Viral vector and mRNA vaccines have been quickly developed and are now broadly used around the globe to master this global challenge. However, it is unlikely that vaccination alone will curb the COVID-19 pandemic, therefore asking for additional therapeutic and prophylactic approaches.The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic has caused more than 2.6 million deaths as for March 16th 2021 .2+ levels, niclosamide also inhibits the release of proinflammatory cytokines such as IL-8, and possibly also other cytokines, which could be of utmost importance to curb the cytokine storm frequently observed in hospitalized Covid-19 patients. Another fortunate aspect is the antibacterial activity of niclosamide that could be most welcome in fighting potential pulmonary superinfections Repurposing of niclosamide has been also proposed for the treatment of other pulmonary conditions, such as asthma Without doubt, the present paper is of large significance to clinicians and health policy makers due to the urgent need for a drug to treat SARS-CoV-2 infections. Although the UK and USA monitoring systems, Yellow card and VAERS do not show an unusual number of adverse reactions or fatal outcome by Sars-Cov-2 vaccines ,8, thereKarl Kunzelmann wrote commentaryDFG-KU756/14–1University of Regensburg, 93053 Regensburg, Germany. PCT/EP2019/077433: COMPOUND FOR USE IN THE TREATMENT OF A DISEASE CHARACTERIZED BY DYSREGULATED MUCUS PRODUCTION AND/OR SECRETION.KK has nothing to declare and no competing interests. Patent application by the


Voxel-wise whole-brain multiple regression analyses were also performed to examine the relationship between obsessive-compulsive symptom severity and neural activity during the task. The two groups did not differ in MR task performance. Both groups also showed similar task-related activation patterns in frontoparietal regions with no significant differences. Activation in the right dorsolateral prefrontal cortex in patients with OCD during the MR task was positively associated with their total Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores. This study identified the specific brain areas associated with the interaction between symptom severity and visuospatial cognitive function during an MR task in medication-free patients with OCD. These findings may serve as potential neuromodulation targets for OCD treatment.Functional neuroimaging studies have implicated alterations in frontostriatal and frontoparietal circuits in obsessive-compulsive disorder (OCD) during various tasks. To date, however, brain activation for visuospatial function in conjunction with symptoms in OCD has not been comprehensively evaluated. To elucidate the relationship between neural activity, cognitive function, and obsessive-compulsive symptoms, we investigated regional brain activation during the performance of a visuospatial task in patients with OCD using functional magnetic resonance imaging (fMRI). Seventeen medication-free patients with OCD and 21 age-, sex-, and IQ-matched healthy controls participated in this study. Functional magnetic resonance imaging data were obtained while the subjects performed a mental rotation (MR) task. Brain activation during the task was compared between the two groups using a two-sample  Obsessive-compulsive disorder (OCD) is a disabling neuropsychiatric condition characterized by recurrent, unwanted thoughts (obsession) and/or repetitive behaviors (compulsion), with a prevalence of 2–3% . AccumulMental rotation (MR) is the ability to rotate mental representations for two- and three-dimensional objects in the mind , and an The brain regions that are activated during an MR task are the superior parietal, frontal, and inferior temporal cortices . The posTherefore, the present study aimed to investigate the functioning of frontoparietal networks related to visuospatial abilities in medication-free patients with OCD. We first compared the performance of the MR task in OCD patients with HCs. Then, we used functional MRI (fMRI) to examine whether brain activation patterns during the MR task differed between OCD patients and HCs. In addition, the association of neural activation during the MR task with patients' symptoms was investigated to reveal the relationship between symptoms, cognitive function, and brain activity in OCD patients. Also, we hypothesized that a certain region belonging to frontoparietal circuits of OCD patients would be associated with obsessive-compulsive symptoms.We recruited 26 medication-free patients with OCD (9 drug-naïve patients and 17 patients who were drug-free for at least 4 weeks) from the OCD clinic at Seoul National University Hospital. All patients underwent the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and fulfilled the criteria for OCD. Twenty-six HCs matched for sex, age, and IQ were also recruited from the community. For all participants, the exclusion criteria were a lifetime history of psychosis, substance abuse/dependence, Tourette's disorder, or other tic-related conditions as well as a history of seizure disorder, head injury, or intellectual disability. Patients were assessed with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) , the Hamn = 3) and depressive disorder not otherwise specified (n = 6). This study was approved by the Institutional Review Board of Seoul National University Hospital, and all participants signed an informed consent form prior to their participation. The demographic and clinical information for both groups is provided in After pre-processing the fMRI data, 3 patients and 2 HCs were excluded due to excessive head motion [>2.5 mm of translation or 2.5° of rotation and >0.30 mm for mean framewise displacement (FD)] (Participants performed a block-designed MR task with the following two conditions: (i) the MR condition and (ii) the zero rotation (ZR) condition as a control condition . For bot*-weighted gradient echo-planar imaging (EPI) sequence during the task. The parameters were echo time (TE) = 30 ms, repetition time (TR) = 2 s, flip angle (FA) = 90°, voxel size = 3.4 × 3.4 × 4.0 mm3, interleaved axial slices = 27, and number of volumes = ~360 per subject. High-resolution T1-weighted magnetization-prepared rapid-gradient echo anatomical images were obtained . To minimize possible motion artifacts, head cushions were used, and the participants were asked to move as little as possible during the acquisition.Image data were acquired with a 3T scanner  using a T2t-tests or Mann-Whitney U-tests. A chi-square analysis or Fisher's exact-test was used for categorical data.Comparisons between OCD patients and HCs for demographic characteristics and behavioral performance during the MR task were made with independent http://www.fil.ion.ucl.ac.uk/spm). After discarding the first 4 volumes, data were corrected for both slice timing acquisition and head motion and spatially normalized to the Montreal Neurological Institute (MNI) reference brain. Then, data were smoothed with a 6-mm full-width at half-maximum (FWHM) Gaussian kernel.Image pre-processing and statistical analyses were performed using SPM12 software  condition for each subject. Next, these first-level contrast images were entered into second-level random effect analysis. One-sample p < 0.05, family-wise error (FWE) corrected for multiple comparisons, and a voxel-level threshold of p < 0.001, uncorrected.Voxel-wise whole-brain multiple regression analyses were also performed to examine whether there was an association between patient symptom severity  and neural activation during the MR task. Patients' HAM-D scores were included in the model as a covariate to control for their depressive symptoms. All statistical results were set at a cluster-level threshold of x, y, z = 51, 33, 33; t-/z-values = 6.39/4.30; cluster size = 75 voxels) of patients.The multiple regression analysis results are presented in To the best of our knowledge, the present study was the first to evaluate the neural responses of patients with OCD while they were performing an MR task. Particularly, all patients were medication-free at the time of the MRI scan. We found that frontoparietal regions showed significant activation during the MR task in both OCD patients and HCs, but there were no significant group differences in brain activation. A conspicuous finding from our data was that higher clinical symptom severity in patients with OCD was significantly associated with greater activation in the right DLPFC. Therefore, these findings suggest that the frontoparietal network is implicated in visuospatial cognition, and the DLPFC in this network is an important element in the pathophysiology of OCD.The brain circuits activated during the MR task were almost the same in patients and HCs and included the bilateral parietal, occipital, and frontal regions. These regions have been reported consistently in previous neuroimaging studies of MR . This fiHowever, we were unable to identify any regions showing significantly increased or decreased activation in OCD patients compared with HCs during the MR task. This result may be explained by the fact that the patients demonstrated a level of performance on the MR task that was similar to that of the control subjects. Likewise, Nakao et al.  found thThe most important clinically relevant finding was that neural activation in the right DLPFC during the MR task was positively associated with obsessive-compulsive symptom severity. Previous studies suggested that there was a relationship between the orbitofrontal-striatal circuit and the generation or severity of obsessive-compulsive symptoms , 46. In Several limitations to this study need to be acknowledged. First, the sample size in the final analysis was relatively small. Some participants were excluded due to the quality of the functional imaging data, and the decreased number of subjects might have affected the statistical power of the results. Therefore, future studies with larger sample sizes are needed to confirm the findings of the present study. Second, nine of the 17 patients with OCD had comorbid axis I disorders such as dysthymic disorder or depressive disorder not otherwise specified. Given that depressive symptoms influence task performance and decreased performance is related to imaging results , it is iIn conclusion, this fMRI study provides the first evidence that neural activation in unmedicated patients with OCD when performing an MR task is not different from that in HCs but is associated with obsessive-compulsive symptom severity. These results improve the present understanding of the neural mechanisms of MR associated with symptoms in OCD and thus provide the potential to identify neuromodulation targets for managing patients' symptoms.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 Institutional Review Board of Seoul National University Hospital. The patients/participants provided their written informed consent to participate in this study.WJ, GS, and JK designed the study. WJ, TK, and GS contributed to the acquisition of MRI data. JK collected the clinical data, interpreted the data, and gave critical comments on the manuscript. SO and WJ performed data analysis and wrote the first manuscript. All authors critically reviewed the manuscript content and approved the final version for publication.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.


There is growing evidence for the possible use of microRNAs (miRNAs) in cancers as diagnostic as well as prognostic biomarkers in the present era of Personalized Medicine. The objective of the present systematic review and meta-analysis was to assess the prognostic role of microRNAs in uterine cervical cancers.  A systematic review and meta-analysis was carried out searching electronic databases for published articles between January 2009 and August 2020 based on standard systematic review guidelines. Meta-analysis was performed by pooling the hazard ratio (HR) with 95% confidence interval (CI) to assess the prognostic value of deregulated miRNAs by the random-effects model. In the present meta-analysis, the aberrant expression of 14 microRNAs in 1,526 uterine cervical cancer cases before definitive therapy from 14 case-control studies were assessed. The pooled HR of two miRNAs, miRNA-155 and miRNA-224 which were upregulated in cervical cancer tissues was 1.76 (95% CI 1.27-2.45) revealing significant association with overall poor survival. Meanwhile, the pooled HR was 1.53 (95% CI 0.94-2.94) when all the deregulated miRNAs in cervical cancer tissues were evaluated. The pooled HR of downregulated miRNAs was 1.46 . Meanwhile, the pooled HR of three upregulated miRNAs-425-5p, 196a, 205 in the serum sample was 1.37 (95% CI 0.45 -4.20). The downregulation of aberrant miRNAs was not associated with poor overall survival rates. Cervical cancer is the fourth most common female cancer after breast cancer, colorectal and lung cancer . India is home to 453.02 million women aged 15 years and above who are at risk of uterine cervical carcinoma and is the second most common cancer among Indian women. Despite being a preventable cancer by Human Papillomavirus (HPV) vaccination and cancer screening, one-fourth of the global burden of cervical cancers was contributed by India alone. Cervical cancer survival rates are highly variable across India and five-year age-standardized relative survival rate is much lower compared to other Asian countries such as China, South Korea, Singapore and Thailand .®)–Health Professional Version - National Cancer Institute,” 2020). In the absence of organized screening programs in India, most women present at advanced stages. Timely detection and management become almost impossible due to non-specific symptoms in the early stages and the absence of organized screening programmes in developing countries. The search for an efficient biomarker for early diagnosis is challenging owing to uncertain cellular and molecular mechanisms of cervical cancer oncogenesis. The most common type of cervical cancer is squamous cell cancer constituting about 90% of uterine cervix cancers followed by adenocarcinoma comprising almost 10%  were discovered. MicroRNAs may function as oncogenes or tumor suppressors at various targets in human cancers leading to aberrant expressions. Recent studies carried out in the last decade reported dysregulation of some microRNAs in cervical cancer oncogenesis. MicroRNAs regulate about 30% of human genes  and 50% of these genes are tumor-related or situated in fragile loci . Upregulation of miR-155 and miRNA-224 was observed to be poor prognostic factors in cervical cancers . Meanwhile downregulation of certain microRNAs was reported to imply poor prognosis in cervical cancers. These markers are stable in serum and are expressed in tissues. Why it is important to do this reviewSeveral years of cytology screening in low- and middle-income countries have not led to a significant reduction in cervical cancer cases which is attributed to financial and technical hurdles in carrying out cytology as well as Human Papillomavirus (HPV) DNA testing, non-compliance for follow-ups and timely management of screen-positive women. Identifying efficient biomarkers for early detection and appropriate management of uterine cervical cancers which can be translated from bench to bedside is the need of the hour. We performed a systematic review and meta-analysis regarding the prognostic value of microRNAs in uterine cervical cancers. A systematic review and meta-analysis of literature was performed searching electronic databases for published articles in English between January 2009—August 2020 based on standard systematic review guidelines. The present rearch work comply with the Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA) statement . The meta-analysis component was modified appropriately to evaluate the prognostic value of miRNAs in cervical cancer.Description of the conditionMicro RNA or miRNA: MicroRNAs are short non-coding, single-stranded RNAs having 18-25 nucleotides length, which regulate gene expression at the post-transcriptional level through target messenger RNAs (mRNAs) and suppress translation or induce mRNAs degradation. Utilizing several molecular mechanisms, microRNAs play a vital role in the origin and progression of cancers, either as oncogenes or as tumor suppressors.Prognosis: Prognosis is the chance of developing cervical cancer or possibilities of getting better after developing cancer. In the present research, the prognosis is reported in terms of overall survival rate due to cervical cancer.Biomarker: Biomarker is a characteristic that can be measured implying normal biological processes, pathogenic processes or responses to an exposure or intervention . A pathological or physiological process can be recognized by testing for a natural gene, enzyme or protein. Study protocolAn electronic search of PubMed/MEDLINE and SCOPUS was carried out using search terms such as miRNA OR microRNA AND cervical cancer AND “survival”. Retrospective case-control studies, employing quantitative real-time polymerase chain reaction (qPCR) for miRNA profiling in cervical squamous cell cancers were chosen for meta-analysis. The published articles in English since 2009 were explored and a manual library search for articles in peer-reviewed journals was performed. The references of retrieved articles were also examined to increase the search sensitivity. miRNA expression in cancer tissue and matched adjacent normal cervical tissue samples or in serum samples of uterine cervix cancer cases belonging to clinical stages I-IV as per International Federation of Gynecology and Obstetrics  classification  were included for the meta-analysis. Case-control studies employing quantitative real-time polymerase chain reaction (qPCR) for miRNA profiling were included. Inclusion process and criteria: Articles regarding All the included studies categorized the samples into low expression and high expression groups based on the mean or median cutoff value of miRNA amplified. The overall survival rate was reported as hazard ratio (HR) with 95% confidence interval (CI) to evaluate the prognostic value of microRNAs. Exclusion criteria: Duplicate publications of the same survey and articles published in languages other than English were excluded. Studies reporting microRNA profiling by microarray were also excluded as these assays are less specific without absolute quantification. MicroRNA profiling extracted by bioinformatics assays, studies reporting only relative risk (RR) and articles with no information on histology of cancers were also excluded. Data extraction A validated proforma focusing on the first author, year of publication, region, sample size, histology, lymph node involvement, duration of follow up, miRNAs amplified, cut-off value, HPV status, and hazard ratio (HR) with 95% CI was used to extract the data.rd August 2020. In this systematic review, the three-stage selection process was carried out for the final inclusion of the studies. One reviewer assessed titles from 4688 records for the relevance for inclusion in the study. Studies applicable for the review were moved to the second stage and articles in languages other than English, irrelevant articles and duplicates were excluded (n= 4443). In the second stage, the abstracts of the studies (n=245) were obtained and two reviewers independently analyzed all the abstracts. All the non-relevant studies were rejected (n=192) and the remaining (n=53) studies were moved to the third stage. Full texts of studies (n=53) were retrieved which were again examined by two reviewers independently. Extracted data from full-text articles by the first reviewer was further reviewed by a second reviewer. Any difference of opinion was settled by discussion. A total of 32 studies were systematically reviewed. Detection of miRNA in cervical cancer cases from 14 case-control studies were included in the quantitative synthesis . The study selection process is depicted in the PRISMA chart . The lasQuality assessmentUtilizing New Castle Ottawa scale (NOS), two reviewers independently and systematically assessed the quality of case-control studies  Data analysis Considering the inclusion of possible confounding factors, articles reporting hazard ratio from multivariable Cox Regression analysis were included for meta-analysis. Adjusted hazard ratio (HR) along with 95% Confidence Interval (CI) from multivariable Cox Regression analysis were extracted from each of the 14 studies qualified for meta-analysis. These hazard ratios were synthesized in a meta-analysis to obtain a pooled HR with 95% CI to evaluate the prognostic effects of miRNAs on the survival of uterine cervical cancer. Meta-analysis was performed using a random-effects model in STATA 13.1 statistical software .using the “Metan” package. Chi-square statistic and I-squared statistic were used as measures of statistical heterogeneity. The results of the meta-analysis are depicted in a forest plot, where the diamond represents the pooled estimate with 95% CI.microRNA. The I2 statistic was computed to test the significance of potential heterogeneity. Forest plots were separately generated for miRNA expressed in tissue and serum samples. In both the meta-analyses a subgroup analysis was carried out based on the high or low expression of Publication biasThe publication bias was evaluated by Egger’s test which includes weighted linear regression with standardized effect estimate, the dependent variable and precision as the independent variable(“(PDF) MIDAS: Stata module for meta-analytical integration of diagnostic test accuracy studies | Ben Dwamena - Academia.edu,” n.d.). In the present study, loge HR was considered as the effect estimate and the precision was given as 1/standard error of loge HR. Weights were allotted by the inverse variance approach (1/variance of the effect estimate). A statistically significant bias coefficient gives evidence for the presence of publication bias.Included studiesThrough electronic search, full texts of 32 articles were reviewed systematically and 14 studies were included for quantitative synthesis. Characteristics of the included studies are shown in microRNA expression in cervical cancer tissues. As shown in The studies qualified for meta-analysis were all from China, the world’s most populous country. Studies reporting the prognostic value of 14 aberrant microRNAs in tissue or serum samples of 1,526 uterine cervical cancer cases prior chemoradiation were included for meta-analysis. Out of the fourteen qualified studies, ten articles reported 361-3p expression when compared to healthy controls . Zhou et al., (2018) also reported lower RFS and overall survival with downregulation of miR1254.The present systematic review observed that four studies reported the recurrence-free survival rate (RFS) apart from overall survival. Out of the 14 qualified studies, only two recent studies generated recurrence-free survival rate (RFS) from Kaplan Meier curves other than overall survival rate (OS)  Deceased patients and cases having recurrence were found to have a lower Quantitative synthesismiRNA expression. The HR with 95% CI  were pooled for miRNAs with low or high expression in tissue samples and analyzed by forest plot . The pooled HR of three upregulated miRNAs-196a, 215, 425-5p in serum samples was 1.37 (95% CI 0.45 -4.20) implying a lack of significant association with overall poor survival . Pooling2 ≥ 50%, indicating considerable heterogeneity, the random-effects model was adopted for pooling. Compared to previous meta-analyses considerable heterogeneity was observed as more number of studies with different miRNA profiles were pooled. As the IPublication biasThe p-value for the bias coefficient was not statistically significant  and 4. HmiRNA-224 was reported to be an independent predictor of poor prognosis, lymph node metastasis and shorter overall survival . MicroRNA-155 is an oncomir which promotes malignant transformation in many human cancers such as cervical cancer, lung cancer, leukemia and breast cancer . Tumor suppressor gene, LKB1 encoding serine/threonine kinase was identified as the potential target of miRNA-155 based on bioinformatics analysis. In cervical cancer cells LKB1 gene was reported to be downregulated . PTX3 was reported to be the target gene for miRNA-224 when analyzed by bioinformatics as well as dual-luciferase reporter assay. Overexpresssion of miRNA-224 and silencing or under expression of PTX3 was related to aggressive progression of cervical cancers .These observations may facilitate the development of potential therapeutic agents against cervical cancer in future. Deregulated expression of microRNAs leads to silencing of the target gene which may be affecting the response to various chemothrepeutic agents . The preservation of certain miRNAs-361-3p, 1254, 664, 155, 26b, 503,145,125a, 126, 224, 101, 425-5p, 196a, 205 in cervical cancer was observed to be associated with improved overall survival and better prognosis . The present meta-analysis observed upregulation of two micro RNAs-155 and -224 in tissues was related to poor prognosis and reduced overall survival. Upregulation of oncogenic miRNA-155 and miRNA-224 was noted in HPV positive cervical cancers . Increased expression of miRNA expression in tissue is more specific for assessing the prognostic value in site-specific cancers. Studies with histological classification were included in the present meta-analysis and except one study squamous cell carcinoma cases was the predominant type in all the 13 articles  which pooled HR from nineteen studies. Dai et al., (201) observed the association of low miRNA with poor survival. Another meta-analysis of seven studies by Chen et al., (2018) observed that poor survival was associated with low levels of miRNA-125, miRNA-145, and a high level of miRNA-196 in tissue samples. We observed vast variation in the histological types of cancer in the studies included by Chen et al., (2018) as well as Dai et al., (2018) which pooled HR from studies carried out in serum and tissue samples in a single meta-analysis. Compared to serum, aberrant articles . SeparatmiRNA expression in cervical cancers was attributed to persistent high-risk HPV infection . Limited number of reviewed studies reported Human Papillomavirus association along with miRNA profiling as in miRNA-361-3p expression in high-risk HPV DNA positive cervical tissues when compared to normal tissues without HPV infection. However, a significant difference in miRNA-361-3p expression was not observed between cervical cancer tissue and normal tissue . Downregulation of tumor suppressor miRNA-145 was observed in HPV positive uterine cervical squamous cell cancers with vascular invasion . There was no significant correlation between HPV positivity and certain tumor suppressors such as miRNA-1254, and miRNA-664 . Chromosomal instability caused by HPV is attributed to upregulation of microRNA-9 in uterine cervical cancers . Fan et al., (2015) reported HPV-induced p53 inactivation resulting in microRNA-125a downregulation. The causal role of Human Papillomavirus (HPV) in cervical cancer is well proven and aberrant Strengths of the studymiRNA expression. Estimates of HR were obtained only from multivariable Cox regression analysis. There was uniformity in the tissue samples preserved for the study in the present meta-analysis.Separate meta-analyses were performed for tissue and serum samples. Subgroup analysis was also performed for differential There were several limitations of our meta-analysis. Except for one study, all the included studies incorporated adjacent normal cervical tissue from cervical cancer cases as controls. There was ambiguity regarding the microscopic examination for malignant changes. There was no uniform cut-off levels even though median or mean cut off values were used in the included studies. Due to the scarcity of published research on the microRNAs, we had to pool different microRNAs for evaluating the prognostic role. However, miRNAs reported to be deranged in at least two research publications were selected for the meta-analysis. Amongst the qualified studies miRNA-155 and -224 were upregulated in tissue samples which was significantly associated with poor overall survival in cervical cancers. This should be interpreted with caution as the pooled HR was generated from only two published articles. RecommendationsFuture research including cervical tissues from women with no cervical cancers as controls is needed. Research work on upregulated microRNAs has to be undertaken among cervical cancer cases wordwide. Large prospective studies are needed to assess the prognostic value of microRNAs in cervical cancer. In conclusion, the downregulation of miRNAs was not associated with poor overall survival rates in cervical cancer. SS and NR and conceptualised the study and developed the research protocol; SS and NR identified articles for full-text review, extracted data from studies, and matched inclusion criteria. N R did the statistical analyses. SS drafted the study. Both the authors approved the final study, and NR agreed to be accountable for all aspects of the work in ensuring that questions related to the integrity of any part of the work are appropriately investigated and resolved.


The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases  and SCS client databases. At baseline, 86.5% of participants  had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of “safer opioid supply” programs and impacts of COVID-19. It is estimated that 2016, 0.70% of Canadians aged 15 to 64 years used injection drugs, up from 0.55% in 2011 . In respSCS are health services where people who inject drugs (PWID) consume pre-obtained drugs under the supervision of health professionals and/or trained peers, and can access clean injection/inhalation equipment, basic healthcare such as wound care, and referrals to other services . Many SCIndividual-level and ecological studies of SCS effectiveness have indicated that SCS are associated with reduced overdose mortality, reduced syringe sharing and infection disease risk, and increased uptake of detoxification and addiction treatment services –9. SCS iExisting quantitative evaluations of SCS have necessarily been observational or quasi-experimental, given the lack of equipoise to justify a randomized trial , 15. HowTo address these critical gaps, the Ontario Integrated Supervised Injection Services cohort study in Toronto (OiSIS-Toronto) was established in November 2018 to evaluate the first three sanctioned SCS in the city. Each is integrated within an existing community health agency (CHA), including two comprehensive community health centers and one harm reduction program. SCS were first implemented in Toronto in the summer of 2017 with an unsanctioned site situated in a downtown park, . These aOiSIS-Toronto is an open prospective cohort of PWID who do and do not use SCS. The primary goals of the OiSIS cohort are to (1) evaluate the impact of various integrated SCS models on client uptake of CHA programming, health service use, and health outcomes; (2) to identify barriers to SCS use; and (3) to identify potential operational and regulatory enhancements to SCS. The cohort draws on three data sources: (1) semi-annual interviewer-administered study questionnaires; (2) linkages to administrative databases at ICES, Ontario’s repository for vital statistics and health administrative data; and (3) linkages to visit-level data from electronic SCS databases at the three CHAs. Consent is sought separately for data linkages and participants may enroll in the cohort without consenting to linkage.Baseline data collection began on 5 November 2018; as the cohort is open, herein we report on participants enrolled by 19 March 2020, prior to the temporary suspension of new enrolments due to COVID-19 restrictions in Toronto. At present, we plan to follow participants up to 2.5 years from baseline for a total of six study visits occurring at semi-annual intervals. The study was approved by the Research Ethics Boards at Unity Health Toronto, the University of Toronto, and Toronto Public Health.Toronto is the largest city in Canada (2017 population = 2.93 million) and among the most ethno-racially diverse in the world. Beginning in 2016, overdose rates in Toronto rose precipitously as the street opioid supply became increasingly potent, as heroin was supplemented with, and ultimately largely replaced by, fentanyl , 20. TheAt baseline, eligible participants had to be 18 years of age or older, report injecting illicit drugs within the previous 6 months, able to speak and understand English, and residing in Toronto. Recruitment materials specified that participants did not need to use SCS to enroll. Clients of the study SCS were primarily recruited on-site at the CHAs. Recruitment of participants who do not use SCS was designed with the aim of composing a comparator group experiencing similar structural vulnerabilities as those who use SCS, and involved a combination of active outreach by study staff at CHAs; non-incentivized peer recruitment; and passive recruitment  at health and social service organizations, on the street, and in needle and syringe packages distributed by CHAs. To avoid eligibility restrictions that might lead to misrepresentation, we also enrolled individuals who use non-study SCS, using the same methods as for non-SCS users. These participants are grouped with other SCS users for analyses of overall SCS outcomes and disaggregated where particular SCS models are being compared. Study interviews are completed at one of the three participating CHAs, or at the research team offices if an alternative site is requested by a participant. At each visit, participants complete an interviewer-administered computer-based questionnaire and receive a CDN $30 honorarium. All participants provided written informed consent for cohort participation and (separately) data linkages.OiSIS-Toronto employs a number of retention strategies commonly used in PWID cohorts , 22. MulVariables to be derived from all data sources are summarized in Table The questionnaire includes self-reported data on demographic characteristics and socio-structural exposures, drug use behaviors, use of SCS, overdose experiences and other health conditions, use of drug checking services, and substance use disorder treatment.Cohort participants are asked to consent to a having their study questionnaire data linked with administrative data at ICES, which broadly captures demographic information, vital statistics, and publicly funded healthcare encounters in Ontario. Consenting participants provide their Ontario Health Insurance Plan (OHIP) number and/or one or more of their name, date of birth, and postal code. This information is then used to link consenting participants with ICES data holdings either via their OHIP number (deterministic linkage) or using probabilistic linkage methods. Questionnaire data will be linked with the following ICES databases: the Registered Persons Database ; the OHIP claims database (billing covering ~95% of physicians in Ontario); the Discharge Abstract Database ; the National Ambulatory Care Reporting System (emergency department visits); the Client Agency Program Enrolment Registry ; the Corporate Provider Database (physician and practice information); the Ontario Mental Health Reporting System ; CONTACT ; the Ontario HIV Database (persons with HIV); and the Narcotic Monitoring System database .Participating CHAs track SCS use in an electronic database; two of three sites use NEO 360, a computerized record-keeping system used by harm reduction programs across Ontario . To tracIn the summer of 2018, a qualitative study was conducted at two study SCS to understand barriers and benefits to accessing integrated SCS, including any contextual factors that affected uptake , 27. IndSince October 2020, OiSIS-Toronto participants who indicate they are enrolling in an SOS program have been invited to participate in a sub-study assessing clinical, health, and social outcomes associated with SOS. Additionally, we conducted a rapid survey to assess the impact of COVID-19 and related restrictions on people who use drugs in Canada, which was administered to 170 cohort participants between June 2020 and April 2021, using a combination of telephone and in-person interviewing, and which was also administered to cohorts of people who use drugs in Vancouver and Montreal.Representatives of the CHAs participating in the study are co-investigators on the project. Participating CHAs have pre-existing community advisory bodies comprised of people who use drugs, who are compensated for their time and expertise. The community advisory bodies are consulted on an ongoing basis on study recruitment and retention procedures, priority research topics, and approaches for disseminating findings to community members. People with lived experience of drug use are prioritized for research staff positions; importantly, this commitment has required advocacy and creativity within a hospital system in which formal educational credentials and criminal background checks are typically required for hiring. While all staff eventually went through those institutional processes, we provided them with close support, including financial assistance to obtain identification needed for the background checks.We calculated descriptive statistics to describe demographic, health status, and drug use characteristics of cohort participants, overall, and stratified by self-reported frequency of SCS use  and by retention status (≥1 follow-up visit vs. lost to follow-up). We used Wilcoxon rank-sum tests and chi-square tests, for continuous and categorical variables respectively, to test for differences in characteristics. We also calculated frequencies of drug-related risks in the full sample.n=182), some , or few  of their injections.As shown in Fig. Overall, 632 participants (90.2%) consented to healthcare administrative data linkages and 521 (82.4%) were successfully linked to ICES databases. In total, 280 study SCS clients (53.8%) provided their client identification code for SCS database linkage, with substantial variation across sites (range = 28–66%), likely due to variation in the extent to which sites actively promote creation and use of a consistent code.n=449). Approximately half of the participants were white (53.6%) and one-third were Indigenous . The vast majority of participants were homeless or unstably housed , and over one-third had recently been incarcerated . Most socio-demographic characteristics did not vary significantly by frequency of SCS use; however, compared to SCS clients, non-SCS users were older (median [IQR] age = 47.5 [37.3–52.8]) and less likely to report some illicit or informal income sources.Socio-demographic characteristics and drug use patterns are shown in Table n=35); self-reported HIV prevalence was lower among those who used SCS more frequently (p <0.01). More than half  reported a lifetime diagnosis of Hepatitis C, of whom 57% (n=191) reported current, chronic infection.Five percent of participants self-reported being HIV-positive (n=333) reported fentanyl as their most frequently injected drug and SCS clients were more likely to do so (p <0.01). Among non-SCS users, stimulant use was most common, with 60.8% (n=56) injecting either crystal methamphetamine or cocaine most often. Participants had been injecting for a median of 13 years; those who used SCS more frequently had shorter injecting histories (p <0.01). Almost one-third  were receiving OAT at the time of their interview, including methadone  and buprenorphine/naloxone . OAT use increased with SCS use frequency (p=0.01).Approximately half of participants  over the previous 6 months and the majority  reported injecting in public. Most had injected alone  and 41.3% (n=289) had needed help to inject. Most participants did not share syringes  but more commonly reported sharing other injecting equipment such as cookers or filters . The majority of participants  had ever overdosed, and 38.6% (n=270) reported an overdose within the previous 6 months. In a published analysis, we found that this overdose risk was not independently associated with frequency of SCS use [Drug-related risks in the full sample are shown in Table  41.3% n=9 had neen=67 of those lost to follow-up vs. 9.3%, n=27 of those retained) and less likely to use SCS for all/most injections ; these differences were statistically significant (p=0.03). Participants lost to follow-up were also less likely to report income from selling drugs  at baseline. For all other variables in Table As of 23 April 2021, 291 participants (41.5%) had completed at least one follow-up visit. Of the 410 (58.5%) deemed lost to follow-up, 15 were known to have deceased, one was known to be incarcerated, four had moved away, and 390 were unreachable. Participants lost to survey follow-up will remain included in administrative data analysis. Baseline SCS use frequency varied by retention status. Specifically, those lost to follow-up were more likely to be non-SCS-users ; however, we recruited a large fraction of SCS clients .With a focus on evaluating the secondary impacts of SCS on healthcare use and identifying how service integration and other operational characteristics impact client outcomes, the OiSIS-Toronto cohort responds to the need for a “second generation” of SCS research that examines how heterogeneous models and client populations impact SCS effectiveness . The coh


The current drive for sustainability demands recyclable matrices for composite materials. Vitrimers combine thermoset properties with reprocessability, but their mechanical performance in highly loaded applications, for instance, composites for aeronautics, is still to be demonstrated. This work presents the complete mechanical characterization of a new vitrimer reinforced with carbon fiber. This vitrimer formulation consists of functional epoxy groups and a new dynamic disulfide crosslinks-based hardener. The testing campaign for the vitrimer composites encompassed tension, compression, interlaminar shear strength (ILSS), in-plane shear (IPS), open-hole tension (OHT) and compression (OHC), filled-hole compression (FHC) and interlaminar fracture toughness tests under mode I and II. Test conditions included room temperature and high temperature of 70 °C and 120 °C, respectively, after moisture saturation. Tension and flexural tests also were applied on the neat vitrimer resin. The results compared well with those obtained for current aeronautic materials manufactured by Resin Transfer Molding (RTM). The lower values observed in compression and ILSS derived from the thermoplastic veils included as a toughening material. This work demonstrates that the vitrimer formulation presented meets the requirements of current matrices for aeronautic-grade carbon-reinforced composites. Thermoset fiber-reinforced composites have been widely used in numerous structural applications, particularly in the aerospace, automotive and wind power industries. Epoxies have excellent thermal and dimensional stability, good mechanical strength, creep and chemical resistance and good electrical isolation thanks to their permanent covalent cross-linked networks. That said, thermosets have long curing times, thus limiting their production to low-medium volume series, for which there is an increasing demand. In addition, thermosets have poor or complex reparability, are non-recyclable and cannot be reshaped after being cured, therefore generating a great deal of waste when components reach the end of their lifespans. The current and most common disposal solutions are pyrolysis and land filling, both of which imply serious environmental and economic issues ,4,5,6,7.Back in 2011, Leibler et al.  presenteVitrimers present new possibilities for fiber-reinforced polymers such as post-curing reprocessing without losing performance, welding composite layers to form new monolithic and multi-layered materials or allowing composites to be welded to generate structural joints between parts. Additionally, the fibers and the matrix can be separated for reuse in other applications. Furthermore, vitrimers allow for the implementation of “enduring” prepregs that could be fully cured and still enable the processing of multi-layered laminates, thus avoiding the need for refrigerated storage and the multiple consumable materials for prepreg protection, in addition to offering a longer shelf life. Vitrimers offer the potential to create reprocessable and reparable thermoset composites, something which currently is a slow and expensive process requiring highly qualified personnel ,22,23,24g), storage modulus (E′) and thermal stability, albeit with a slightly lower degradation temperature (Td), possibly due to the disulfide species that are less energetically stable than other species in the formulation. Both the vitrimer and the thermoset showed comparable traction strength, suggesting that the use of dynamic formulations on composites will not affect their mechanical performance. The authors demonstrated the possibility of reshaping a cured composite sample manufactured by RTM and thermoforming it in a hot press. The reparability of the vitrimer formulation was illustrated by inducing delamination during an ILSS test and healing it by means of heating and pressure.A pioneering publication on fiber-reinforced vitrimers by Ruiz de Luzuriaga, A. et al.  presenteOver the past years, several vitrimer composites with diverse synthetic or natural monomers and dynamic formulations have been applied in continuous glass or carbon fiber reinforcements, showing promising mechanical properties compared to their thermoset counterparts ,35,36,37The EU H2020 project AIRPOXY  ,42 was fThis work is developed as part of the AIRPOXY project, and its objective is to present a full mechanical characterization of a new carbon-fiber-reinforced vitrimer based on disulfide exchange bonds, designed to compete in performance with current and widely used aerospace-grade thermoset epoxy resins. In this paper, we focus on composite properties; details of the vitrimer formulation and its properties will be published in separate works under the Airpoxy project. Two reinforcement configurations were selected and evaluated under different mechanical tests at room temperature and in humidity and high-temperature conditions to obtain a full spectrum of this vitrimer formulation’s mechanical performance. We present a description of the mechanical tests selected, along with their outcomes, materials and manufacturing processes. Following that, we present a discussion on the results and draw some conclusions. We used a new formulation of an aeronautical-grade epoxy-based vitrimer (referred to from here on as AIR-3R) that has low viscosity at processing temperatures so that it can be processed by infusion and RTM processes. It consists of a catalyst-free formulation composed of commercially available functional epoxy groups and a new hardener with dynamic crosslinks based on aromatic disulfide species, also commercially available. This is a patented formulation, created, characterized and provided by Cidetec  ,44,45.2 propane-based formulation from Yuan, Y. et al. . In thisIn all temperature conditions, the AIR-3R vitrimer performed well . The croIn view of the influence of the PA veil on the compression response, another batch of ILSS samples was manufactured with the cross-ply fabric without the PA veil and tested at RT. These samples showed better performance than the original testing set, surpassing the baseline thermoset by 20%  and demoThe IPS modulus for the vitrimer composite was generally better than the thermoset-based composite in both cross-ply and UD fabrics, particularly in high-temperature conditions : −2.2% iRegarding the in-plane shear strength , the vitThe ILSS shear strength and IPS shear modulus suggest that the AIR-3R vitrimer has good toughness, good adhesion to the reinforcements, good adhesion between layers and good shear resistance, even after hot wet conditioning of the specimens. As was seen for the ILLS, the lower in-plane shear strength could be attributed to the thermoplastic PA veil inside the laminate.AIR-3R ILSS performance was slightly higher compared with other vitrimer formulations, being comparable with the Imine VA/HTDA system . The BAPAt RT conditions, the AIR-3R formulation is comparable to the base thermoset resin . After mSpecimens had a proper failure mode under the specified standard. The AIR-3R vitrimer had a slightly lower compressive strength than the thermoset baseline . The PA The FHC strength for the AIR-3R vitrimer composite was slightly lower (−13.6%) than the baseline at RT and reached the same value for the HW70 condition . All theNevertheless, the results are still comparable to the base thermoset composite. There are no reports of other vitrimer formulations having been tested on OHT, OHC and FHC.IC) at RT but were still comparable to the base thermoset resin in that they exhibited a 11.4% difference (The AIR-3R vitrimer specimens presented lower fracture toughness under mode I (Gfference .IIC) was not defined. The AIR-3R vitrimer composite presented a mean energy value of 876.19 J/m2.A baseline value for the fracture toughness under mode II (GIC) was comparable to reported thermoset composites toughened with thermoplastic veils: T300 UD CF 167 g/m2–Epoxy RTM6-2 with 20 wt% PAEK veil [2–Epoxy L160 with 17 g/m2 PA-66 veil [2 and 9 g/m2 PA-66 veils [Fracture toughness under mode I  fracture toughness was lower than in similar thermoset composites toughened with thermoplastic veils [IIC) were more complex than mode I (GIC), depending on most on the neat properties of the matrix and the architecture of the reinforcement, rather than the fiber bridging effect. The clarification of this topic deserves further research.Mode II  was comparable to reported thermoset formulations with toughening thermoplastic veils. Mode II appears to be lower than the references with and without the thermoplastic veils. Further research should be carried out to clarify the micro-mechanisms behind the fracture behavior of this vitrimer formulation, as well as the impact of the thermoplastic veils, their melting temperature and aerial weight on the in-plane vitrimer composite properties.Fracture toughness in mode I (GIn summary, the mechanical properties of the AIR-3R and the composites prepared with this new vitrimer formulation were comparable to those currently used in aircraft materials. Dynamic properties of this particular formulation have to be studied in order to establish a processing window in which this formulation could be reprocessed by maintaining the overall composite properties.


Background: Psoriasis is a chronic dermatological condition characterized by lesions on extensor surfaces, hands, feet, and genital areas. Chronic renal failure is often associated with metabolic syndrome and inflammatory conditions, such as psoriasis. Case report: In this paper, we report a patient with stage-three chronic renal failure that improved his renal condition after treatment with ixekizumab, an anti-IL17A drug used in the treatment of various cutaneous and rheumatological conditions. Conclusions: IL17A blockage may help to treat various autoimmune and inflammatory conditions, such as psoriasis, that may lead to renal impairment. Further investigation is necessary in order to prove the effectiveness of this drug in renal conditions. Psoriasis is a chronic dermatosis characterized by scaly erythematous patches found prominently on extensor surfaces . Other aA 44-year-old male with a diagnosis of psoriasis since adolescence and chronic mild nephropathy since 2016 came to our attention seeking medical treatment. The patient was previously treated with topical and systemic steroids, cyclosporin A, adalimumab, and phototherapy. None of these therapies led to a constant improvement of cutaneous manifestations. During the dermatological evaluation, psoriasis with an inverse and a palmoplantar component was evidenced . A PsoriA treatment with anti-interleukin 17 Ixekizumab  to treat psoriasis was started.During the first follow-up visit, three months after the beginning of treatment, cutaneous lesions were dramatically improved (PASI 5). After six months, another complete blood panel was performed. Creatinine dropped to 1,0 mg/dL, and therefore a GFR exam was performed; results showed a filtration rate of 95 mL/min, corresponding to a stage-one renal failure. After one year of anti-interleukin 17 therapy, at the third follow-up visit, the patient’s skin clearance was almost complete (PASI 1), and creatininemia was still 1.0mg/dL .The effectiveness of biological drugs in stabilizing renal function in patients treated for rheumatoid arthritis was recently proved in a study. Patients receiving anti-TNF alpha therapy had a better GFR over time than patients not receiving biological treatments. The researchers hypothesized that these results were related to the drug’s anti-inflammatory effect, as renal failure is usually associated with systemic inflammation .A recent retrospective study on 32 patients with renal failure treated for psoriasis with different biologic drugs evaluated this issue. These patients, all characterized by a GFR inferior to 60 mL/min, were followed during their biological treatment. Although the results showed no statistically significant differences in mean GFR before and after treatment, eight patients showed remission of the GFR. One of these was treated with ixekizumab. The other patients treated that showed remission were treated with infliximab (four patients), ustekinumab (two patients), and adalimumab (one patient). All GFR improvements ranged from 1 to 46%, and the patient treated with ixekizumab registered an improvement of 7% . SimilarIL-17A is an essential component of the IL-17 cytokines’ family, together with IL-17B, C, D, E, and F. IL-17A is a pleiotropic molecule generating proinflammatory effects acting in synergy with other inflammatory mediators such as IL-1-β and TNF .Summers et al. proved that the in vivo delivery of Th17 cells into mice resulted in the development of albuminuria, glomerular neutrophil infiltration, and increased renal CXCL1 mRNA levels .Ixekizumab is a humanized antibody that binds anti-interleukin 17A (IL-17A), neutralizing the inflammation derived from this molecule . HumanizIn renal biopsies of patients with a histopathological diagnosis of hypertensive nephroangiosclerosis, IL-17A-positive cells were found mainly in areas of focal inflammatory cell infiltration .IL-17A targeting decreased kidney inflammation in preclinical renal damage models, suggesting that ixekizumab could be an anti-inflammatory treatment to prevent hypertension-induced renal inflammation .IL-17F has been described as a circulating inflammatory molecule linked with an augmented risk of renal damage progression. Interestingly, circulating IL-17A levels are linked to the gravity of CKD and progressively decrease from subjects with low levels of blood sugar to subjects with type 2 diabetes with and without diabetic nephropathy, highlighting once more the tight connection between IL17 and inflammation and the possible effectiveness of anti-IL17 drugs also in diabetic nephropathy .In this regard, blocking the Th17/IL-17A axis has been suggested as a novel treatment for inflammatory kidney diseases. Beneficial effects of IL-17A blockade were described in preclinical immune- and nonimmune-mediated renal damage .In our case, we think that reduction in the renal failure stage was due to the effectiveness of ixekizumab on the inhibition of the interleukin 17-induced inflammation axis.This case and the literature findings indicate that IL17A blockage may help treat various autoimmune and inflammatory conditions that lead to renal failure .Limitations of this case are related to the fact that no renal biopsy was performed to better assess the nephrologic condition on the basis of renal impairment. A biopsy would have been helpful, as an increase in renal function could easily be related only to a subset of nephrologic conditions. Considering the different renal conditions driving the progression of renal failure, further prospective studies may be necessary to prove the efficacy of this drug in renal impairment.However, given the promising results obtained in this case, we believe that anti-IL17 should be the drug of choice in patients affected by psoriasis and renal failure, and the use of drugs targeting IL17A (such as ixekizumab) should be tested in prospective clinical trials to control hypertension-related secondary conditions.


Notably, although only a minority of the vaccinated uninfected group showed neutralisation capacity against SARS-CoV-2, all vaccinated and infected individuals showed high-titre neutralisation of SARS-CoV-2 including the alpha and beta variant. Large SARS-CoV-2 outbreaks can occur in fully vaccinated populations, but seem to associate with mild disease. SARS-CoV-2 infection in fully vaccinated individuals is a strong booster of the humoral immune response providing enhanced neutralisation capacity against immune evasion variants.Prophylactic vaccination against SARS-CoV-2 is one of the most important measures to contain the COVID-19 pandemic. Recently, break-through infections following vaccination against this virus have been reported. Here, we describe the humoral immune response of break-through infections in fully vaccinated individuals of old age from an outbreak in a nursing home. In cooperation with the local health authority, blood samples from fully vaccinated and infected as well as fully vaccinated and uninfected residents of the nursing home were collected 4 weeks after the onset of the outbreak. The humoral immune response was determined in a neutralisation assay with replication-competent virus isolates and by a quantitative ELISA. In this outbreak a total of 23 residents and four health care workers were tested positive for SARS-CoV-2. Four residents were unvaccinated, including one with a severe course of disease who later severe disease course who later succumbed to infection. Despite their old age, all vaccinated residents showed no or only mild disease. Comparison of the humoral immune response revealed significantly higher antibody levels in fully vaccinated infected individuals compared to fully vaccinated uninfected individuals ( Prophylactic vaccination against SARS-CoV-2 is one of the most important measures to contain the COVID-19 pandemic . The vecDespite these positive effects of vaccination, however, there are still groups of people in whom the vaccination response is reduced. These include patients with certain diseases or treatment associated with a reduced immune response, such as renal failure requiring dialysis or immunosuppressive therapy after organ transplantation –12. NotaThe breadth and magnitude of the immune response has also gained importance in the context of newly emerged virus variants . In addiMeanwhile, there are initial reports of outbreaks of SARS-CoV-2 following vaccination in care homes for the elderly . The hopIn early April, the Institute of Virology of the Heinrich-Heine-University was notified by the director of a nursing home for the elderly about a suspected SARS-CoV-2 outbreak after vaccination. Of the vaccinated residents, 24 received the Biontech Comirnaty (BNT162b2) and one received the Moderna mRNA-1273) vaccine. All vaccinations were carried out in the period between December 2020 and February 2021. In collaboration with local public health authorities, the outbreak was investigated and all residents of the facility where the infections had occurred were offered voluntary blood donations for analysis of anti-SARS-CoV-2 seroprevalence and humoral immune responses. In late April, about 3–4 weeks after the onset of infections, blood samples were collected in accordance with the local public health authority. The retrospective analysis of the outbreak was approved by the ethics committee of the Medical Faculty of the Heinrich-Heine University Duesseldorf (study no. 2021-1481). When possible, whole-genome sequencing (WGS) of SARS-CoV-2 was performed by the diagnostic laboratory where the initial PCR testing was performed. Characteristics of the study population are summarised in Samples were tested for anti-SARS-CoV-2 antibodies using two commercially available test systems. To distinguish antibody responses induced by vaccination from those induced by SARS-CoV-2 infections, the SARS-CoV-2 IgG chemiluminescent microparticle immunoassay (CMIA) from Abbott was performed on an ARCHITECT i2000Abbott. It detects SARS-CoV-2 nucleocapsid-specific (N) IgG antibodies. SARS-CoV-2 spike specific IgG antibodies, induced by either vaccination or infection were measured using the Euroimmun SARS-CoV-2-QuantiVac-ELISA on the Euroimmun Analyzer I-2P according to the manufacturer's instructions.50 SARS-CoV2 virus solution for 1 h at 37° C. After pre-incubation, 100 μl of cell suspension containing 7 × 104/ml Vero cells (ATTC-CCL-81) were added. Plates were incubated at 37°C, 5% CO2 for 4 days before microscopic inspection for virus-induced cytopathic effect (CPE). The neutralisation titre was determined as the highest serum dilution without CPE. Positive, negative, virus only, and cell growth controls were run during each assay.A serial dilution endpoint neutralisation test was performed to determine the neutralisation capacity of serum samples against an early SARS-CoV-2 B.1 isolate (GISAID accession ID: EPI_ISL_425126), a SARS-CoV-2 alpha variant , a SARS-CoV-2 beta variant  and a SARS-CoV-2 delta variant (B.1.617.2 GISAID accession ID: EPI_ISL_3104827). For all isolates, the neutralisation test was performed as previously described , 21. BriRNA was extracted from nasopharyngeal swabs that were tested positive for SARS-CoV-2. Obtained RNA samples were reverse transcribed and amplified using the Ion AmpliSeq SARS-CoV-2 Research Panel (Thermo Fisher) and resulting libraries were sequenced on the Ion Torrent S5 platform. Adapter sequences were removed from raw reads by Cutadapt v3.2 and aligned to the SARS-CoV-2 reference sequence NC_045512.2.fasta using bwa v0.7.17-r1188. SARS-CoV-2 genome sequences were reconstructed with iVar v1.3.1. Sequences are available via GISAID .Statistical analysis was performed in GraphPad Prism 9.0.00 . For comparison of the groups, a one-way ANOVA  with Dunn's correction for multiple comparisons was performed.In early April, a health care worker with mild symptoms in a care home was tested positive for SARS-CoV-2 by antigen tests. When possible contacts were tested by antigen testing the next day, a second health care worker tested positive, and the remaining tests on eleven individuals were negative. Confirmatory testing of positive antigen test results by PCR was also positive. Both health care workers with SARS-CoV-2 infection were unvaccinated. A few days later, all health care workers and all 42 residents of the care home were tested by antigen tests, of which nine individuals including seven fully vaccinated were positive. During additional testing in the following days a total of 23 residents and four health care workers were tested positive during this outbreak either by antigen test, PCR test or both. Whole viral genome sequences were available from 11 individuals including the two health care workers who were initially tested positive, confirming identical or nearly identical sequences consistent with a single source outbreak with the alpha variant . NotablyThe anti-SARS-CoV-2 spike response was determined by ELISA quantifying binding antibody units (BAU/ml). The median anti-SARS-CoV-2 spike antibody levels in the vaccinated and uninfected group was 268.7 BAU/ml including one outlier with a substantially higher level . Importantly, the median anti-SARS-CoV-2 spike level was significantly higher in the fully vaccinated and infected group . The anti-SARS-CoV-2 spike levels were on average 6.6-fold higher after infection than in the uninfected group . NotablyThe results of the ELISA were confirmed in a neutralisation assay using a replication competent SARS-CoV-2 B.1-isolate in cell culture. While all fully vaccinated and infected individuals showed high neutralisation titres the mean titre was significantly lower in the uninfected but fully vaccinated group, including four of eleven individuals with no neutralising activity . When thSARS-CoV-2 infections after vaccination have been described in various reports and demonstrate that sustained sterile immunity against COVID-19 is not always achieved. The outbreak described here in a nursing home for the elderly described here demonstrates that a super-spreading event can also occur even in the context of full vaccination. Given the short duration of the outbreak event, a reliable reconstruction of the infection chain is challenging. The first cases of infection had been detected in two non-vaccinated staff members of the facility when they had developed symptoms. A possible common source of infection for these two cases could not be found. The further timing of infections among facility residents suggests that at least one of the unvaccinated staff members and possibly both were responsible for transmission to secondary cases. Nearly all secondary cases of infection had contact with these two staff members in the phase prior to initial diagnosis. Phylogenetic analysis of the available complete viral genomes confirmed the assumption of an outbreak in which the isolates from staff and residents are almost identical and form a distinct cluster to all regionally circulating alpha variants studied. During the outbreak, a total of 27 infections could be detected by PCR and/or antigen test within 2 weeks, 19 of them in fully vaccinated persons. Although it cannot be formally ruled out with certainty, there was no evidence from the chronology that the secondary cases of infection had originated from vaccinated individuals.The outbreak was caused by the alpha variant (B.1.1.7), which was the dominant variant in the region at that time, accounting for about 90% of the infection cases. In the outbreak isolate, an additional substitution in the spike gene was detected, which leads to an amino acid exchange at position 779 (glutamine to lysine). Based on the localisation outside the receptor binding domain in the S2 domain of the spike protein, we speculate that this substitution has no strong influence on the efficacy of humoral immunity. This substitution has also not been associated with immune escape in the context of known variants of concern. In publicly available databases, this substitution has been described only in single isolates and is not present in 4095 isolates sequenced from regional infections . AlthougThe size of the outbreak allowed us to comparatively analyse the antibody response of vaccinated individuals with and without infection. On one hand, the detection of antibodies against the nucleocapsid confirmed contact with the virus in an indirect detection method in 13 of 15 infections. At the same time, in all 11 cases in which there was no evidence for infection either anamnestically or in direct virus detection assays, the test for nucleocapsid-specific antibodies was negative. Testing of nucleocapsid-specific antibodies in vaccinated persons, therefore, may provide additional information whether an infection has occurred, although the absence of these antibodies does not reliably rule out an infection. While studies show a high sensitivity and specificity for nucleocapsid antibodies as infections markers fifteen or more days after symptom onset , it coulThe high antibody levels most likely reflect a boost to the immune system by the infection. Unfortunately, samples from before the infection are not available, so it is not possible to exactly determine the extent of immune boosting by the infection. It is also not clear whether immunity was weaker in the group of infected people before infection than in the group without infection. Even among those individuals without infection, there were contacts with the suspected super spreaders, so exposure seems possible. The lack of longitudinal data as well as a control group of persons without vaccination examined in the same period after infection are important limitations of this study. It is noteworthy that the neutralisation titres were on average significantly lower in unvaccinated convalescents analysed at our lab with the same assay compared to vaccinated and infected individuals (data not shown). Generally, the levels of neutralising antibodies are suggested to be predictive markers of immune protection, at least from symptomatic infections , 26. In Even after complete vaccination, neutralising antibodies are not detectable in all individuals. Especially in elderly and immunosuppressed people, immunity after vaccination is less pronounced. In a previous study, about 30% of those over 80 years of age had no neutralising activity against the prototype virus 3 weeks after the second dose of an mRNA vaccine . In thisin vitro.It should be highlighted that only the humoral immune response was investigated in this study. The relevance of cellular immunity by T cells was not part of the analysis and is certainly also of great importance. This retrospective study also does not allow any conclusions about the causal mechanisms that led to the infections after vaccination. This would require longitudinal studies in vaccinated persons up to the time of a subsequent infection. In summary, the results confirm the observation that SARS-CoV-2 outbreaks are possible in a fully vaccinated risk group, but these are associated with rather low disease severity. Furthermore, we conclude that humoral immunity is significantly enhanced after infection in a vaccinated risk group and also protects against immune escape variants, at least The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Supplementary Material.Sampling and serological testing of SARS-CoV-2 specific antibodies have been performed in collaboration with the local public health service to analyse the extent of the outbreak. The retrospective analysis of neutralising antibodies in the available diagnostic samples and the evaluation of humoral immunity have been reviewed and approved by the Ethics Committee of the Medical Faculty of the University of Düsseldorf (study no. 2021-1481). As this is a retrospective analysis from diagnostic samples, the approval of the Ethics Committee to conduct the study was granted with waiver of a written informed consent form.JT and EB: conceptualisation. LM, MA, PO, NJ, GF, HW, HS, ID, AW, and OA: investigation. JT, AW, MA, LM, and PO: formal analysis. NJ, GF, HW, EH, KV, and FK: resources. LM, MA, EB, AW, and JT: writing—original draught preparation. LM, MA, PO, NJ, GF, JF, EB, EH, KV, FK, HW, HS, ID, AW, OA, and JT: writing—review and editing. All authors contributed to the article and approved the submitted version.This work was supported by the VIRus ALliance NRW (VIRAL) from the Ministry of Culture and Science of the State of North Rhine Westphalia (323-8.03-151826) and the Jürgen Manchot Foundation.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 impact of benign gynecological conditions on life of women and on costs for the society is high. The purpose of this study is to gain knowledge and understanding of costs of the treatment of these disorders in order to be able to improve the clinical care processes, gain insight into feasible savings opportunities and to allocate funds wisely.The healthcare processes of 311 women attending university or community hospitals in the Helsinki and Uusimaa Hospital District between June 2012 and August 2013 due to a benign gynecological condition were followed up for two years and treatment costs analysed.Total direct hospital costs averaged 689€ at six months and 2194€ at two years. The most expensive treatment was that of uterine fibroids in the short term and that of endometriosis and fibroids later on. Costs did not depend on hospital size. Surgical operations caused nearly half of hospital costs. Productivity loss caused biggest expenses outside of the hospital. LNG-IUD (levonorgestrel-releasing intrauterine device) accounted for the largest pharmaceutical costs for patients. Hospital treatment was associated with a reduced need for outpatient services during follow-up.A majority of direct hospital costs arise over time. This stresses the need for prolonged healthcare management. To control costs, the need for repetitive doctors’ appointments, monitoring tests, and ward treatments should be carefully evaluated. Procedures not needing an operation theatre (for example hysteroscopy for polypectomy), should be done ambulatorily. The impact of common benign gynecological conditions on the life of women  and on tLimited healthcare resources mandate that more focus is set on optimizing healthcare processes and on the cost-effectiveness and opportunity costs of treatment. As the ageing of the population and the desire for improved quality-of-life are associated with high healthcare costs , it is iThis study provides new, original, short- and long-term data on the healthcare processes and costs of treatment of common benign gynecological conditions in a publicly funded healthcare setting. Our study also reports the indirect costs of treatment and the more seldom reported other out-of-hospital costs. Furthermore, the study is set to answer whether the distribution of costs differs depending on the treated condition or the hospital size and whether hospital treatment diminishes the need to seek care elsewhere and thus decreases costs and indirect societal costs. This knowledge enables better recognition of patient groups whose treatment protocols need further development.st, 2012 and August 31st, 2013 were invited to participate. Patients with uterine fibroids or some other benign uterine neoplasms, endometriosis, adenomyosis, uterine prolapse, endometrial or cervical polyps, gynecological bleeding disorder, dysmenorrhea or lower abdominal/pelvic pain or some other benign uterine finding were included in the study. The patients were grouped according to the ICD-10 classification codes after clinician’s routine assessment. If a specific condition/pathology was found behind the presenting symptoms , the patient was categorized according to this primary diagnosis. If no apparent reason for the condition was found, the patient was grouped according to this idiopathic symptom (for example idiopathic menorrhagia in the bleeding disorder group).A prospective observational cost study conducted in the obstetrics and gynecology departments of the hospitals of the Helsinki and Uusimaa Hospital District: the Helsinki University Hospital  and four smaller community hospitals. All women treated for a benign gynecological condition in these hospitals between June 1Patients were treated according to typical clinical practice in the Finnish publicly funded (taxation based) healthcare system. The clinical care process was tracked regarding doctor’s appointments, laboratory examinations, imaging, pathological examinations, outpatient clinic procedures, surgical operations, and ward/inpatient treatment in the different patient groups. The direct hospital costs were acquired from the clinical patient administration database and are reported at the current cost level of the follow-up time (from June 2012 –August 2013 (study intake) until June 2014 –August 2015 (last follow-up survey). These direct hospital costs were analysed both in short-term (six-month follow-up) and in long-term (two-year follow-up). The average exchange rate during the study period varied between 1EUR = 1.11–1.33USD.To take out-of-hospital costs into account, the patients were asked to fill in a questionnaire concerning the use of services outside of the hospital before treatment , and at the six-month and the two-year follow-up. Patients reported nurses’ and doctors’ appointments at primary health care centres or private clinics, laboratory examinations, imaging, treatment for the same condition in other hospitals or clinics, drug purchases (including pain killers (for example NSAIDs), blood loss diminishing medicines (for example tranexamic acid), progesterone derivates  and separately LNG-IUD (levonorgestrel-releasing intrauterine device)) and absence from work during a three-month time period before each follow-up. Healthcare unit costs, productivity costs in Finland , 16 and Paired samples t-test was used to test the statistical significance of the change in costs during follow-up. The statistical significance of the differences in the mean costs between two unrelated groups was tested by independent samples t-test. Two-sided p-values < 0.05 were considered statistically significant. The data were analysed using SPSS for Windows statistical software version 22.0 .The Ethics Committee of the Helsinki University Central Hospital approved the study protocol (registration number 538/E0/02). The study was conducted in accordance with the 1964 Helsinki declaration and its later amendments. Informed written consent was obtained from all participants.Of the 1173 women invited to participate, 543 (46.3%) completed the baseline questionnaire. Of these, 425 (78.3%) answered also at six months and 397 (73.1%) at two years. The inclusion criteria  were met by 389 patients at six months and 311 patients at two years. Of them, 178 (57.2%) were treated in the university hospital and 133 (42.8%) in community hospitals. Patients were treated because of bleeding disorders (n = 94), uterine fibroids (n = 79), polyps (n = 68), dysmenorrhea/pelvic pain (n = 24), endometriosis (n = 23), uterine prolapse (n = 7) or some other benign uterine disorder (n = 16). The mean duration of the long-term follow-up was 24 months 11 days (SD±12days). The mean age of the patients at baseline was 49.6 years .Of all patients, 167 (46.3%) underwent surgery in an operation theatre. Of university hospital patients 44.4% (n = 79) and of community hospital patients 48.9% (n = 65) were treated operatively . Patients with uterine fibroids or a prolapse were most often treated operatively  and patients with bleeding disorders, pelvic pain or some other benign gynecological condition least often . The only statistically significant difference in operative treatment between the hospitals was that polyp patients were more often treated in the operation theatre in the community hospitals compared to the university hospital (66.7% versus 36.8%) .The total direct costs averaged 688.6€ (SD±1098.8 €) at six months and 2193.8€ (SD±2158.6€) at two years. Treatment of uterine fibroids was the most expensive intervention at six months. At two years, the costs were highest in the endometriosis and uterine fibroids groups. The treatment of other benign gynecological conditions was less expensive during the whole follow-up . There wNearly half of total direct costs (48.4%) was caused by surgery. Doctor’s appointments, inpatient/ward treatment, and outpatient procedures all accounted for similar proportions (13–17%) . Doctor’Mean direct costs outside of the hospitals  decreased in the whole study group significantly compared to baseline (450.2€ ±339.7) at both the six-month (309.0€ ±204.9) and two-year follow-ups (281.3€ ±421.9) (p<0.001). This decrease was seen in patients treated in university hospitals , but not in those treated in community hospitals . These direct costs were similar for patients treated conservatively or operatively. However, the productivity costs were temporarily, at six months, higher for patients treated operatively than for those treated conservatively , but returned to low levels by two years (58.3€ vs. 117.7€).The highest mean direct costs outside of the hospital were at baseline in the endometriosis group (735.0€ vs. 225.4–570.2€ in the other groups) and at six months in the pelvic pain group (598.3€ vs. 221.8€ - 370.5€). At the two-year follow-up, patients with a bleeding disorder, prolapse or some other benign gynecological condition reported significantly lower direct out-of-hospital costs than at baseline (p<0.05) .At baseline, endometriosis and pelvic pain patients  and at six months patients with fibroids, pelvic pain or prolapse  had the highest mean productivity costs compared to the other patient groups. In the long-term, however, marked productivity costs were observed only in endometriosis patients (803.5€ vs. 0–89.3€ of patients in the other groups). A significant decline in these costs during follow-up was noted in patients with a bleeding disorder or pelvic pain .Absence from work and ultrasound examinations performed by private gynecologists generated the highest costs outside of the hospital at baseline followed by appointments with general practitioners at primary health care centres or private clinics, LNG-IUD purchases, and appointments with private gynecologists. The burden of sick leave declined from the six-month high back to baseline levels by two years, however, still accounting for the highest proportion of costs outside of the hospital. Already by six months, costs due to private gynecologists’ appointments had, instead, diminished. Appointments with general practitioners at primary health care centres decreased throughout the whole follow-up, whereas costs due to appointments with general practitioners at private clinics and purchases of LNG-IUD persisted throughout the follow-up. Purchases of painkillers, progesterone derivatives, and pharmaceuticals diminishing blood loss decreased from baseline to two years. Cost distribution was otherwise similar in patients of the university hospital and community hospitals throughout the study but only the costs of blood loss diminishing medicines declined significantly in the community hospitals .At baseline, patients with pelvic pain used private gynecologists’ services least frequently but visited general practitioners most regularly. At six months, the difference in general practitioners’ visits at primary health care centres prevailed, but there were no longer differences in costs caused by private clinic general practitioner visits or private gynecological services between the diagnosis groups. At two years, also the use of general practitioners’ services at primary health care centres had evened out. At two years, endometriosis patients used private gynecological services significantly more than patients with a bleeding disorder or pelvic pain .At baseline, patients with endometriosis or pelvic pain purchased more analgesics than the other diagnosis groups. This tendency persisted throughout the follow-up. At six months, endometriosis patients used significantly more oral progesterone derivatives but fewer bought LNG-IUDs compared to patients with a bleeding disorder. Patients with fibroids used blood loss decreasing medicines significantly more often at the short-term follow-up than patients with polyps. At the long-term follow-up, endometriosis patients purchased more pharmaceuticals to diminish blood loss than patients with a bleeding disorder or a polyp .Benign gynecological conditions are often thought to be minor inconveniences rather than actual diseases. However, these conditions greatly affect the quality-of-life of women , 8, 9 anPrior studies have shown annual direct hospital costs of gynecological patients to vary from $5400  to $9500  , 11. Thest century [Very few studies have analyzed how money is spent in the actual day-to-day environment of gynecological clinics. One previous study with a six-month follow-up from the same area  in Finland was published ten years ago . Only pa century  and bleeIn endometriosis patients, 29% of direct costs have previously been reported to be caused by surgery, 19% by monitoring tests, 18% by hospitalization, and 16% by doctors’ appointments . In our Our study showed the treatment of fibroids to be the most expensive in the short-term. By two years, costs of endometriosis and fibroids were the highest. This is in line with two previous studies reporting similar annual costs in these groups , 11. As Less money, on the other hand, was used on the treatment of polyps in the university hospital. In accordance with previous reports , 19, ourOur study showed that the economic burden outside of the hospital declines after treatment initiation. However, indirect costs due to sick leave do not decrease in the long-term. This finding may indicate a relatively minor need for absence from work in the study group which is reflected in stable productivity costs. The reason why treatment reduces out-of-hospital costs more in patients treated in the university hospital than when treated in community hospitals remains unclear. Since baseline expenses do not differ, the explanation cannot be in different healthcare behaviour in the more rural areas.Cost data of common benign gynecological conditions in a typical real-world setting, and based on actually realized costs, are rare. Thus, as a strength of the study, our results are valuable for future cost-effectiveness analyses. A small uncertainty is associated with the out-of-hospital costs since these data were gathered by asking patients to recall their use of healthcare services, purchases of pharmaceuticals and days absent from work. In order to minimize bias caused by uncertain memory the surveys were limited to a three-month time period, which also enabled the comparison of equal time periods. Non-medical out-of-pocket costs such as menstrual pads and incontinence pads were unfortunately not gathered from study patients which could also increase the cost burden of some of the study patient groups. The patient material of the study is that of a referral hospital out-patient clinic. The patients were grouped according to clinical assessment using the ICD-10 classification codes based on primary disease. The authors feel that this kind of classification serves clinicians and healthcare assessment better than a symptom based classification as patients most likely present with more than one lead symptom and different diseases present with partly the same symptoms. The authors also feel that this approach may facilitate comparison to data obtained elsewhere as the ICD-10 classification codes are global and often used both in clinical work and scientific studies. Clinical data of women who chose not to participate in the study is unfortunately out of reach of this study. Generally, as clinical practice and resources vary in different countries, cost data should be interpreted by taking into account factors such as local purchasing power parity. As relatively few studies have been published in this field, the possibility of international cost comparison is limited.A majority of direct costs does not arise during the first months of treatment but accumulate with time showing the need for prolonged healthcare management and cost follow-up. Lower costs could be achieved by fewer repeated doctors’ appointments, fewer monitoring tests and by re-evaluating the need for hospitalization and length of ward treatment. Procedures that do not need to be done in the operation theatre should be done ambulatorily. Hospital treatment reduces the need to seek medical attention outside of the hospital and decreases out-of-hospital expenses.S1 Fig(DOCX)Click here for additional data file.S2 Fig(DOCX)Click here for additional data file.S1 Table(XLS)Click here for additional data file.