV analysis is a reproducible and accessible non-invasive technique that is widely used to assess sympathetic and parasympathetic modulation of the heart . Multiple studies have shown reduced overall HRV and reduced parasympathetic indicators –11. DecrSeveral studies have explored heart rates during piano performance. Two studies examining professional musicians’ heart rates while performing showed significantly higher heart rates while playing than at rest, as well as significantly higher heart rates during a concert performance than rehearsal , 13. HeaFurther studies have established a relationship with music and HRV beyond the relationship with heart rate. Firstly, listening to music can affect HRV . More sprelationship between psychological flow and the autonomic-cardiovascular activity in musicians. Further, MPA levels are reported to decrease with pre-performance rituals such as mental rehearsal or meditation  and positive valence (reflected by HRV markers of parasympathetic modulation) over the course of performance and their association with self-reported flow state.This study was approved by the Research Ethics Board of the University of Toronto (protocol number 34638). Participants provided written informed consent.We recruited individuals between the ages of 15–22 who had at least a Royal Conservatory of Music (RCM) Grade 8 piano certification, or the minimum amount required to obtain a high school music credit in Canada and apply to a non-piano undergraduate music program. We excluded individuals who reported an acute or chronic medical condition that affects cardio-respiratory function, smokers, and individuals using prescribed medications known to affect cardiac function. Participants were asked to refrain from alcohol and caffeine for at least 12 h prior to their scheduled session.Participants were asked to prepare Johann Sebastian Bach’s Prelude No. 1 in C Major, Erik Satie’s Gymnopedie No. 1, and a piece of their choice 2 weeks in advance. Bach’s Prelude No. 1 in C Major and Satie’s Gymnopedie No. 1 were chosen due to their clear melodic and harmonic structure and popularity in the world of piano repertoire. Slower pieces were chosen  to avoid the faster heart rate from a faster piece confounding autonomic modulation of the heart brought about by psychophysiological changes. Participants selected a preferred piece as we expected that this performance might yield a higher flow state.The RCM grading system  determined participants’ piano certification. Immediately prior to testing, participants completed the Godin-Shephard leisure time exercise questionnaire  and the Performer electrocardiogram data was measured with a Polar 800 watch  for 5 min before performances, during performance and for 5 min immediately post-performance. Its lack of interference with performance made it well-suited to explore MPA. The Polar 800 watch is a non-invasive monitoring device that provides continuous R-R interval data from which autonomic modulation of the heart was assessed. Heart rate variability (HRV) was assessed using Kubios HRV Analysis Software  for 5-min intervals at pre-performance, performance, and post-performance. These intervals were analyzed in 2.5-min segments, in order to detect short-term changes in cardiac-autonomic modulation.2 (ms2) and normalized units (nu)  was used as an indicator of the overall variability of the RR intervals.Spectral analysis of the R-R interval segments produced power measures which were interpreted as follows: high frequency peak  representing primarily parasympathetic modulation, low frequency peak  reflecting both sympathetic and parasympathetic modulation . LF and its (nu) . The LF/its (nu) . Total pDuring the final recovery period, performers completed the Flow State Scale FSS, , a 36-strandom.org. Performers were instructed to loop or cut their playing of each piece to provide a 5-min recording. HRV was measured for a 5-min post-performance recovery period and participants completed one FSS questionnaire for each piece. A 1–2-min rest period was subsequently taken between each piece.Resting HRV was established by monitoring heart rate over a period of 5-min prior to beginning performance. Each participant performed the three above-noted piano pieces on a grand piano in random order, as specified using 2 and one-way analysis of variance (ANOVA) in SPSS 25.0. Data were screened for potential covariates, such as baseline anxiety and depression (HADS questionnaire)   and physonnaire) . Mean fl2), and LF and HF power in normalized units (nu). Normalized HRV measurements were calculated through division of the index (LF or HF) by the short-term frequency bands summated (LF+HF). We examined partial Pearson correlations to determine if HADS scores affected relationships between HRV indices and flow.We selected the piece with the highest level of flow to allow for the most direct examination of physiological conditions that correlate with flow. Pearson correlations were used to identify any potential correlations between flow and HRV indices, as well as baseline characteristics including age, sex, anxiety, depression, and pre-performance HRV components: heart rate (HR), LF and HF power in absolute values . Our final sample size consisted of nine women and thirteen men, ages 15–22 years old . There wt(21) = -2.51, p = 0.02. Furthermore, the prevalence of positive flow (≥3.5) among performers was greater during the Bach performances as compared to the Satie  while the difference approached significance for the self-selected piece (Own), t(21) = -2.02, p = 0.057. Given these findings, the Bach piece was chosen for the remainder of analyses of HRV and flow.t(21) = 4.484, p < 0.001 and it stayed low throughout performance. Total power decreased significantly from pre-performance 1 to performance onset, t(21) = 4.742, p < 0.001, while there was no significant change observed between pre-performance 1 to pre-performance 2, t(21) = 0.878, p = 0.39. LFms2 and HFms2 also both decreased in line with the drop in total power. Lastly, the LF/HF value decreased due to the proportionally smaller drop in HFms2 compared with LFms2 over the course of performance.Change in HRV indices from the first 2.5-minute pre-performance interval were observed . The RR-2) influences in the pre-performance condition. Partial correlations controlling for anxiety presented a similar pattern of results (table available upon request).Correlations were observed among the autonomic indicators at pre-performance, mean flow during the Bach performance, and HADS anxiety score . Anxiety2 in the pre-performance condition  for a positive association between LFms2 activity and flow.Peak flow was accompanied by decreased LF HRVmsondition , and witondition  prior toow state . Examina2). This suggests that increased vagal heart rate modulation and lower sympathetic arousal prior to performance may be necessary to facilitate flow state during performance.In this pilot study among elite musicians, we observed that autonomic activity in the pre-performance condition significantly predicted psychological flow during the performance of a pre-selected Bach piece across multiple HRV indices. Peak flow was associated with relatively higher vagal-HR modulation (indicated by HFnu) and lower sympathetic modulation . The lack of a live audience removes one of the key components of a performance that may trigger anxiety. Future studies could make use of a non-invasive measurement apparatus to observe the association between HRV and flow during live performances, such as the study undertaken by Iñesta et al. . The setFuture research could extend to other possible physiological indicators/modulators of flow state, including blood pressure variability or skeletal muscle activity such as frontalis muscle or temporomandibular muscle activity. For example, Manzano et al.  found thOur pilot study of monitoring of autonomic-cardiac modulation demonstrated sequential shifts in HRV indices that were associated with the achievement of an increased flow state during musical performance, and specifically in the pre-performance or preparatory period. Our results suggest that a global shift toward vagal modulation and relatively lower sympathetic activity during pre-performance may be a necessary condition to facilitate peak flow. The present results contribute to an improved understanding of psychological flow during performance, as well as possible mechanisms to decrease the impact of MPA. Further research is warranted to explore HRV-based therapies for musicians who are required to perform optimally in recurrent stress-evoking situations such as the performance stage.The raw data supporting the conclusions of this article will be made available by the authors, upon request, without undue reservation.The studies involving human participants were reviewed and approved by Health Sciences Research Ethics Board, Faculty of Kinesiology and Physical Education, University of Toronto. Written informed consent to participate in this study was provided by participants.All authors contributed to drafting and revising the manuscript and approved its final version. SJ, RN, ST, and AO were involved in the concept and design of the study. SJ and AO were involved in data collection. SJ, AO, and NS were involved in the systematic search, screening of articles, extraction of data, and the statistical analysis. RN, ST, AO, and NS revised the work critically and provided suggestions for improvement.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.


The first case of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in Rio Grande do Norte, northeastern Brazil, was diagnosed on March 12, 2020; thereafter, multiple surges of infection occurred, similar to what was seen elsewhere. These surges were mostly due to SARS-CoV-2 mutations leading to emergence of variants of concern (VoC). The introduction of new VoCs in a population previously exposed to SARS-CoV-2 or after vaccination has been a challenge to understanding the kinetics of the protective immune response against this virus. The aim of this study was to investigate the outbreak of SARS-CoV-2 reinfections observed in mid-January 2022 in Rio Grande do Norte state, Brazil. It describes the clinical and genomic characteristics of nine cases of reinfection that occurred coincident with the introduction of the omicron variant.Of a total of 172,965 individuals with upper respiratory symptoms tested for SARS-CoV-2, between March 2020 through mid-February 2022, 58,097 tested positive. Of those, 444 had documented a second SARS-CoV-2 infection and nine reinfection cases were selected for sequencing. Genomic analysis revealed that virus lineages diverged between primary infections and the reinfections, with the latter caused by the Omicron (BA.1) variant among individuals fully vaccinated against SARS-CoV-2.Our findings suggest that the Omicron variant is able to evade both natural and vaccine-induced immunity, since all nine cases had prior natural infection and, in addition, were fully vaccinated, emphasizing the need to develop effective blocking vaccines. The pattern of the COVID-19 pandemic has been characterized by multiple surges of infection with a variety of outcomes. By December 2021, about 75.3% of the population of the state of Rio Grande do Norte in northeastern Brazil, had been fully vaccinated against SARS-CoV-2 and a decrease in case detection from a mean of 32% of positives to about 8% of cases tested. Nevertheless, with the introduction of the Omicron variant at the end of 2021, the number of new SARS-CoV-2 infections reached its highest peak, with 75% of the suspected cases testing positive. Among the positive cases diagnosed in the Institute of Tropical Medicine between March 2020 to mid-February 2022 a total of 444 reinfections were identified; of which 62.3% (n = 277) occurred during the Omicron outbreak. Of the reinfection cases, nine were sequenced as part of genomic surveillance. Analysis showed that the reinfections’ lineages belonged to BA.1 introduced multiple times into the region; whereas, the isolates from the first infection belonged to different lineages. Thus, our data suggest that the Omicron variant evades immunity from natural infection from any other SARS-CoV-2 variants as well as from the available vaccines, indicating the need for development of effective blocking vaccines. The world has followed closely the spread of SARS-CoV-2 since 2019 in real time. However, after two years since the first cases of Coronavirus Disease 2019 (COVID-19) were reported in China, much is still unknown about the mutations and the molecular evolution of SARS-CoV-2 ,4.SARS-CoV-2 variants with potentially increased transmissibility, virulence, and resistance to antibody neutralization have already been reported in several locations ,6. The dThe multi-surge COVID19 pandemic dynamics fit different scenarios depending on the geographic location of emergence of the SARS-CoV-2 variants and the time when the variant was introduced and the previous burden of other variants. Some variants can have a significant impact in specific parts of the world. For example, studies have shown that the Gamma (P.1) variant was more prevalent in South America –14. In cRecently, Brazil faced the third wave of COVID-19 pandemic with a record upsurge of cases that started at the end of December 2021 and had been sustained by the highly transmissible variant B.1.1.529, a VoC, named Omicron . In BrazFrom March 2020 to mid-February 2022, 444 reinfection episodes were detected in our clinic, of which 277 cases were diagnosed in the first two months of 2022. Thus, we hypothesized that the reinfection cases detected were caused by the recently introduced Omicron strain. Here, we describe nine reinfection cases with the Omicron variant in January 2022 among people who had been fully vaccinated. We provide genomic variation data and clinical features between primary infection and reinfection cases.The study protocol was reviewed and approved by the Federal University of Rio Grande do Norte Ethical committee (36287120.2.0000.5537) and participants gave formal consent to be included into the study.The Institute of Tropical Medicine of Rio Grande do Norte at the Federal University of Rio Grande do Norte (IMT-UFRN), located in Natal, Brazil, provided service throughout the COVID-19 pandemic for diagnosis of SARS-CoV-2 infection for 17 municipalities in the State of Rio Grande do Norte and conducted an outpatient clinic for COVID-19. Clinical data and nasopharyngeal swab specimens were collected at the municipalities or at the IMT-UFRN. All clinical data were stored in the IMT-UFRN database. Nasopharyngeal swabs collected and placed in Viral Transport Medium. Samples were tested for SARS-CoV-2, within 24 hours after collection, by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), using CDC/EUA protocol [We conducted a descriptive retrospective survey of a large cohort to assess reinfection among the cases tested at IMT-UFRN between June 2020 and February, 2022, in which of 172,965 people tested for SARS-CoV-2 a total of 58,097 were positive. Of those positive, 444 had a second SARS-CoV-2 infection. However, we selected isolates for sequencing from nine reinfection cases  who presented at the outpatient clinic and whose follow-up data were known. The 18 samples had a cycle threshold (Ct) value ≤ 30. This work was part of a larger genomic surveillance effort performed by the Institute of Tropical Medicine of Rio Grande do Norte at the Federal University of Rio Grande do Norte to follow for potential entrance of newly SARS-CoV-2 variants.Viral RNA was isolated from 200-μl samples collected from people suspected of having SARS-CoV-2 infections using the QIAamp Viral RNA Mini kit  according to the manufacturer’s instructions. Virus genome sequencing was carried out on all positive samples selected using a COVIDSeq protocol .https://artic.network/). The primer pool additionally had primers targeting human RNA, producing an additional 11 amplicons. The PCR-amplified product was later processed for tagmentation and adapter ligation using IDT for Illumina Indexes. Further enrichment and cleanup were performed as per protocols provided by the manufacturer (Illumina Inc). All samples were processed as batches in 16-well plates. Pooled samples were quantified using Qubit 2.0 fluorometer (Invitrogen Inc.) and fragment sizes were analyzed in 4150 TapeStation System (Agilent Inc). The pooled library was further normalized to 4nM concentration and 25 μl of each normalized pool containing index adapter set A were combined in a new microcentrifuge tube to a final concentration of 100pM. The pooled libraries were loaded and clustered onto iSeq 100 i1 Reagent v2 (Illumina) with a flow cell and sequenced using synthesis (SBS) chemistry on the Illumina iSeq 100 sequencing system. The sequencing run was created with Local Run Manager software installed on the iSeq 100 instrument. Using the Generate FASTQ Analysis module with the custom library preparation kit options, the number of sequencing cycles was set to 151 bp and the paired-end sequencing option was determined.cDNA synthesis was performed from the extracted RNA using a multiplex polymerase chain reaction (PCR) protocol, producing 98 amplicons across the SARS-CoV-2 genome  using the BWA-MEM V0.7.12-r1039 . Next, tff V5.0e .FastaAlternateReferenceMaker function from GATK, and for the final fasta file those positions covered by fewer than 10 reads were replaced by Ns, by using an in-house script written in Python 3.8 (available at GitHub). All sequences were submitted to the Pangolin COVID-19 Lineage Assigner v.3.1.17 [Sequence consensus calling was performed by the v.3.1.17  (accessehttp://tree.bio.ed.ac.uk/software/figtree/ last accessed 2021-11-29).The 18 genome sequences obtained in this work were aligned to 700 other genome sequences from Rio Grande do Norte, Brazil, obtained from GISAID on January 20, 2022, using MAFFT v.7.394 . Then, whttps://sas.anac.gov.br/, accessed on January 24, 2022). Data from January-1-2022 to January-20-2022 was obtained from ANAC by means of consultation of planned flights .Since there were multiple introductions of Omicron into the state of Rio Grande do Norte within a few days after the variant was introduced in Brazil, we hypothesized that more likely cities that had more flights to Rio Grande do Norte could be implicated in the type of lineage introduced. Therefore, we collected data on the total number of flights landing in Rio Grande do Norte, from December 1, 2021 to December 31, 2021, as registered at the National Civil Aviation Agency (ANAC), by accessing the page Consultations of past flights , when thereafter a decrease of COVID-19 cases was observed until the beginning of January 2022 , followed by a rapid increase in positivity . Among tOf the 444 individuals with documented SARS-CoV-2 reinfection, nine immunocompetent and fully vaccinated individuals were chosen to have their isolates sequenced Figs  and S1. outbreak.info website.In order to distinguish between reinfection and residual RNA from a previous infection, so-called long-term viral persistence, we performed a maximum-likelihood (ML) phylogenetic analysis of all SARS-CoV-2 whole genomes from Rio Grande do Norte state, recovered from GISAID on January 20, 2021, and combined with two pairs of isolates taken from each individual during SARS-CoV-2 primary infection and reinfection . The earAmong the nine individuals who had reinfection, the elapsed time between infections was from 584 to 70 days . InteresTo better characterize the Omicron variant detected during the reinfection cases, we aligned it against all other Brazilian BA.1 whole genomes available in the GISAID database until January 20, 2022. In addition, we also selected an African B.1.1.529 reference sequence as an outgroup (accession EPI_ISL_6704867). The second ML tree  revealedSARS-CoV-2 infection episodes by emerging variants in previously naturally infected or vaccinated individuals are already a real phenomenon worldwide, which poses an important issue for understanding human immune responses to this virus and its response to vaccines . ReinfecThe Brazilian Health Ministry criteria for a SARS-CoV-2 reinfection is two positive RT-qPCR confirmations at least 90 days apart, with clinical manifestations characteristics of COVID-19, positive viral culture, and with additional viral RNA sequencing from both episodes showing different strains ,26. Our Recent studies have demonstrated that Omicron-infected cases tend to cause mild symptoms such as pharyngitis, headache, and nasal congestion , which cOur data support the findings that neither the current vaccines available nor previous history of COVID-19 is sufficient to establish a robust response against the Omicron variant and to promote a reduced risk of infection and overt disease. Although we did not perform any neutralizing antibody assays on the nine participants in this study, others have found that the ability to neutralize Omicron was lower in those who were vaccinated and had previously been infected, or in those who were only vaccinated, compared to prior lineages –31, althWe have only begun to explore the many ways that the Omicron lineage or newer variants are capable of causing reinfections and continuous genomic surveillance is needed to understand the role of SARS-CoV-2 mutations, which could lead to immune response evasion generated by prior infections due to other variants or to the available vaccination. A recent study has hypothesized that some mutations in the spike RBD domain, present on Omicron, are enough to anchor the virus on the ACE2 receptor, leaving the rest of the receptor binding motif free to develop further mutations, which would facilitate the evasion of the neutralizing antibodies . AlthougOur study does have some limitations. The number of RT-PCR tests performed on samples collected from people with respiratory symptoms decreased as a result of the increased use of COVID-19 rapid antigen testing and the outbreak of influenza, concomitant to the introduction of Omicron. In addition, people who had mild symptoms tended not to seek testing or care, or did at home COVID test and not reporting the results, therefore limiting the detection of more reinfection cases and true estimate of the surge. We sequenced only 18 isolate samples (two per subject) since we aimed to carry on surveillance of new variants, not only reinfection cases. Aside from that, those who received the same vaccine did not have comparable dose intervals to assess long term immunity and we have a limited number of subjects who received the second–third dose of vaccine. In regards to the participant’s immunocompetence, we were unable to determine whether they were capable of producing antibodies in response to vaccinations and/or natural infections, which could be properly assessed using a neutralization assay , consideIn summary, our data suggest that the Omicron variant evades immunity provided by different types of vaccines or from natural infection by any other earlier SARS-CoV-2 variants of concern and may be related mostly to the mild symptoms of the upper respiratory tract for the majority of the subjects. Thus, along with vaccination, the reassurance of protective measures needs to be held to prevent further spread of SARS-CoV-2 variants or the risk of the appearance of new variants.S1 Table(XLSX)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 FigThe Omicron genomes sequenced here are indicated with the red tips.(PDF)Click here for additional data file.S3 FigThe order from the Brazilian federative unit with the most flights to Natal  from, to the lesser one, is: São Paulo (604 flights); Pernambuco (227 flights); Brasília (199 flights); Minas Gerais (85 flights); Rio de Janeiro (78 flights); Bahia (53 flights); Ceará (52 flights); Rio Grande do Norte (20 flights); Paraná (4 flights); Goiás (1 flight); and also Portugal with 22 international flights.(PDF)Click here for additional data file.


Racial/ethnic disparities during the first six months of the COVID-19 pandemic led to differences in COVID-19 testing and adverse outcomes. We examine differences in testing and adverse outcomes by race/ethnicity and sex across a geographically diverse and system-based COVID-19 cohort collaboration.Observational study among adults (≥18 years) within six US cohorts from March 1, 2020 to August 31, 2020 using data from electronic health record and patient reporting. Race/ethnicity and sex as risk factors were primary exposures, with health system type  as secondary. Proportions measured SARS-CoV-2 testing and positivity; attributed hospitalization and death related to COVID-19. Relative risk ratios (RR) with 95% confidence intervals quantified associations between exposures and main outcomes.5,958,908 patients were included. Hispanic patients had the highest proportions of SARS-CoV-2 testing (16%) and positivity (18%), while Asian/Pacific Islander patients had the lowest portions tested (11%) and White patients had the lowest positivity rates (5%). Men had a lower likelihood of testing (RR = 0.90 [0.89–0.90]) and a higher positivity risk (RR = 1.16 [1.14–1.18]) compared to women. Black patients were more likely to have COVID-19-related hospitalizations (RR = 1.36 [1.28–1.44]) and death (RR = 1.17 [1.03–1.32]) compared with White patients. Men were more likely to be hospitalized (RR = 1.30 [1.16–1.22]) or die (RR = 1.70 [1.53–1.89]) compared to women. These racial/ethnic and sex differences were reflected in both health system types.This study supports evidence of disparities by race/ethnicity and sex during the COVID-19 pandemic that persisted even in healthcare settings with reduced barriers to accessing care. Further research is needed to understand and prevent the drivers that resulted in higher burdens of morbidity among certain Black patients and men. In the United States, medical literature has exposed significant disparities in testing, infection, and adverse outcomes related to COVID-19 (caused by SARS-CoV-2); in particular, Black and Hispanic Americans have been disproportionately impacted by COVID-19 , none ofEarly data suggested COVID-19 testing and positivity differed by sex and race/ethnicity, with reduced testing among minority populations but higher positivity among Black and Hispanic Americans compared to White Americans , 21, 22 We sought to evaluate racial/ethnic and sex differences in SARS-CoV-2 testing and positivity and COVID-19-related hospitalization and death within six demographically and geographically diverse cohorts, and to determine if these differences persist in the context of different health system models.The Corona-Infectious-Virus Epidemiology Team (CIVET) is a collaboration of three integrated health systems, two academic health centers, and one interval cohort which was a clinical cohort of people with and without HIV.  that parThe CIVET cohort included individuals from each site who met study inclusion and exclusion criteria. Each cohort restricted their study population to include: 1) individuals who were alive as of March 1, 2020; and 2) individuals who were “in care” or “in cohort,” which was operationalized differently for each cohort but based on individuals who had recently interacted with the health system or interval study .We conducted a retrospective analysis of the CIVET cohort to investigate differences by race/ethnicity and sex in COVID-19-related outcomes  among adults (≥18 years old) between March 1, 2020 and August 31, 2020. The study period was restricted to the initial viral serotype timeframe to limit possible differences by variants. An index date for each participant was defined as either: 1) the first positive SARS-CoV-2 polymerase chain reaction (PCR) test laboratory date, 2) the last negative or pending/invalid SARS-CoV-2 PCR test laboratory date (if no positive test found), or 3) March 1, 2020 (for those not found to have been PCR tested). Patient-level data were aggregated at each site and sent to KPMAS. American Community Survey (ACS) data from the US Census Bureau was also collected for population level comparisons , 29.Sex  was identified by data availability of sex at birth or self-reported sex/gender. Other and unknown sex categories were too small and excluded. Race/ethnicity was self-reported and classified as non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander (API), other, and unknown . To determine the robustness of racial/ethnic and sex differences to barriers to healthcare, participating clinical cohorts were further grouped by type of health system, defined as integrated health systems , academic health systems , and interval cohort (MWCCS). Integrated systems represented lower barriers to care, with membership allowing patients to readily communicate with healthcare professionals, initiate e-visits, and access SARS-CoV-2 testing. In contrast, academic systems are open to the public and often serve as safety-net providers in their communities, but acknowledging these differences are fluid . The intSARS-CoV-2 RT-PCR testing status (yes/no), date, and result  were extracted from electronic health record (EHR) systems and reported as composite data from each cohort. During the study period (March–August 2020), routine testing was limited and generally at the discretion of a clinician due to changes in testing availability and guidelines, which differed by state and healthcare system. Testing was calculated as those tested among the entire study population. Positivity was calculated as the number testing positive among those tested.Patients hospitalized with clinical syndrome of COVID-19 within seven days prior to and 45 days after their first positive SARS-CoV-2 test were included. To identify inpatient encounters associated with clinical COVID-19, the following International Classification of Disease, Tenth Edition (ICD-10) codes were pulled from hospitalization records: B97.2x, J12.8x, J12.9, J18.x, J20.8, J22, J80, J96.0x, J96.2x, J96.9x, M35.8x, A41.x, R65.x. We were unable to discriminate between COVID-19 as the primary cause of hospitalization versus hospitalization primarily for another cause but with COVID-19, so patients with non-specific COVID-19 codes were included . AdditioMortality data and the death outcome were measured by patients who were known to be deceased after their first positive SARS-CoV-2 test during the study period. The rest were presumed alive. Death data was obtained from EHR systems, claims, the VA Vital Status File, which includes data from inpatient records, the VA Beneficiary Identification Records Locator Subsystem, Social Security Administration, and the Center for Medicare and Medicaid Services.a priori study team consensus-driven minimal important difference of +/-3% to guide our interpretation of differences in the outcomes by race/ethnicity and sex, and a chi-squared (χ2) test statistic (α = 0.05) in the pooled aggregated data for interpretation of statistical significance.Each site shared standardized de-identified, aggregate tables with KPMAS, and were pooled for analyses. We calculated the proportion tested (among the study population), the proportion with detectable SARS-CoV-2 PCR test results (among those tested), and the proportions who were hospitalized and died (among those with detectable SARS-CoV-2 PCR results). We used an We calculated Cochran–Mantel–Haenszel stratification-adjusted relative risk ratios (RR) and associated 95% confidence intervals (CI) to quantify associations between race/ethnicity and sex and study outcomes. We adjusted for race/ethnicity or sex to isolate risk factor effects and stratified the estimated outcome proportions and the RRs by clinical cohort health system type  to determine if the differences persisted in the setting of lowered barriers to healthcare. Due to differences in the size and cohort selection criteria , the analyses in the integrated health systems group were further stratified by cohort  to determine the robustness of the intragroup differences; it was determined that the three cohorts were similar enough to remain cohesively grouped. Analyses were performed using SAS 9.4 . Approval was obtained from each participating site’s institutional review board, which included waivers of written informed consent.A total of 5,958,908 patients  were included in the study population, of whom 5,724 were hospitalized with clinical syndrome COVID-19 diagnoses and 1,399 died after a detectable SARS-CoV-2 PCR test result . The oveDuring the study period, 1% of the study population tested positive for SARS-CoV-2, 11% tested negative, and 88% had no evidence of testing. Demographics differed by testing status. Hispanic patients formed the plurality of those testing positive (37%) but only 14% of those not tested, while White patients formed the plurality of those testing negative (47%), aligning with the race distribution in those who were not tested. There was a greater proportion of women among those who tested positive (52%). The age distribution among those with positive test results was skewed to younger ages, with 82% <60 years old, whereas the age distribution among those who tested negative was more evenly distributed across age groupsThose hospitalized with a clinical COVID-19 diagnosis  were predominantly Hispanic  and male . Those who died after a detectable SARS-CoV-2 test result  were more likely to be White  and male .Among the six clinical cohorts, Hispanic patients had the highest proportion tested for SARS-CoV-2, while Asian/Pacific Islander had the lowest proportions tested, overall and when stratified by sex . After cPatterns in overall positivity percentages  followedThe proportions of those testing positive who were hospitalized  or died The racial/ethnic differences in the proportion tested were attenuated in integrated health systems, but not negated. When stratified by health system classification, testing percentages between the integrated health systems and academic health systems varied . TestingPositivity varied by health system type . NotablyWhen stratified by health system, the percent of patients hospitalized for COVID-19  was loweWithin the interval cohort, testing proportions  were higThe COVID-19 pandemic has brought the issues of health disparities and racial inequities in the United States to the forefront. This CIVET cohort analysis bolsters prior smaller, regional, and single-center studies , 21 by fThe observed racial differences have been previously associated with systemic inequities among vulnerable populations. Multiple factors may contribute to the higher risk of infection with SARS-CoV-2 and severe complications. Type of work and inability to social distance  increased exposure to SARS-CoV-2 for many in the US, particularly minority workers . Lower sWe have shown significant differences in COVID-19 testing and outcomes by health system type. The interval cohort includes participants who are closely affiliated with their healthcare providers, many having participated in the HIV study for decades. This group had a high rate of testing, which indicates they had the access and knowledge necessary to secure testing. Similarly, patients of the integrated health systems are established members of the system and have a well-defined entry point for all care, facilitating testing access. In contrast, the lowest levels of testing were seen in the academic setting, where patients may need to secure testing independently or are using the health system for the first time. Confirmation of infection is key to slowing the spread of disease, and while COVID-19 testing was in most places without patient cost, this evolved over time and early access to testing was more limited , 39. ThoWhen comparing integrated health systems, with lower perceived barriers to care, to academic systems, we found that racial disparities were reduced but persisted in the integrated healthcare setting. While access to care is important, it represents the end of the disparity pathway, not the beginning; individual, household, and structural differences among Black and Hispanic populations and men may be driving forces leading to disparities in testing and outcomes related to COVID-19 regardless of access. Though we could not measure these factors directly, our results are consistent with disparities seen throughout the US. These results highlight the overarching need to address racial disparities for the long-term, not just in response to this pandemic. These findings should bolster the evidence to inform culturally competent policy changes to address health inequalities .In addition to describing differences in COVID-19 testing and adverse outcomes, our findings correspond to the next phases of the pandemic: vaccination and long-term health consequences of COVID-19. The swift development and deployment of multiple vaccines have led to declines in cases, adverse outcomes, and deaths nationally ; howeverThis study does have limitations. To expedite data sharing and protect patient privacy, aggregated datasets were compiled by each cohort and submitted to KPMAS for analysis. While these summary-level data limited our capabilities with the analytic approach and did not allow for deeper dives into patient-level effects, the large sample size and diversity within each cohort provided adequate data to describe differences by race/ethnicity and sex in COVID-19 outcomes over an extended period. Additionally, some COVID-19-related data may have been missing due to lack of coding early in the pandemic or care that occurred outside of the represented cohorts not captured. Importantly, guidelines for testing differed by state and healthcare system over the course of the pandemic, and testing was ultimately at the discretion of clinicians and by patients to a limited extent. The known delays of death certificate data, which limited our ability to directly attribute deaths to COVID-19, may have contributed to larger variances in COVID-19 death estimations. However, our large sample size provided sufficient power for robust statistical analysis to generate findings. Further, we included only deaths among SARS-CoV-2 positive patients, if they occurred during our study period, therefore capturing inpatient deaths rather completely. We also acknowledge that no formal analysis was conducted to see if the CIVET cohorts were representative of the population; however, risk analysis attenuates this limitation by controlling for base population rates, thus maintaining the generalizability of our results.There were limitations specific to each cohort. The interval cohort and one of the integrated health system cohorts are HIV cohort studies of persons with and without HIV, differing from the other health systems cohorts which represent whole populations; however, the proportion SARS-CoV-2 positive in the HIV cohort for this integrated health system are consistent with a national study . For theThis study identified significant racial/ethnic differences in COVID-19 outcomes within a large diverse cohort, which were attenuated in settings with lower barriers to care , but not negated. Further research is needed to understand the underlying mechanisms behind why Hispanic and Black men in America have a higher burden of disease during the COVID-19 pandemic and how to combat those disparities.S1 Table*The Kaiser Permanente Mid-Atlantic and Northern California HIV Registries are databases of members diagnosed with HIV since 1998. Primary sources used to identify HIV patients are HIV-specific laboratory tests, diagnosis by infectious disease physicians, hospital-based HIV diagnosis, and antiretroviral therapy. Abbreviations: Multicenter AIDS Cohort Study = MACS; PWH = Persons with HIV; PWoH = Persons without HIV; Women’s Interagency HIV Study = WIHS.(PDF)Click here for additional data file.


The Veterans Administration has joined the Age-Friendly Health Systems (AFHS) movement as part of its Whole Health initiative to provide safe, high-quality geriatric care using a set of evidence-based practices known as the “4Ms”—What Matters, Medication, Mentation, and Mobility—to provide care across all care settings. Two healthcare centers utilized an automated review of 4Ms care. For non-templated notes in the TVHS GeriPACT clinic over a 30-day period, all the 4Ms health factors (HFs) were addressed in only 1% of patients, and 16% had three HFs, 37% had two HFs, and 71% had one HF addressed. During the pilot of a new templated note and associated dashboard at the RICVAMC, GeriPACT and Home-Based Primary Care (HBPC) addressed all the age-friendly health factors in 41% of patients, while 24% had three health factors, 10% had two health factors, and 13% had one health factor addressed, and 10% were indeterminate by manual review. For both facilities, What Matters Most had the lowest prevalence, representing the most difficult individual health factor to address. The use of a templated note improves the reliable delivery of age-friendly care compared to non-templated notes and facilitates the dashboard display of practice- and provider-specific age-friendly encounter data, which may provide useful QI information to clinicians and health systems. As a High-Reliability Organization, the Veterans Administration has joined the Institute for Healthcare Improvement’s (IHI) Age-Friendly Health Systems (AFHS) movement as part of its Whole Health initiative to provide every older veteran with safe, high-quality care aligned with what matters most. Becoming an Age-Friendly Health System means that hospitals and healthcare systems reliably use a set of evidence-based practices known as the “4Ms”—What Matters, Medication, Mentation, and Mobility—to provide care for older, disabled, and medically complex patients across all care settings. When provided together in clinical practice, the 4Ms represent a broad cultural shift toward patient-centered care consistent with the mission of focusing on what matters most to individuals .Implementing the IHI 4Ms age-friendly principles into primary care is challenging because there is no best practice to identify the documentation of delivery or to provide feedback to providers. Leveraging the electronic health record (EHR) is a potential way to automate this process. Note templates facilitate the incorporation of information into the EHR, whereas dashboards represent information management tools which use data visualization to display performance indicators to facilitate the tracking of performance . We descThe TVHS does not have a templated note or age-friendly dashboard. To automate the assessment of 4Ms care, age-friendly principles for primary care were discussed at IHI peer coaching webinars, and PDSA cycles were employed among clinic staff to define each of the 4Ms for the TVHS geriatric outpatient practice’s Geriatric Patient-Aligned Care Team (GeriPACT). SQL scripts were used to build field and note title searches  for the 4Ms, defined as: (1) Mentation—mini-COG and PHQ2 (nursing intake), (2) Medication—medication review and provider reconciliation, (3) Mobility—ADL mobility questions (nursing intake), and (4) What Matters Most—patient portal messages, as the utilization of a patient portal in an integrated health system relates to functional engagement with the patient. Clinic visits in April 2021 were assessed for 4Ms age-friendly care in the TVHS GeriPACT. Plan-Do-Study-Act (PDSA) cycles with stakeholder clinicians reviewing dashboard-derived data refined the searches with improvement in accuracy. Templated notes to document 4Ms care were not utilized.The RICVAMC uses a local templated 4Ms documentation tool designed to abstract data for QI and to standardize care across settings, which is incorporated into local note templates. Simultaneously, 4Ms health factors were developed by the VA Office of Patient Care and Cultural Transformation, and added to the Whole Health—Health Factors Dashboard (WH4ALL)  which isThe dashboard displays for the age-friendly WH4ALL and the RICVAMC-specific dashboards are provided in For non-templated TVHS GeriPACT clinic notes over a 30-day period, all the 4Ms health factors (HFs) were addressed in only 1% of patients, and 16% had three HFs, 37% had two HFs, and 71% had one HF addressed. During the pilot of a new templated note at the RICVAMC, GeriPACT and Home-Based Primary Care (HBPC) addressed all the age-friendly health factors in 41% of patients, while 24% had three health factors, 10% had two health factors, and 13% had one health factor addressed, and 10% were indeterminate by manual review.  For bothLeveraging the EHR to display the simultaneous documentation of 4Ms for a primary care population could facilitate improved provider-driven interventions to provide 4Ms care to older adults. The Agency for Healthcare Research and Quality (AHRQ) utilizes the Common Elements for Event Reporting-hospitals (CFER-H) in developing the National Patient Safety Data Dashboard . A dashbLocal clinical access coordinators can add the standardized 4Ms template containing age-friendly health factors to any EHR progress note template or as a text reminder by identifying the desired health factor component and creating a text integration utility (TIU) using the selected health factor object(s) . CliniciLocal SQL script searches are labor-intensive and not generalizable. Dashboards connected to the CDW permit the standardization and dissemination of data. Age-friendly note templates can be developed that are appropriate for all levels of care, including primary care, inpatient, long-term care (Community Living Centers—CLCs), home care (Home-Based Primary Care—HBPC) and consultation use. A dashboard display derived from encounter flags permits clinicians to customize their delivery of 4Ms care and clinical documentation and may be superior to pop-up alerts, which subject clinicians to alert fatigue. Dashboards may also be useful in identifying older or high-risk patients in a general population to facilitate targeting 4Ms care.Building, standardizing, and disseminating age-friendly dashboards and data capture could help health systems to incorporate 4Ms care, identify barriers and target populations for implementation, and inform best practice to enhance the delivery of age-friendly care to the older adult.Work continues to educate providers about incorporating 4Ms templates into their clinical documentation to facilitate age-friendly workload credit and facility QI monitoring. The 4Ms Health Factor enhanced WH4ALL dashboard does not search other fields such as note titles and clinical reminders and does not include a natural language-processing (NLP) text-search function to identify elements of age-friendly care within clinical notes.An operational dashboard may help inform the delivery of 4Ms care. The use of a templated note improves the reliable delivery of age-friendly care compared to non-templated notes. A dashboard display of practice- and provider-specific age-friendly encounter data could provide useful QI information to other clinicians and health systems. Patient portals may be a potential source of information regarding patient–clinician engagement.