The in-depth, intensive, three-day TTS training program had a lasting impact. Providers reported greater commitment to helping their patients quit and maintain tobacco cessation habits.There is a need for program evaluations associated with educating healthcare professionals about the treatment of patients who use tobacco. The purpose of this study was to evaluate a Tobacco Treatment Specialist Training program with a pre-test and post-test (provided six months after the program) to determine if participants-maintained knowledge and practices to help patients with tobacco cessation in a mixed-model analysis. A pre-test survey was administered to attendees of a three-day tobacco treatment training continuing education certification program. After 6 months, the attendees were provided a post-test survey with open-ended and Likert-style questions. There were 98 participants who completed the pre-test and 16 who completed the post-test. Responses to the knowledge, confidence, and skills post-test indicated that there was significant improvement and maintenance at the six-month post-test. For example, knowledge improved from a mean of 61.1% (SD: 25.6%) to a mean of 87.9% (SD: 14.4%); medians of 66.7% and 77.7%, respectively,  The use of tobacco is the leading preventable risk factor for premature death in Western countries . While tThe good news, though, is that in a recent study, 68% of people who smoke cigarettes in the U.S. want to quit . In cessThese findings underline the need for effective interventions to assist with tobacco cessation. One powerful tool is the education of healthcare providers with evidence-based cessation strategies. This is critical as conventional products are changing and newer tobacco products are emerging.Tobacco Treatment Specialist Training Programs (TTSTP) are educational programs for healthcare providers to have current, evidence-based knowledge and skills to encourage and assist with tobacco cessation. It was through the work of the Association for the Treatment of Tobacco Use and Dependence that the initial programs were developed and educational competencies established. Through an interprofessional effort, they formed a council . In 2008 the Council developed a comprehensive approach to implementing evidence-based standards and supporting the growth of accredited programs across the U.S. Currently, there are 25 accredited programs. The goal of CTTTP is to educate healthcare participants to be able to aid people from diverse backgrounds in their tobacco cessation attempts. There are 11 competency requirements: (1) tobacco dependence knowledge and education; (2) counseling skills; (3) assessment skills; (4) treatment planning; (5) pharmacotherapy; (6) relapse prevention; (7) diversity and specific health issues; (8) documentation and evaluation; (9) professional resources; (10) laws and ethics; and (11) professional development.The program helps healthcare to determine the intensity of treatment required to aid in tobacco cession intervention techniques. While many patients can be treated with low-intensity treatment, many individuals need high-intensity (combination) treatments to effectively address nicotine withdrawal, motivation, self-efficacy, and managing skills . For thiThis study received West Virginia University Institutional Board approval as an exempt protocol, number 20039360. A mixed-method study design was used.The study sample included professional healthcare registrants, ages ≥18 years, who provided consent and completed the May 2021 TTSTP. The sample included physicians, dentists, dental hygienists, nurses, advanced practice nurses, respiratory therapists, social workers, licensed professional counselors, and addiction counselors who were licensed or students in the healthcare field.The TTSTP was a 3-day event with multiple interprofessional speakers and participants from medicine, dentistry, social work, pharmacy, nursing, and public health. The program involved lectures about conventional and newer tobacco and nicotine delivery systems, role-playing, group discussions, treatment planning, and relapse prevention. Participants were provided information on the use of the Fagerstrom Test for Nicotine Dependence (FTND), Heaviness of Smoking Index (HS), Hooked on Nicotine Check List (HONC), Fagerstrom Nicotine Dependence Scale—Smokeless Tobacco (FTND-ST), and the Penn State Nicotine Dependence Index. The pre-test and post-test questions were developed through a consensus of experts in tobacco cessation treatment and were a sample of the most meaningful and important aspects of knowledge and practices associated with tobacco cessation.Participation in the research study was not a requirement for participation in the educational program. Participants were informed that the questions would involve their knowledge, skills, practices, and confidence in providing tobacco cessation assistance in Likert-style questions. Open-ended questions on the post-test were used for the qualitative aspect of the study.The research was conducted using the Kirkpatrick Four Levels for Effective Evaluation of Training programs in which (1) participant reaction, (2) learning, (3) behaviors, and (4) outcomes are considered . Partici® SPSS® Statistics Version 26 . Mann–Whitney U non-parametric test was used for each separate Likert-style question. A t-test was used for the summary knowledge scores. Significance was set at p < 0.05.The data were analyzed with IBMThe May 2021 TTSTP included 122 healthcare providers from medicine, dentistry, pharmacy, nursing, advanced practice nursing, respiratory therapy, licensed professional counseling, addiction counseling, and social work. Participants who responded to the pre-test were primarily (90.6%) non-Hispanic white participants, female (71.5%), and from the dental field (57.2%). Demographic data were not asked on the post-test. There were 98 (80%) participants who completed the pre-test, and 16 (13%) participants completed the post-test.Qualitative ResultsThree themes emerged from the participants’ comments. These were (1) appreciation for current, evidence-based content—foundational knowledge; (2) perception of increased confidence; and (3) increased skills in pharmacotherapy and combined treatment for tobacco cessation.“I feel like I have more complete information to offer;”“I will assess and advise differently;”“I am more knowledgeable about tobacco cessation.”“[I] feel more confident talking with my clients on how they can quit;”“[I will] provide formal tobacco cessation education; prescribe medication for tobacco cessation and perform more thorough counseling;” and“[I will] be doing more in prescribing; begin actively helping patients with smoking cessation more.”Common participant reactions for appreciation for having current, evidence-based content in the program included statements such as:“[I] feel more confident talking with my clients on how they can quit;”“[I will] provide formal tobacco cessation education;prescribe medication for tobacco cessation;and perform more thorough counseling;” and“[I will] be more confident in prescribing;begin actively helping patients with smoking cessation more.”Common reactions for the second theme (increased confidence) that were evident from participants’ reactions after the program were statements such as:“I can now apply evidenced based medicine and safely and efficiently prescribe, to best serve my patients and community;”“Offer pharmacotherapy;” and“Recommend combination pharmatherapy [sic].”The third theme centered around the participants’ recognition of having increased skills in pharmacotherapy and combined treatment for tobacco cessation. This then was exemplified by statements such as:Quantitative Resultsp < 0.001. Details for specific questions are presented in For the nine learning/knowledge questions, the mean score on the pre-test was 61.1% (SD: 25.6%), and the median was 66.7% correct. The mean score on the post-test was 87.9% (SD: 14.4%), and the median was 77.8%, In this study, participants reported significant improvement in knowledge, confidence, and evidence-based practices in managing patients with tobacco cessation on a post-test administered six months following a TTSTP program. Participants were more likely to report being at an expert level in skills associated with tobacco cessation on the post-test as compared with the pre-test. Comments about the skills learned and confidence gained were positive, and the participants expressed appreciation for having had the learning experience.There is a lack of comparable program evaluation studies related to tobacco cessation programs for healthcare provider interprofessional education. In one similar study of program evaluation, the researcher evaluated a train-the-trainer program . HoweverIn another study, researchers used a pre-test/end-of-academic year post-test format to evaluate a 4-h webinar format, an interprofessional faculty train-the-trainer program designed for respiratory therapy faculty . The empAnother tobacco evaluation study was conducted with qualitative methods. The researchers interviewed 18 participants of the Rx for Change: Clinician-Assisted Tobacco Cessation program and reported that participants had increased confidence and counseling skills, enhanced treatment practices, and useful background information even 12–14 years after having participated in the program [In a study in which researchers used a data-driven community-based participatory research approach, online educational modules were created and tested by community leaders and academic researchers . They coThis study has both strengths and limitations. A study limitation is the number of responses received on the post-test. It was sent to participants twice. However, the response rate was low. Reasons for the low response rate include the impact of the COVID-19 pandemic on available healthcare provider time and changes in contact information over the six months of the study. A strength of the study is the use of questions that had been vetted by experts in tobacco treatment to hone in upon the factor that was most important: helping patients to quit tobacco use and maintain being tobacco-free.There remains a considerable need to help patients with tobacco cessation. Programs that have summative success, such as this program, are of great importance to public health. They should be supported and expanded into professional healthcare students’ education. Future research should include economic impact based on the number of successful tobacco cessations participants experience after having completed the program.While there was a limited six-month response rate in this study, results showed overwhelming improvement in knowledge, confidence, and skills in managing patients with tobacco cessation. The in-depth, intensive, three-day TTS training program had a lasting impact on those responding healthcare providers’, and some rated themselves at the expert level in many skill areas associated with cessation. More research needs to be completed on the impact of TTS training, particularly as conventional and newer tobacco products continue to flood the market.


Determining whether SARS-CoV-2 exhibits seasonality like other respiratory viruses is critical for public health planning. We evaluated whether COVID-19 rates follow a seasonal pattern using time series models. We used time series decomposition to extract the annual seasonal component of COVID-19 case, hospitalization, and mortality rates from March 2020 through December 2022 for the United States and Europe. Models were adjusted for a country-specific stringency index to account for confounding by various interventions. Despite year-round disease activity, we identified seasonal spikes in COVID-19 from approximately November through April for all outcomes and in all countries. Our results support employing annual preventative measures against SARS-CoV-2, such as administering seasonal booster vaccines in a similar timeframe as those in place for influenza. Whether certain high-risk individuals may need more than one COVID-19 vaccine booster dose each year will depend on factors like vaccine durability against severe illness and levels of year-round disease activity. Globally, waves of infection, hospitalization, and mortality have paralleled the emergence of new variants of concern which have shown increased transmissibility2 and improved ability to evade vaccine- and infection-induced immunity3. Vaccination strategies to date have struggled to keep pace, and booster doses have been deployed to bolster protection against infection and symptomatic disease and maintain peak protection against severe disease throughout the pandemic8.The Coronavirus Disease 2019 (COVID-19) pandemic has caused unprecedented worldwide morbidity, mortality, and social and economic disruption10. These patterns are likely caused by a combination of host, pathogen, and environmental factors, including increased indoor activity and seasonal weather fluctuations known to impact viral stability outside the host13. Further, containment measures and pandemic virus variants have been shown to impact epidemic curves across various countries and could shift seasonal patterns15.Many respiratory viruses show distinct seasonal patterns and result in waves of illness during the winter months18. Determining whether SARS-CoV-2 exhibits seasonal spikes in disease activity is critical for public health planning, including informing vaccination policy about the optimal timing for deploying additional doses. To help answer this urgent public health question, we used time series models to evaluate the seasonal patterns of COVID-19 cases, hospitalizations, and mortality in the United States and Europe with the objective to determine if COVID-19 follows typical respiratory virus seasonal patterns.To date, there is still discussion about whether SARS-CoV-2 currently follows, or will follow in the future, similar seasonal patterns to other respiratory viruses20. OWID sources case and mortality data from Johns Hopkins University21 and hospitalization data from various official country-specific sources18. Data were included from 01 Mar 2020 through 31 Dec 2022, as available by country. If daily data were missing or unavailable, data were substituted from that country’s corresponding weekly data.We followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for our ecological study. Daily rates of COVID-19 cases, hospitalizations, and mortality per million population by country for the United States, all countries in the European Union, and the United Kingdom were obtained from the public-use Our World in Data (OWID) GitHub repository23. In these models, we decomposed the observed data into a trend component and weekly and annual seasonal components and included the country-specific stringency index as a regressor to account for potential confounding by nonpharmaceutical interventions. The stringency index was developed by the Oxford Coronavirus Government Response Tracker project and is a composite of nine metrics including school closures, workplace closures, cancellation of public events, restrictions on public gatherings, closures of public transport, stay-at-home requirements, public information campaigns, restrictions on mobility and access to services, and international travel restrictions24. Uncertainty interval widths for computed point estimates were set to 95%, with 2000 uncertainty samples used to compute the intervals. Bayesian sampling was performed with 2000 Markov Chain Monte Carlo samples to obtain uncertainty intervals for seasonality estimates. In our models, we focused our analysis on the annual seasonal component only, which models the annual seasonal changes in observed rates after any long-term trends. The estimated rate is the sum of the long-term trend, weekly, and seasonal components, as well as the estimated effect of the country-specific stringency index. Positive values for the seasonal component indicate rates during that time of year are higher than during other parts of the year, while negative values indicate decreased rates during that season.We used a Prophet time series model to decompose daily country-specific time series rates of COVID-19 cases, hospitalizations, and mortality separately and adjusted for the country stringency index in an additive, linear time seriesIn addition to extracting the decomposed trend, annual seasonal component, weekly seasonal component, and the estimated effect of the stringency index, the monthly median value of the annual seasonal component was computed and displayed in a country-level heatmap to depict the months driving annual seasonal increases more clearly.25. This approach was used to assess whether the model would predict well-documented annual seasonal patterns for influenza and if those patterns matched those we documented for SARS-CoV-2. Influenza positivity rates were defined by computing the percent positive specimens of all respiratory specimens processed from 04 Oct 2009 through 19 Dec 2021 using the same countries . Malta was not evaluated, as influenza data were not available from the World Health Organization.To validate our modeling approach, we applied the same Prophet model (excluding the stringency index regressor) to pre-pandemic country-level influenza data from the World Health OrganizationAll data used in this study were publicly available and de-identified and therefore did not constitute human subjects research per 45 CFR 46.102. Due to this, the study did not require IRB registration or review.R version 4.2.2  was used for all analyses.Collapsed across all years of our study period, our model showed distinct annual seasonality consistent across COVID-19 case  also documented the well-established annual seasonality of pre-pandemic influenza between December and April over twelve US influenza seasons Fig. , consist27. Our results indicate seasonal spikes are consistent with seasonal patterns seen for influenza27, respiratory syncytial virus (RSV)28, and other coronaviruses29, and are compatible with mathematical simulations of COVID-19 activity17.Although SARS-CoV-2 continues to cause disease throughout the year, we identified seasonal spikes in COVID-19 cases, hospitalizations, and mortality from November through April across all years of the pandemic to date in the United States and Europe, a finding that is consistent with the typical months of seasonal respiratory virus epidemics in the northern hemisphere18. Regardless of the mechanisms, knowledge of pathogen seasonality is imperative for instituting targeted interventions to lessen the impact when the burden on our healthcare infrastructure is the greatest. Accordingly, our findings have important vaccine policy implications. Additional doses of COVID-19 vaccines or modified versions of the vaccines administered before the winter months will likely have the most significant public health impact on the COVID-19 burden. This is analogous to providing influenza vaccine before peak flu activity each year to mitigate the largest spikes in disease burden. Despite evidence that protection provided by current mRNA COVID-19 vaccines wanes significantly against omicron infection and symptomatic disease after only 3–4 months, even after a booster30, this short-term added protection could still provide meaningful defense against SARS-CoV-2 infection if deployed just before seasonal waves which last 3–4 months on average.There are many possible reasons for the seasonality of respiratory viruses, including climate-related changes in viral transmissibility, modified host factors , and changes in human behavior during the winter months31. COVID-19 continues to cause substantial morbidity and mortality throughout the year, including outside of the traditional viral respiratory season. In addition, rapid evolution of new variants or subvariants could impact seasonal patterns. Our data showed smaller waves of COVID-19 in the summer months, which were likely driven by new variants that emerged during this time period over the course of the pandemic 32. Novel variants or subvariants that exhibit enhanced immune escape or transmissibility or any other property that increases viral fitness could alter seasonal patterns or cause an off-season outbreak33. Thus, additional COVID-19 vaccine booster doses may be needed at a frequency greater than once annually for certain high-risk individuals. This determination will be a careful balance between epidemiological, benefit-risk, and programmatic considerations (including concerns regarding “booster fatigue”35) moving forward and will likely depend primarily on COVID-19 vaccine durability against severe illness and levels of year-round disease activity. For this reason, continued surveillance of real-time vaccine performance and the emergence of new variants remains critical.Because SARS-CoV-2 appears to be more transmissible than influenza and other seasonal respiratory viruses, it seems likely that year-round SARS-CoV-2 activity will remain elevated compared to other pathogens36. A pandemic was declared on June 11, 2009 and cases peaked in July. It was not until the second autumn wave that disease patterns became more aligned with the typical influenza season36. In addition, pandemic containment measures can impact seasonal trends. For example, during the COVID-19 pandemic, both influenza and respiratory syncytial virus transmission followed atypical patterns37. Further, at the time of writing, China is currently experiencing a large wave of COVID-19 that likely corresponds with the lifting of country-wide lockdown measures38 Vaccination could also shift the seasonality of respiratory viruses, however, this has not occurred for influenza, the only other respiratory virus for which vaccination is available and uptake is high.It should be noted that other viral pathogens also have, on occasion, followed atypical seasonal patterns. For example, the 2009 H1N1 influenza pandemic began in the spring of 2009 toward the end of the typical influenza season in the Northern Hemisphere28, underscoring the utility of the methodology we used for detecting seasonal patterns in common respiratory viruses. Regardless, our results have at least five limitations. First, we could not account for the potential underreporting of cases, which may have a large effect more recently with increases in at-home SARS-CoV-2 testing that may not be reported39. Finding similar results for COVID-19 hospitalizations and deaths, which are less likely to be under-reported, however, was reassuring. Second, statistical modeling may not fully reflect the intricacies of preventing transmissible infectious diseases, such as the impact of COVID-19 vaccination, waning immunity, or changes in testing, nonpharmaceutical interventions, or healthcare-seeking behavior over time. Third, although the pandemic is in its third year, the longitudinal data available for modeling was limited compared to other common seasonal viruses. Because of this, similar models created in the future may illustrate different outputs given variable prevention behaviors, vaccines and vaccine uptake, and novel SARS-CoV-2 variants. Fourth, our findings are not generalizable beyond the United States and Europe. More research is needed to understand if the same annual seasonal patterns in SARS-CoV-2 activity are seen in the Southern Hemisphere or Asia–Pacific regions. Finally, with SARS-CoV-2, there is always the potential for new variants to emerge that could meaningfully escape prior vaccine- or infection-induced immunity and cause significant epidemics outside of regular seasonal patterns identified thus far in the pandemic. Therefore, the public health community should continue to plan and maintain the capability for sufficient response in the event of this possibility.Our methodology also detected the annual seasonality of influenza virus in the same countries, corresponding to known annual seasonal patterns of influenzaOur study suggests that COVID-19 activity and associated hospitalization and mortality in the United States and Europe peak during the traditional winter viral respiratory season despite continual transmission throughout the year. Thus, employing annual protective measures against SARS-CoV-2 such as administering seasonal booster vaccines or other non-pharmaceutical interventions for the general population in a similar timeframe as those already in place for influenza prevention  is a prudent strategy to stay ahead of likely forthcoming seasonal waves of COVID-19. However, whether certain high-risk individuals may need more than one booster dose each year will depend on factors like vaccine durability against severe illness and levels of year-round disease activity. Additional confirmatory studies are needed, including those conducted in the Southern Hemisphere and other regions outside the United States and Europe.Supplementary Figures.


Amaranthus spp. with herbicides inhibiting acetolactate synthase (ALS) has been observed for several years in soybean fields in north-eastern Italy, but to date only a few ALS-resistant populations have been confirmed. An extensive sampling of putatively resistant Amaranthus accessions was completed in the Friuli Venezia Giulia region, across an arable land area of about 3000 km2. In total, 58 accessions were tested to confirm their resistance status, recognize the Amaranthus species, identify the mutant ALS alleles endowing the resistance and determine the efficacy of 3 pre-emergence herbicides. Most accessions resulted in cross-resistance to thifensulfuron-methyl and imazamox. Genomic DNA were extracted from single seeds with a newly developed protocol; an allele-specific PCR assay revealed the presence of the 574-leucine in 20 accessions, of the 574-methionine in 22, and of both alleles in 9 accessions. The two variants showed a different spatial distribution. All resistant populations were ascribed to A. hybridus. A. hybridus resistant to ALS herbicides is well-established in this Italian region and its resistance is due to two ALS mutant alleles. Metribuzin, clomazone and metobromuron can be used as alternative herbicides to be applied in pre-emergence and they should be integrated into the management strategies to limit the spread of resistance.Poor control of  Weeds are among the pests that can determine crop losses if not adequately controlled . HerbiciAmaranthus genus is frequently involved in herbicide resistance: until now, 9 species (out of the roughly 70 commonly recognized) have evolved resistance to at least one herbicide site of action (SoA)  buffer, originally developed for plant tissue, had been adapted  to extraALS gene was partially amplified to look for point mutations at position 574. Primers AMA-2F (TCCCGGTTAAAATCATGCTC) and AMA-2R (CTTCTTCCATCACCCTCTGT) were used to amplify a region 337 bp following a previously described procedure , while the relative fresh weight (FW) was calculated as the percentage of [the fresh weight of survived seedlings in treated pots/seedlings in non-treated pots]. The experimental layout was a complete randomized design with 3 replicates (pots) per treatment and 4 replicates per non-treated pots, and 50 seeds per pot. The experiment was conducted twice. Standard error (SE) was calculated for each data mean and data were analyzed with R [To test if accessions were susceptible to non-ALS herbicides, the same six accessions described in d with R  in RStudd with R . A t-tes


The COVID-19 pandemic has severely impacted populations globally, and knowledge, attitudes and practices (KAPs) surrounding the virus have necessarily evolved. This study was conducted in partnership with International Care Ministries (ICM), a Philippine-based non-governmental organization that runs the “Transform” poverty alleviation program. The main objective of this study was to describe the changes in COVID-19 KAPs among households experiencing extreme poverty in the Philippines over an 8-month period.A KAP questionnaire was integrated into the household survey collected as part of ICM’s regular monitoring and evaluation of “Transform”. Data collection for the first survey was conducted between February 20 and March 13, 2020, and the second survey was conducted between November 12 and December 12, 2020. Frequencies and proportions were calculated to describe the respondents’ responses and the Kruskal-Wallis test was used to assess if there were significant differences in KAP identification between the two time points.We observed a distinct increase across all KAP domains. Over 90% of study participants were able to correctly identify COVID-19 transmission modes and preventive measures, and an even higher percentage reported adopting these measures. However, the intention to seek care from public hospitals for COVID-19 symptoms dropped from 43.6% to 28.4%, while reports of self-treatment using stored medicines or antibiotics increased. Trust in community members and local health authorities was correlated with higher knowledge and practice scores.Our study results reflect the extraordinary speed of information dissemination and behaviour change globally over the course of the pandemic, but they also highlight the changes in KAP that show the additional challenges faced by populations experiencing poverty in the Philippines. Prioritization of reducing inequities in the implementation and adoption of the evolving public health measures will be integral as the pandemic continues. COVID-19 has spread wider and persisted for longer than most people expected, but the end of the pandemic is still far from sight. Virtually no country has been left untouched by COVID-19, with most having experienced multiple waves of infections and the unintended consequences of imposing a series of measures to control its spread , the govA previous study on the knowledge, attitudes, and practices (KAP) of COVID-19 among households experiencing extreme poverty in the Philippines was conducted between February 20 and March 13, 2020 . These pThe objectives of this study were 3-fold: 1) To describe the changes in COVID-19 KAPs among households experiencing extreme poverty in the Philippines over a period of about 8 months, 2) to examine the socio-demographic characteristics correlated with COVID-19 knowledge and practices during the second survey period, and 3) to assess whether receiving targeted health education was correlated with greater KAP towards COVID-19.This study was conducted in partnership with International Care Ministries (ICM), a Philippine-based non-governmental organization (NGO) working to support extreme low-income households through a poverty-alleviation program called “Transform”. ICM’s “Transform” program works exclusively with individuals and households experiencing extreme poverty, defined by the organization as households that report having a daily income below US$0.50 per person . EmbeddeThe survey was carried out from November 12, 2020, to December 12, 2020, about 8 months since the first COVID-19 KAP questionnaire was administered , attitudes , practices (preventive measures adopted), and sources consulted for information about COVID-19  COVID-19 tests were provided at ICM’s regional field office sites, and enumerators were required to submit a negative test prior to entering the communities. Data collection periods were phased across field office sites to account for testing needs and local travel restrictions. Upon arrival at the household, enumerators were instructed to first inquire if anyone in the household was confirmed or suspected of being infected with COVID-19, being monitored for COVID-19, or currently undergoing quarantine. If so, this was noted by the enumerators and the survey was not conducted.Households in rural, urban, and coastal settings from the following twenty provinces in the Philippines were surveyed: Palawan, North Cotabato, Zamboanga Del Sur, Misamis Occidental, Zamboanga Del Norte, Sultan Kudarat, Zamboanga Sibugay, Sarangani, Davao Del Sur, South Cotabato, Guimaras, Siquijor, Antique, Aklan, Capiz, Iloilo, Negros Oriental, Bohol, Negros Occidental, and Cebu.P < 0.05) in KAP identification between the two time points.Frequencies and proportions were calculated for each KAP question from both surveys conducted during the early pandemic period and the mid-pandemic period. Given that our continuous outcome measures did not follow a normal distribution via examination by the Shapiro-Wilk test, the Kruskal-Wallis test was used to assess whether there were significant differences  for the number of COVID-19 transmission modes identified, the number of COVID-19 preventive measures identified, and the number of COVID-19 preventive measures taken were constructed as the outcome variables. The Kruskal-Wallis test indicated whether the means of the outcome variables were significantly different between the categories of each socio-demographic variable, which included: income level, geographical location, educational attainment, access to mobile phones or televisions, social ties with regional health and government units, and whether the respondent completed the “Transform” program.The correlation of these socio-demographic characteristics with attitudes towards COVID-19 during the mid-pandemic period was also examined. Whether respondents were worried about contracting COVID-19 was used as the binary outcome measure. Odds ratios and 95% confidence intervals (CIs) were calculated using multivariable logistic regression. The number of COVID-19 transmission modes identified and whether respondents felt that their lives had been changed by the virus were also included as predictors in the model. All statistical analyses were conducted using Stata 13   and R veData collection was approved by the University of Toronto Research Ethics Board (Protocol Number: 39138), and verbal informed consent for survey participation was obtained from all respondents.1) and mid-pandemic period (t2). The samples were highly comparable, as no significant differences were detected between them on most demographic characteristics: notably, over 90.0% of respondents at both time points were female, and the average age was 41.7 years old (SD = 14.4) in the mid-pandemic period, compared to 41.3 years old (SD = 14.6) in the earlier survey. From the characteristics where there were significant differences, we were able to observe some of the socio-economic ramifications due to COVID-19 in this population. Where 57.0% of respondents were living on less than US$1.00 a day in early 2020, this figure had risen by 65.0% by the end of the year. As most of the respondents are day labourers, farmers, fishermen, and under-employed, frequent work disruptions caused by anti-epidemic measures, such as regional lockdowns and community quarantine restrictions, can have tremendous impacts on their income sources. The apparent movement of respondents from urban to rural areas may also reflect the decisions of households to relocate away from cities with strict and prolonged implementation of lockdown restrictions.A total of 3354 participants representing 174 communities were targeted for the mid-pandemic period survey, of which 2453 participants from 158 communities were successfully surveyed (78.2%). This response rate was lower than for the early pandemic period survey  as some communities could not be accessed due to local COVID-19 travel restrictions. 2) of respondents reporting using it to stay up to date about the virus, similar to the early pandemic period survey’s report (P = 0.600). The next most frequently sought information source, the radio, saw a dramatic increase in its reported use from 56.1% (t1) to 74.2% (t2) (P < 0.001). Compared to the earlier survey, there were substantial increases in respondents who reported consulting other community members for information about COVID-19, notably friends, family or neighbours  and local government officials . While the use of social media  and internet sources  also increased, the use of digital media was comparatively less common.Traditional media were still the dominant sources of information about COVID-19 (1) during the early pandemic period (P < 0.001). It is evident that the effects of the virus and the associated policy restrictions to curb its spread were far-reaching, as the percentage of those who reported having their lives disrupted by COVID-19 increased from 54.0% (t1) to 90.5% (t2) (P < 0.001). This heightened awareness of the virus was also reflected in increased knowledge, as all COVID-19 transmission routes presented in the survey were identified by over 90% (t2) of respondents. Identification of relevant preventive practices was also largely accurate, with increases in the selection of handwashing , face masks , hand sanitizers , and staying away from people who are sick  as ways to protect themselves from COVID-19. An increase was also seen for the option of avoiding large crowds , but its relatively lower identification as a preventive practice may be because it is less relevant in remote rural and coastal areas. Drastic improvements in practices were also observed compared to the early pandemic period, with almost universal implementation of recommended preventive measures among survey respondents, including avoiding crowded places , hand washing , having access to hand sanitisers , and wearing face masks . Notably, in both surveys, the percentage of respondents who reported practising these preventive measures was greater than the percentage of those who identified it as a preventive measure.The mid-pandemic survey was conducted when COVID-19 was widespread both globally and in the Philippines. At this time, 99.3% of respondents reported having heard of the virus, compared to 94.0% , use stored medicine at home , or seek antibiotics , whereas the intention to visit public hospitals saw a substantial drop from 43.6% (t1) to 28.4% (t2) (P < 0.001).There were also changes in what respondents reported they would do if they displayed COVID-19 symptoms. There were noteworthy increases in the number of people who reported they would stay at home and wait to get better , possibly played a key role in determining COVID-19 knowledge and practices. Respondents who reported higher levels of trust in their neighbours, on average, correctly identified and adopted more COVID-19 preventive measures. Higher levels of trust in respondents’ barangay health station or RHU were correlated with greater average scores on all three outcomes: correct identification of COVID-19 transmission routes, and preventive measures identified and taken. Lastly, and perhaps surprisingly, being a graduate of “Transform” did not have a significant effect on KAP scores.We further examined the socio-demographic characteristics correlated with COVID-19 knowledge and practices during the mid-pandemic period  with those who had dropped out of the program before the training, we did not have a strict control group and were unable to make causal inferences. Also, as the survey results were based on self-reported rather than observed practices, some measures may have been overestimated due to social desirability bias. While we did not control for the possible effects of survey enumerators on responses, they had received training not to influence responses among participants.The merit of this study is in its utilization of a repeated cross-sectional design, allowing for observation of how Given the rapidly changing landscape of COVID-19, survey tools should also be updated as appropriate to capture the current state of knowledge and priorities. Future KAP studies, for example, should incorporate additional items to assess testing and vaccination. Additionally, as this study has demonstrated, KAP is time-sensitive, so it is imperative that studies report the time frame of data collection for meaningful interpretation of the results. This is likewise applicable to systematic reviews and meta-analyses of KAP studies, where the pooling of estimates without considering their position in the pandemic period should be avoided. As a complement to KAP studies, conducting qualitative research into determinants of trust in COVID-19 public health messaging and response measures would also be an important step to strengthen health service provision and access for populations experiencing poverty.The across-the-board increases in KAP towards COVID-19 observed in our study, alongside similar observations across multiple contexts and socioeconomic circumstances , reflect


This cohort study assesses the association of rare variants of cardiomyopathy and arrhythmia genes with all-cause mortality among patients with early-onset atrial fibrillation. In patients with early-onset atrial fibrillation (AF), are rare variants in cardiomyopathy and arrhythmia genes associated with increased all-cause mortality?In this cohort study of 1293 participants diagnosed with AF before 66 years of age, time to death was significantly associated with a disease-associated variant, age at AF diagnosis, and the interaction between age at AF diagnosis and variant status.The findings suggest that among patients with early-onset AF, the presence of a disease-associated rare variant for an inherited cardiomyopathy or arrhythmia syndrome may be associated with an increased risk of mortality. Patients with early-onset atrial fibrillation (AF) are enriched for rare variants in cardiomyopathy and arrhythmia genes. The clinical significance of these rare variants in patients with early-onset AF is unknown.To assess the association between rare variants in cardiomyopathy and arrhythmia genes detected in patients with early-onset AF and time to death.This prospective cohort study included participants with AF diagnosed before 66 years of age who underwent whole-genome sequencing through the National Heart, Lung and Blood Institute’s Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data were analyzed from February 26 to September 19, 2021.Rare variants identified in a panel of 145 genes that are included in cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories.The primary study outcome was time to death and was adjudicated from medical records and the National Death Index. Multivariable Cox proportional hazards regression was used to evaluate the association of disease-associated variants with risk of death after adjustment for age at AF diagnosis, sex, race, body mass index, left ventricular ejection fraction, and an interaction term of age at AF diagnosis and disease-associated variant status.P = .05); the association remained significant in multivariable modeling when adjusted for age at AF diagnosis, sex, race, body mass index, left ventricular ejection fraction, and an interaction term between disease-associated variant status and age at AF diagnosis. The interaction demonstrated that disease-associated variants were associated with a significantly higher risk of mortality compared with no disease-associated variant when AF was diagnosed at a younger age (P = .008 for interaction). Higher body mass index  and lower left ventricular ejection fraction  were associated with higher mortality risk. There were 73 cardiomyopathy-related deaths, 40 sudden deaths, and 10 stroke-related deaths. Mortality among patients with the most prevalent genes with disease-associated variants was 26% (10 of 38 patients) for TTN, 33% (6 of 18) for MYH7, 22% (2 of 9) for LMNA, 0% (0 of 10) for MYH6, and 0% (0 of 8) for KCNQ1.Among 1293 participants , disease-associated (pathogenic or likely pathogenic) rare variants were found in 131 (10%). During a median follow-up of 9.9 years , 219 participants (17%) died. In univariable analysis, disease-associated variants were associated with an increased risk of mortality (hazard ratio, [HR], 1.5; 95% CI, 1.0-2.1; The findings suggest that rare variants in cardiomyopathy and arrhythmia genes may be associated with increased risk of mortality among patients with early-onset AF, especially those diagnosed at a younger age. Genetic testing may provide important prognostic information for patients with early-onset AF. Patients with idiopathic or lone AF were first reported5 to have a higher risk of mortality almost 40 years ago, but the pathophysiology was unknown.6 The recognition that patients with early-onset AF are enriched for rare genetic variants associated with inherited cardiomyopathy (CM) and arrhythmia syndromes suggests that in some patients, AF may be the first sign of a more serious underlying genetic disease.10 A study11 recently reported that sequencing of a 145-gene CM and arrhythmia panel identified pathogenic or likely pathogenic variants in 10.1% of patients diagnosed with AF before 66 years of age and 16.8% of those diagnosed before 30 years of age.The independent association between atrial fibrillation (AF) and increased risk of mortality is well established in older populations.19 Accordingly, we hypothesized that disease-associated rare variants in patients with early-onset AF would be associated with a higher risk of mortality and that there would be an interaction between genotype-positive status and younger age at AF diagnosis in terms of mortality risk. We assessed a cohort of 1293 patients with early-onset AF who underwent whole-genome sequencing11 and searched the Centers for Disease Control and Prevention National Death Index (NDI) to identify participants who died during follow-up.The effect of rare genetic variants on clinical outcomes and long-term prognosis in patients with early-onset AF remains undefined. Among patients with hypertrophic CM (HCM), dilated CM (DCM), Brugada syndrome, and long QT syndrome, genotype-positive patients have been consistently shown to have worse clinical outcomes, such as a higher risk for malignant ventricular arrhythmias, progression to end-stage heart failure, and mortality.11 All participants provided written informed consent, and ethical approval for the study was obtained from the Vanderbilt University Medical Center institutional review board. Baseline demographic and clinical characteristics were recorded at the time of enrollment (eAppendix 2 in the STROBE) reporting guideline.This cohort study included participants enrolled in the Vanderbilt Atrial Fibrillation Registry or Vanderbilt AF Ablation Registry from November 23, 1999, to June 2, 2015  and subsequent manual adjudication were used to classify variants according to American College of Medical Genetics and Genomics (ACMG) criteria as benign, likely benign, variant of undetermined significant, likely pathogenic, or pathogenic.21 Participants with a pathogenic or likely pathogenic variant for an autosomal dominant or X-linked dominant syndrome were defined as having a disease-associated rare variant.The sequencing methods and quality control steps for the Trans-Omics for Precision Medicine Program AF Project have been previously described.International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes listed for causes of death. Deaths were considered CM-related, sudden deaths, or stroke-related based on inclusion of a corresponding ICD-10 code . A sensitivity analysis tested whether presence of disease-associated variants restricted to a smaller gene panel composed of only strong or definitive evidence genes  with early-onset AF enrolled from 1999 to 2015 who underwent whole-genome sequencing. Of those, 219 died during follow-up (16.9%) . The med11 Overall, a disease-associated rare variant was detected in 131 participants (10%). Of these, 93 participants carried a disease-associated variant in a DCM gene, 43 in an HCM gene, and 37 in an arrhythmogenic CM or arrhythmogenic right ventricular CM gene. There was considerable overlap between genes associated with DCM, HCM, and arrhythmogenic CM or arrhythmogenic right ventricular CM genes as shown in eTable 3 in the Full results of the ACMG variant classification have been previously published.P = .05). In multivariable analysis, the presence of a disease-associated variant was associated with a significantly higher risk of all-cause mortality, as shown in the adjusted survival curve  (P = .008 for interaction). Owing to this interaction, the estimates and 95% CIs for disease-associated variants are not presented separately, but instead using partial effects plots (P = .98), White race , increased BMI , and lower LVEF  were associated with increased mortality risk. In the analysis of the association of age with mortality, older age was associated with a higher risk of death for both genotype-positive and genotype-negative male and female participants. However, as shown in Among participants with a disease-associated variant, 31 (24%) died during follow-up compared with 188 participants (16%) without a disease-associated variant . In univio test) A. The prts plots B. In theResults from the sensitivity analysis that restricted disease-associated variants to only those from strong or definitive evidence genes also demonstrated significant associations with mortality for disease-associated variants, age at AF diagnosis, BMI, and the interaction between disease-associated variants and age at AF diagnosis. Findings for race and ethnicity and sex remained nonsignificant. eFigure 1 in the P = .03 for interaction). This model was also adjusted for BMI , male sex , and White race . For sudden deaths, disease-associated variants  and age at AF diagnosis  were associated with a increased risk of mortality. The analysis of sudden death was not powered to test for an interaction. The data set was not powered to determine an association of variant status with time to stroke-related death.Of 219 deaths, 73 were CM-related (33%), 40 were sudden deaths (18%), and 10 were stroke-related (5%). The adjusted cumulative incidence plots of CM-related death and sudden death by variant status are presented in Genetic variants were seen in all groups defined by baseline ejection fraction at enrollment. LVEF was associated with risk of mortality among participants with reduced LVEF (<50%) and preserved LVEF (≥50%) A and B. CASQ2 variant. There were 2 participants with both a disease-associated CM variant and a channelopathy variant.Among the 92 participants with a disease-associated variant in any CM-related gene , there were 24 deaths (26%) compared with 1 death (10%) among the 10 participants with a disease-associated variant in a channelopathy-related gene  C. The deTTN (OMIM 188840), MYH7 (OMIM 160760), MYH6 (OMIM 160710), LMNA (OMIM 150330), and KCNQ1 (OMIM 607542). The number of deaths observed was 10 of 38 (26%) for TTN, 6 of 18 (33%) for MYH7, and 2 of 9 (22%) for LMNA compared with 0 of 8 for KCNQ1 and 0 of 10 for MYH6  than sudden death (18%) or stroke-related (5%), and the risks of CM-related and sudden death were significantly higher among patients with disease-associated variants. Most disease-associated variants in patients with early-onset AF were in CM genes. However, most of the participants who had reduced LVEF at the time of enrollment did not have a rare disease-associated variant. These data suggest that genetic testing may identify patients with a subtype of early-onset AF who are at higher risk of mortality, relative risk associated with a disease-associated variant may be higher when AF is diagnosed at a younger age, and relative risk may be associated predominantly with variants in CM-related genes.The association between AF and higher risk of mortality in younger patients with minimal clinical risk factors was previously unexplained.Our results showed that age at AF diagnosis was significantly associated with a higher risk of mortality for both genotype-positive and genotype-negative participants. However, in genotype-positive participants, younger age at AF diagnosis was associated with significantly higher relative risk of mortality. This finding is consistent with the observation found across a variety of disorders that more deleterious genetic variation occurs in patients with younger age at disease onset. However, our data also demonstrated that as age at AF diagnosis approached 60 years, the mortality curves crossed such that genotype-negative participants started to have a higher risk of mortality. We suspect this finding was attributable to the clinical risk factors for AF found in the genotype-negative group  that were associated with higher risk of mortality at older age at AF diagnosis. However, the genetic variants associated with older age at AF diagnosis in the genotype-positive group may have been those that are less deleterious and have reduced penetrance.TTN variant, 10 (26%) died during follow-up. TTN encodes the sarcomeric protein titin and is the most prevalent genetic contributor to both early-onset AF8 and DCM.24 Among the 18 participants with a disease-associated MYH7 variant, 6 (33%) died during follow-up. MYH7 encodes the beta myosin heavy chain subunit and is expressed in the atria and ventricles. Disease-associated variants in MYH7 are among the most prevalent genetic contributors to HCM25 and are associated with higher risk for AF than variants in MYBPC3 and thin filament genes.27 Among the 9 participants with a disease-associated LMNA variant, 2 (22%) died during follow-up. LMNA encodes lamin A and C, which are structural proteins that comprise the inner nuclear membrane. Patients with LMNA variants can present with any combination of DCM, atrioventricular block, atrial or ventricular arrhythmias, or Emery-Dreifuss muscular dystrophy.31The gene panel used in this study was large and included genes associated with a variety of different syndromes with variable risks of mortality due to heart failure, sudden death, and stroke. To describe the effects of individual genes, we presented the mortality rate among patient with the most prevalent genes with disease-associated variants. Among the 38 participants with a disease-associated TTN, MYH7, and LMNA, none of the 10 participants with a disease-associated MYH6 variant died during follow-up. MYH6 encodes the alpha myosin heavy chain subunit and is predominantly expressed in the human atria.33 These results suggest that patients with early-onset AF associated with an MYH6 variant may have more isolated atrial involvement compared with those with an MYH7 variant and may have a genetic subtype of early-onset AF associated with lower risk of mortality. Similarly, none of the 8 participants with a disease-associated variant in KCNQ1, the gene associated with LQT type 1, died during follow-up. Larger studies are needed to validate and potentially explain the lower rate of mortality observed in MYH6 and KCNQ1 variant carriers compared with carriers of other genes.In contrast to participants with variants in According to the primary or contributing causes of death as listed on death certificates, CM-related deaths (n = 73) were more common than sudden deaths (n = 40) and stroke-related deaths (n = 10). Furthermore, carrying a disease-associated rare variant was associated with a significantly higher risk of CM-related death and sudden death. Our results suggest that therapies to prevent sudden death and the progression of CM should be prioritized for further investigation to address the excess mortality observed among genotype-positive patients with early-onset AF.9 Specifically, most of the disease-associated variants in channelopathy genes were in KCNQ1; thus, it is unknown whether these results are generalizable to other channelopathy genes, such as KCNH2, SCN5A, and RYR2. Furthermore, although this study defined the association between rare variants and mortality among patients with early-onset AF by querying the NDI, future studies using deep phenotyping methods will be needed to better define clinical characteristics, such as CM subtypes. The reliability of cause of death information as listed on death certificates is a potential limitation, and thus the specific mechanism of death remains uncertain. Future studies will be needed to replicate these results, and prospective trials will be needed to investigate whether genetic testing in patients with early-onset AF improves clinical outcomes.This study has limitations. Although the primary analysis was sufficiently powered to demonstrate an association between disease-associated rare variants and mortality, subgroup analyses were underpowered and larger studies will be needed to define the risk according to variants for individual syndromes, individual genes, and in racial and ethnic minority groups.In this study, patients with early-onset AF who carried a disease-associated CM or arrhythmia variant had a higher risk of all-cause mortality and a higher risk for CM-related death and sudden death. Compared with genotype-negative patients, those with a disease-associated variant had a higher relative risk of death when AF was diagnosed at a younger age. Most patients with a history of reduced LVEF at enrollment did not have a disease-associated variant, but among those who did, the mortality rate was 48% during a median 9.9 years of follow-up. Furthermore, the mortality rate among participants with preserved left ventricular function and a disease-associated variant was 18% during follow-up. These data suggest that there is prognostic value for genetic testing in patients with early-onset AF regardless of ejection fraction at the time of presentation. Future studies are needed to prospectively define whether genetic testing improves clinical outcomes in patients with early-onset AF.


General population studies have shown strong humoral response following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination with subsequent waning of anti-spike antibody levels. Vaccine-induced immune responses are often attenuated in frail and older populations, but published data are scarce. We measured SARS-CoV-2 anti-spike antibody levels in long-term care facility residents and staff following a second vaccination dose with Oxford-AstraZeneca or Pfizer-BioNTech. Vaccination elicited robust antibody responses in older residents, suggesting comparable levels of vaccine-induced immunity to that in the general population. Antibody levels are higher after Pfizer-BioNTech vaccination but fall more rapidly compared to Oxford-AstraZeneca recipients and are enhanced by prior infection in both groups. Antibody responses to vaccination in older residents of long-term care facilities are comparable to those in the general population. Although antibody levels are initially greater, they fall more rapidly following Pfizer-BioNTech vaccination than Oxford-AstraZeneca. Prior infection enhances responses in both groups. Residents of long-term care facilities (LTCF) have experienced extremely high rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and mortality . Since DVaccine effectiveness in the general population has been demonstrated for at least 6 months following second dose administration , 4. HoweCurrent SARS-CoV-2 vaccines target the viral spike protein, and anti-spike antibody levels are an important correlate of vaccine efficacy . Early sXXX  is a prospective cohort study of residents and staff of LTCFs in England . EligiblBlood samples undergo SARS-CoV-2 nucleocapsid immunoglobulin G (IgG) testing using the Abbott ARCHITECT semi-quantitative immunoassay . Quantitative antibody titers against SARS-CoV-2 spike and nucleocapsid IgG are measured using the Meso Scale Diagnostics (MSD) V-PLEX COVID-19 (coronavirus disease 2019) Respiratory Panel 2 kit . Anti-nucleocapsid antibodies are used to identify immune responses stimulated by prior infection. MSD observations were included from ≥21 days after second vaccine dose administration, corresponding to peak antibody response , up untiTo model postvaccination MSD assay anti-spike antibody levels, individuals were categorized as either having no evidence of prior infection or evidence of prior infection. The latter group included individuals with at least 1 record of an active infection defined by PCR or point-of-care lateral flow test positivity or hospitalization with COVID-19 prior to second vaccine dose, and those with presence of anti-nucleocapsid antibodies on either Abbott or MSD assay. To exclude breakthrough infections, which may have boosted antibody levels, observations with active infection recorded after second vaccine dose but prior to index date were dropped from analysis, as were observations following postvaccination anti-nucleocapsid seroconversion.An index value ≥0.8 defined the Abbott anti-nucleocapsid assay positivity . A thresVIVALDI has been granted research ethics approval by the South Central-Hampshire B Research Ethics Committee (reference number 20/SC/0238).10-transformed MSD anti-spike levels were modeled using linear mixed-effects models. Time was centered at 21 days after second vaccine dose, with random intercept and slope terms for each participant. This approach allows for the analysis of all available data within a single statistical model and can accommodate irregular numbers and timings of measurements for each participant. Intercept terms from the model correspond to estimated peak antibody levels, and slope terms correspond to rate of decline over time on the log scale.Log10 antibody level of log10(0.5). Formal sample size calculation was not undertaken.An initial model was fitted with independent effects assumed for vaccine type, sex, staff/resident status, and prior SARS-CoV-2 infection, followed by a model with interaction terms between vaccine type and each other variable. A further model was considered with addition of subject age (centered at 70 years) as a linear predictor of both intercept and slope by vaccine type. Half-life values were calculated based on estimated time to drop in mean logP = .15 for difference between groups on Mann–Whitney test). Median time from second vaccine dose to blood sample was 136 days . Four observations from 4 residents and 4 from 3 staff were dropped from analysis as they followed detection of an active breakthrough infection. Eight residents and 8 staff each had 1 observation excluded because of indirect evidence of breakthrough infection .We describe 558 anti-spike antibody (MSD) results from 402 LTCF residents and 759 from 632 staff. A total of 774 people had 1 observation, 237 had 2 observations, and 23 had 3 observations. Median age was 86 years  for residents and 50 years  for staff. Samples included in the analysis were collected between 15 March and 22 October 2021. The median time between first and second dose was 74 days  for residents and 74 days  for staff , and a further improvement was found by adding age as linear predictor of peak antibody levels and slope .The interaction model, allowing different effects by vaccine type, was found to provide better fit to the data than the simpler independent effects model (P < .01), although we also observed a steeper annual decline in this group  (P < .01) and Oxford-AZ  recipients. Male sex was associated with slightly higher peak in antibody levels for both vaccines  but steeper decline, particularly for Oxford-AZ recipients. LTCF resident vs staff status was not associated with any statistically significant difference in peak antibody level or slope of decline. However, increasing age was associated with lower antibody peak for Oxford-AZ recipients.Based on findings from the mixed-effects model, peak antibody titers were greater in Pfizer-BioNTech recipients than in Oxford-AZ recipients  . Prior i“Half-life” estimates of antibody decline were in the range of 60–120 days for most subgroups, with values >6 months in female Oxford-AZ recipients with prior infection, but 95% CIs were wide .We present postvaccination serological data from a large cohort of frail LTCF residents in England, a group in whom published data are scarce. Our findings are broadly consistent with longitudinal studies conducted in the general population and healthcare workers , 10 whicConsistent with previous studies, we find higher peak antibody titers following vaccination with Pfizer-BioNTech compared to Oxford-AZ , 10. WeiThe collection of samples up to 9 months after vaccination allowed us to assess the rate of spike-specific antibody decline from peak value. The mean half-life of antibody decline was reported as 85 days  after Oxford-AZ in the CIS study, and this was increased to 131 days in those with prior infection. They found a comparable mean half-life after Pfizer-BioNTech of 101 days , which was extended to 188 days in those with prior infection [Our study is consistent in finding higher peak levels and longer half-life associated with prior infection for both vaccine types, and higher peak levels following Pfizer-BioNTech vaccination. However, we find no difference between staff and residents besides a lower peak antibody response in older Oxford-AZ recipients. The level of exposure to infection was much greater in LTCFs than in the community , and thoOur study is limited by a modest sample size, so there is uncertainty regarding the presence and magnitude of observed effects. It is also possible that some individuals labeled as infection-naive may have waned below the positivity threshold following infection early in the pandemic . To accoInsights into the magnitude and duration of vaccine-induced immune responses are crucial to inform the timing of booster vaccination, particularly with the emergence of novel variants such as Omicron. Our findings reveal that current COVID-19 vaccines retain high immunogenicity in the LTCF setting but factors such as peak antibody response and rate of antibody waning, which will be used to guide the need for future vaccinations, are strongly influenced by vaccine regimen and prior infection status. Ongoing assessment of humoral immunity will be important to guide introduction of optimal booster regimens that maintain immunity over the longer term.The Journal of Infectious Diseases online . Supplementary materials consist of data provided by the author that are published to benefit the reader. The posted materials are not copyedited. The contents of all supplementary data are the sole responsibility of the authors. Questions or messages regarding errors should be addressed to the author.Acknowledgments. We thank the staff and residents in the long-term care facilities (LTCFs) that participated in this study and Mark Marshall at the National Health Service (NHS) England who pseudonymized the electronic health records.Data sharing. De-identified test results and limited metadata will be made available for use by researchers in future studies, subject to appropriate research ethical approvals once the VIVALDI study cohort has been finalized. These datasets will be accessible via the Health Data Research UK Gateway.Disclaimer. The views expressed in this publication are those of the authors and not necessarily those of the NHS, Public Health England, or the Department of Health and Social Care. Funding to pay the Open Access publication charges for this article was provided by the Wellcome Trust as part of M.K.'s fellowship.Financial support. This work is independent research funded by the Department of Health and Social Care (COVID-19 surveillance studies). M. K. is funded by a Wellcome Trust Clinical PhD Fellowship (222907/Z/21/Z). L. S. is funded by a National Institute for Health Research Clinician Scientist Award (CS-2016-007). A. H. is supported by Health Data Research UK (LOND1), which is funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation, and Wellcome Trust.jiac146_Supplementary_DataClick here for additional data file.


Hodgkin lymphoma (HL) can present with extra-nodal disease, but spinal cord compression is exceptionally rare. We describe a 15-year-old presenting with hip/back pain with normal initial examination. Persistent pain and raised inflammatory markers prompted further investigation with MRI, which revealed an epidural mass causing spinal cord compression. On examination, there was no palpable lymphadenopathy or cauda equina syndrome, but absent lower limb reflexes were noted. Following multidisciplinary discussion, it was determined that cauda equina syndrome was imminent and therefore surgical debulking was undertaken, both to prevent this complication and establish a diagnosis. At surgery, the tumor was highly vascular. Frozen section confirmed lesional material. Following surgery, and given the frozen section findings, a short course of steroids was commenced to reduce any peri-surgical edema. Unfortunately, histopathology was ultimately non-diagnostic, due to failure of immunohistochemistry on technically challenging material. Consequently, ultrasound-guided excision biopsy of a  cervical lymph node was performed five days later; histopathology showed typical effacement of the normal architecture and a conspicuous population of CD15/CD30-positive larger pale cells present, confirming nodular sclerosis classic HL, despite recent steroids. We review the available literature for HL presenting with spinal cord compression and describe the challenges for diagnosis and initial management in such cases. HL is characterised by the presence of binucleated giant cells termed Reed-Sternberg cells or large mononuclear cell variants (lymphocytic and histiocytic cells) on a background of inflammatory cells and is broadly divided into two pathologic classes: classic or nodular lymphocyte predominant disease.3 Immunophenotyping is essential to distinguish between the two classes, with classic HL expressing CD30 in nearly all cases and CD15 in 75-85%, whilst typically lacking expression of the B-cell markers .4 PAX-5 is the only B-cell restricted antigen that is nearly always expressed in classic HL, but staining is often weaker than that seen in reactive B-cells and is a useful diagnostic feature. Classic HL accounts for the majority of childhood, adolescent and young adult cases,3 with the nodular sclerosis type being the most common subtype, primarily affecting adolescents and young adults (15-34y) with a female predominance.35 Treatment advances have dramatically increased HL survival over the past 40 years across all patient age-groups. Age-standardised 10y survival has increased from 47% in 1971 to 80% in 2011 in the UK. Outcomes are better still for children and young adults, with 5y survival exceeding 95% across much of Europe and the US.5 Current trials in this group are aimed at maintaining overall survival whilst minimising the morbidity associated with the late-effects of treatment, with a move away from radiotherapy as standard treatment.6Hodgkin lymphoma (HL) is primarily a malignancy of the lymph nodes but can present with extra-nodal involvement. Incidence follows a bimodal age distribution, rising sharply during childhood and peaking initially in young adults aged 20-24 years (y), with a second larger peak in incidence during the eighth decade of life. In the UK, 435 children and young adults (<25y of age) are diagnosed with HL each year,79 which may result in more advanced stage at presentation. Although overall survival is generally not compromised in such cases, advanced stage disease requires more treatment for cure and hence late-effects are likely to be more substantial. Consequently, raising awareness of such extra-nodal cases is important to minimise time-to-diagnosis and late sequelae. In particular, extra-nodal HL only very rarely presents with spinal cord compression (SCC), described in only a few rare case reports.1012 Hence, it may not be in the list of potential differential diagnoses and management of such patients may be suboptimal as a result. Here, we describe the case of a pediatric, adolescent patient presenting with SCC and discuss the challenges for HL diagnosis and initial management.A prolonged time-to-diagnosis is recognised in patients with cancer, including HL,9/L, and platelets 444 × 109/L. Urea and electrolytes (U&E) and bone (BFT) and liver function tests (LFT) were normal and antinuclear antibody (ANA) and rheumatoid factor were negative. At four months from symptom onset (117 days), she was seen in pediatric rheumatology, where clinical examination was normal, and further investigations revealed persistently elevated CRP (44mg/L) and ESR (75mm/hr); other bloods including repeat FBC, U&E, LFTs, creatine kinase (CK) and immunoglobulins were all normal. Five months after symptoms onset (159 days) left hip pain was worse, and lower back pain and stiffness had developed causing antalgic gait. The MRI of hip, spine and pelvis was delayed due to the COVID-19 pandemic, and undertaken seven months after symptom onset (208 days), showing an epidural soft tissue mass, resulting in referral to pediatric oncology for suspected cancer.A 15-year-old female presented to primary care after 2 months (68 days) of left hip pain and shooting pains in the left shin. She was given non-steroidal anti-inflammatory drugs with some improvement, and referred to pediatric rheumatology after blood testing revealed raised inflammatory markers [high erythrocyte sedimentation rate (ESR) 76mm/hr and C-reactive protein (CRP) 17mg/L]. Full blood count (FBC) at this time revealed hemoglobin 127g/L, white cell count 10.7 × 10By this time, examination findings were bilaterally absent lower limb reflexes only, with no clinical evidence of cauda equina syndrome. No palpable lymphadenopathy was detected. The MRI scan demonstrated widespread lymphadenopathy, with multiple enlarged carotid and submandibular lymph nodes as well as numerous para-aortic lymph nodes extending around the fourth lumbar (L4) vertebral body and via the L3/4 and L4/5 neural foramina bilaterally into a largely anterior epidural mass . The masFollowing multidisciplinary discussion, it was determined that cauda equina syndrome was imminent and therefore surgical debulking was undertaken, both to prevent this complication and establish a diagnosis, with emergency decompression of the theca and left L4 nerve root. At surgery, the tumor was noted to be highly vascular. Frozen section confirmed lesional material. Following surgery, a short course of oral steroids was commenced to reduce any peri-surgical edema. However, the material presented for histopathologic examination was ultimately non-diagnostic, both by conventional pathology and urgent flow cytometry. Samples showed poorly preserved connective tissue with diathermy and freezing artefacts. An excess of eosinophils was seen with some larger cells noted . Immunosfluoro-deoxyglucose (FDG) positron-emission-tomography (PET) scan demonstrated high tracer uptake in enlarged lymph nodes on both sides of the diaphragm, spleen, retroperitoneal nodules, paraspinal soft tissue and bone marrow, consistent with stage 4 disease. During the final few days of diagnostic work-up, prior to commencement of treatment, the patient developed ‘B’ symptoms (night sweats) and therefore assigned 4B staging. The patient was enrolled on the EuroNet-PHL-C2 Phase 3 trial for children and young adults (<25y) with classic HL, in treatment level 3 (TL3), and responded well to treatment. Early-response-assessment FDG-PET after two cycles of induction ‘OEPA’ chemotherapy confirmed the need for radiotherapy following completion of chemotherapy. Late-response-assessment FDG-PET after four cycles of consolidation ‘COPDAC’ chemotherapy showed further treatment response but showed some residual increased uptake at the site of disease around the L4 vertebral body, confirming the need for radiotherapy boost to this area.Consequently, and following further MDT discussion, open surgical excisional biopsy of  cervical lymph nodes was performed five days later as guided by ultrasound findings, along with bone marrow sampling due to the putative HL diagnosis, and insertion of a central venous access device in order to deliver systemic chemotherapy. On histopathology, effacement of the normal lymph node architecture was observed, with prominent bands of fibrosis and a marked infiltrate of eosinophils. A conspicuous population of larger pale cells was present with varying nuclear morphology . These l Of this time-to-diagnosis, the median diagnostic interval (help-seeking to diagnosis) was nearly three times greater than the median patient interval (symptom onset to help-seeking), namely 87 days and 30 days, respectively. These findings are consistent with this case, with a protracted diagnostic interval and total time-to-diagnosis of seven months, exacerbated by the COVID-19 pandemic, and similar to other reports. As a result of variability in time-to-diagnosis, over one-quarter of HL patients present with advanced stage (3 or 4) disease. The majority (80%) of patients with classic HL present with painless lymphadenopathy, usually involving the supraclavicular and cervical nodes.4 Of note, our patient did not have palpable lymphadenopathy, adding to the diagnostic challenge. A similar proportion of adolescents and young adults will have anterior mediastinal involvement at presentation, often asymptomatic.4 Extra-nodal involvement usually arises from hematogenous dissemination.This case highlights a number of challenges in establishing the diagnosis, and of the early management of spinal cord compression (SCC), in the context of previously undiagnosed Hodgkin lymphoma (HL). Prompt diagnosis of HL is important to minimise the morbidity associated with the late-effects of the more intensive treatment required to cure high-stage disease, and, in the setting of SCC, to optimise functional outcomes. Whilst we are not aware of published data on the time-to-diagnosis of HL in purely pediatric populations, a recent published study found that self-reported time-to-diagnosis was a median of 158 days (interquartile range 84-288 days) for HL in an adult population (>18y).12 It is the main presenting feature in only ∼0.2% of cases. Epidural lesions in HL may arise from hematogenous dissemination but are more likely to develop as a result of local invasion from retroperitoneal or thoracic lymph nodes. The thoracic spine appears to be the most commonly implicated site, followed by the lumbar spine. Of note, back pain is not an uncommon complaint in the pediatric population, with a prevalence of ∼10% at age 10y and ∼30% at 13y of age. That notwithstanding, chronic back pain has a relatively high yield for serious pathology including mechanical, infectious, inflammatory and neoplastic etiologies. For this reason, it is important to keep a very broad differential when a child or adolescent presents with back pain. For example, back pain in a child causing waking from sleep should result in urgent referral to pediatrics and neurological deficits should also always be considered a ‘red flag’ and urgent imaging arranged. A study of patients presenting with a malignant cause for spinal cord compression found that neuroblastoma (29%), soft-tissue sarcomas (21%), neuroectodermal tumors (17%) and non-Hodgkin lymphoma (13%) made up the majority of cases. Other malignant causes included astrocytoma, Wilms tumor and leukemia. Another study showed that SCC was the presenting feature of a previously undiagnosed malignancy in 75% of cases. Motor deficit was the presenting symptom in all patients, while pain was reported in 60% and sphincter dysfunction in 43%.SCC is a rare extra-nodal manifestation of HL, occurring in ∼5% of cases and usually in the context of progressive or advanced disease. Steroids are, however, contraindicated in those patients with a significant suspicion of lymphoma. HL is highly steroid sensitive, with treatment protocols utilising them as a key backbone of therapy.19 Even very short courses of steroids prior to biopsy may reduce the likelihood of reaching a definitive and accurate histologic diagnosis in such cases. Although most cases of classic HL can be diagnosed on morphologic and immunophenotypic features, there are a number of malignant lymphoid proliferations that can display histological features resembling HL. These include grey-zone lymphoma, EBV-positive diffuse large B-cell lymphoma, anaplastic large-cell lymphoma and peripheral T-cell lymphoma with ‘Hodgkin-like’ cells. Despite steroids being withheld in this case for these reasons until after the first biopsy, a diagnosis could not be reached from the spinal biopsy alone. In this clinically emergent setting of spinal cord compression, a rapid and accurate pathological diagnosis is however important. It should be noted that although the morphological appearances of the original epidural biopsy were concerning for HL, and a very small minority of HL cases can be PAX5 negative, the combination of negative staining for both CD15 and PAX-5 in this first biopsy in conjunction with the poorly preserved morphology, meant it was not felt possible to make a formal diagnosis on this tissue. This is likely to be related to poor preservation of tissue due to technical (diathermy/freezing artefact) reasons; immunohistochemistry is sensitive to tissue handling and preservation. However, use of diathermy was required to safely neurosurgically decompress the spinal cord and nerve roots, given the highly vascular nature of the tumor. In this case, as the patient had undergone emergency decompression of the theca and left L4 nerve root and had started steroids, with some clinical improvement, and given the putative HL diagnosis, it was therefore deemed clinically prudent to obtain more tissue to securely establish the exact diagnosis under the same general anaesthetic used for central line placement and staging bone marrow examination five days later. Clearly, such a decision for repeat biopsy or otherwise has to be assessed on a case-by case basis. In certain instances, where repeat biopsy is not feasible, or if repeat biopsy is non-diagnostic due to steroid delivery, a pragmatic and empirical diagnosis may have to be accepted based on the findings of the original biopsy.The UK NICE guidelines for the emergency management of malignant SCC recommend steroids as an essential component and that they should be offered to all patients while definitive treatment is planned.In summary, we present a 15-year-old with HL presenting with SCC, advanced stage disease and prolonged time-to-diagnosis. The diagnosis was challenging as the first neurosurgical biopsy was non-diagnostic, resulting in a second ultrasound-guided excision biopsy of a non-palpable cervical lymph node five days later, that allowed the diagnosis of nodular sclerosis classic HL to be made, despite the interim use of steroids following the first biopsy. The case highlights that pediatric and adolescent patients presenting with back pain need timely investigation and onward referral if any abnormal signs, symptoms or results, and the need to maintain a broad differential when assessing such patients. Such an approach will minimize diagnostic intervals and result in optimized patient outcomes.


Healthcare delivery reorganization during the COVID-19 emergency may have had a significant impact on access to care for older adults with chronic conditions.We investigated such impact among all adults with chronic conditions aged ≥65 years, identified through the electronic health databases of two local health agencies - ATS Brianza and ATS Bergamo - from the Lombardy region, Italy. We considered hospitalizations for 2020 compared to the average 2017-2019 and quantified differences using rate ratios (RRs).Overall, in 2017-2019 there were a mean of 374,855 older adults with ≥1 chronic condition per year in the two ATS and 405,371 in 2020. Hospitalizations significantly decreased from 84,624 (225.8/1000) in 2017-2019 to 78,345 (193.3/1000) in 2020 (RR 0.86). Declines were reported in individuals with many chronic conditions and for most Major Diagnostic Categories, except for diseases of the respiratory system. The strongest reductions were observed in hospitalizations for individuals with active tumours, particularly for surgical ones. Hospitalization rates increased in individuals with diabetes, likely due to COVID-19-related diseases.Although determinants of the decrease in demand and supply for care among chronic older adults are to be further explored, this raises awareness on their impacts on chronic patients’ health in the medium and long run.


Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with thrombosis. We conducted a cohort study of consecutive patients, suspected of SARS-CoV-2 infection presented to the emergency department. We investigated haemostatic differences between SARS-CoV-2 PCR positive and negative patients, with dedicated coagulation analysis. The 519 included patients had a median age of 66 years, and 52.5% of the patients were male. Twenty-six percent of the patients were PCR-positive for SARS-CoV-2.PCR positive patients had increased levels of fibrinogen and (active) von Willebrand Factor (VWF) and decreased levels of protein C and α2-macroglobulin compared to the PCR negative patients. In addition, we found acquired activated protein C resistance in PCR positive patients. Furthermore, we found that elevated levels of factor VIII and VWF and decreased levels of ADAMTS-13 were associated with an increased incidence of thrombosis in PCR positive patients. In conclusion, we found that PCR positive patients had a pronounced prothrombotic phenotype, mainly due to an increase of endothelial activation upon admission to the hospital. These findings show that coagulation tests may be considered useful to discriminate severe cases of COVID-19 at risk for thrombosis. The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection , has a hCOVID-19 is associated with a prothrombotic phenotype with an increased risk for thrombosis , 12. SevWe conducted a single center, cross-sectional cohort study: the MArkers in COVID-19 And Relations to Outcomes in the Netherlands (MACARON) study. The study was performed in accordance with the Declaration of Helsinki. Approval was obtained from the local Medical Ethical Committee (TWO 20–043). The need for informed consent was waived by the ethics committee because of urgency of data collection in patients with a new disease with suspected increased risk of thrombosis. Plasma remnants of routine blood drawing were used for laboratory testing and patient samples were analyzed completely anonymously. Patients were not subjected to invasive procedures and only additional experimental laboratory assays were performed.et al.  or standard error of the mean (SEM)) or median (interquartile ranges [IQR]). Differences between group means were tested with a Mann Whitney U test for continuous variables and with a Chi square test for categorical variables. A p-value of <0.05 was considered statistically significant.A total of 591 patients suspected of SARS-CoV-2 infection presented to the emergency department of the Meander Medical Center in the Netherlands. Five patients did not meet the inclusion criteria as they were younger than 18 years and were excluded from the study. Subsequently, 586 patients were included in the study. Of those, 519 (87.8%) were included in the analysis. Sixty-seven patients (12.9%) were excluded from analysis: either due to no nasopharyngeal swab taken (n = 38), or insufficient plasma sample material (n = 29). Of the 519 patients, 135 (26.0%) had a positive SARS-CoV-2 PCR result. All hospitalized patients had complete follow-up until discharge or death.Table 1 shows baseline characteristics of the PCR positive and PCR negative patients. The proportion of males compared to females was significantly higher in PCR positive patients compared to PCR negative patients , whereas age distribution was comparable between the two groups (64 years [IQR: 55–75 years] vs. 57 years [IQR:53–78 years]). PCR positive patients were more often non-Caucasian than PCR negative patients . There were no differences between PCR positive and PCR negative patients in presence of pulmonary or cardiovascular comorbidities. PCR positive patients used less frequently anticoagulation with direct oral anticoagulant or antithrombotic agents.Table 2). Mortality was significantly higher in PCR positive patients than PCR negative patients . This effect was attributed to a higher mortality in the female subset of the PCR positive compared to PCR negative group . No difference in mortality was found between male PCR-positive or -negative patients (16.4% vs. 10.4%).Of the PCR positive patients 113/135 (83.7%) were hospitalized with a median duration of admission of 5 days (IQR 3–12 days). Of the hospitalized patients 28/113 (24.8%) were admitted to the ICU. Thrombotic complications during follow-up occurred significantly more often in PCR positive patients as compared to PCR negative patients  . General coagulation analysis revealed significantly prolonged aPTT in PCR positive patients compared to PCR negative patients . Additionally, fibrinogen levels were increased in PCR positive patients , which is in line with the increase in other acute phase proteins CRP and ferritin). D-dimer levels were above the normal range in both groups, and the D-dimer level did not differ between the PCR-negative as PCR-positive group.The total thrombin production (ETP) and speed of thrombin production (thrombin peak and velocity index) were within the normal range and did not differ between PCR positive patients and PCR negative patients. The time-dependent variables lag time and time-to-peak were prolonged compared to the normal range and the lag time was significantly prolonged in PCR positive patients compared to PCR negative patients . Other variables related to thrombin generation such as the decay index, time-to-tail, and the curve width (time-to-tail–lag time) did not differ significantly between PCR positive patients and PCR negative patients. Adding thrombomodulin to test the activated protein C dependent inhibition of both factors V and VIII showed less effect in PCR positive patients than in PCR negative patients , indicating a certain level of acquired activated protein C resistance.2M as inhibitor of FIIa levels . In contrast, we found that the antithrombin levels (inhibitor of FIIa) were slightly, but statistically significant increased in PCR positive patients , but in both groups within the normal reference range.Several markers of the inhibitory pathways of coagulation were decreased: Protein C as inhibitor of factor V and VIII was lower in PCR positive patients compared to PCR negative patients , similar to αPCR positive patients showed signals of vascular system activation by means of elevated levels of total von Willebrand Factor (VWF) antigen  and active VWF . This did not lead to higher FVIII activity levels. Propeptide levels of VWF were comparable between groups, but elevated compared to the normal ranges.Fibrinolysis as expressed by the endogenous plasmin potential (EPP) was increased in PCR positive patients compared to PCR negative patients . Analogous, the plasmin peak, defined as the maximum speed of plasminogen into plasmin conversion, was also increased  and time-dependent parameters, such as lag time and time-to-peak, were shorter in PCR positive patients.Table 3 shows demographic, general laboratory testing and specific haemostatic testing of PCR positive patients with thrombosis and without thrombosis. Thrombosis was more common in males than in females. There was no difference in age. Mortality was higher in the non-thrombosis group than in the thrombosis group . PT, aPTT, D-dimer and fibrinogen levels did not differ significantly, but ferritin and CRP levels were significantly higher in the thrombosis group . Coagulation inhibitors Protein C and antithrombin did not differ between PCR positive patients with thrombosis compared to those without thrombosis, but α2M was decreased in those with thrombosis . There were no differences in thrombin or plasmin generation between both groups. VWF levels were significantly higher in patients with thrombosis , as were FVIII levels . Active VWF and VWF propeptide levels did not differ between PCR positive patients with or without thrombosis. ADAMTS-13 levels were significantly lower in PCR positive patients with thrombosis .In the PCR-positive group 19 patients (14.4%) developed thrombosis versus 19patients (5.1%) in PCR negative patients. The median duration of hospitalization was 25 days (IQR 12–40 days) for the thrombosis group as compared to 5 days (IQR 3–9 days) for the non-thrombosis group. In this study we investigated a broad range of specific haemostatic parameters in SARS-CoV-2 PCR positive patients presenting at the emergency department during the first period of the SARS-CoV-2 pandemic. We found that SARS-CoV-2 PCR positive patients had a prothrombotic phenotype as seen by higher fibrinogen and VWF levels , and acqMost laboratory variables in the PCR positive patients are in line with a biochemical prothrombotic phenotype, although there are some remarkable differences. For example, although antithrombin levels were slightly higher in the PCR positive group , no significant differences were observed between PCR positive subjects with or without thrombosis. Furthermore, increased plasmin generation in PCR positive patients indicates that fibrinolysis is increased, which can be explained by a continuous activation of coagulation. In another study, we previously reported an increase of plasmin generation in COVID-19 patients, which is in line with our current results . The difAdditionally, increased plasma VWF levels are an indicator of endothelial dysfunction, as the vascular endothelium is involved in the VWF production , 30. HigIn addition to the changes in the patients coagulation profile, we observed the increase of inflammatory markers such as ferritin and C-reactive protein in SARS-CoV-2 PCR positive patients confirming previous reports . EspeciaWe acknowledge several limitations of our study. Firstly, the study was conducted during the first months of the pandemic. At that current time, no evidence of immunomodulatory therapy such as dexamethasone was available and experimental treatment strategies such as the use of hydroxychloroquine were still applied. Secondly, we only included patients based on a positive PCR for SARS-CoV-2 in the initially obtained oro-/nasopharyngal swab. Varying sensitivity of the PCR in this type of specimen in comparison to a specimen obtained from the lower respiratory tract could have led to the misclassification of some of the patients. Thirdly, there is a risk for observational bias for venous thromboembolism, as diagnostic tests such as computed tomography are more likely to be performed in PCR positive patients compared to patients in routine clinical care. Fourthly, 519 patients with suspected OCVID-19 were enrolled in the study at the time of hospital admission, of which only 135 tested positive for SARS-CoV-2, and the other 384 hospitalized patients formed the control group for this study. In our opinion, the enrollment of patients at the time of hospital admission gives valuable clinical information, as this is the time at which clinical decisions are needed. Additionally, we compare COVID-19 positive patients admitted to hospital to control patients that are admitted to the hospital instead of healthy controls. Even though patient cohort is not very extensive, this does allow the comparison mortality and thrombosis rate of SARS-CoV-2 patients to other hospitalized controls.In conclusion, SARS-CoV-2 PCR positive patients have a more pronounced biochemical prothrombotic phenotype and subsequently more frequent thrombotic complications. Elevated levels of established risk factors for thrombosis, in particular elevated levels of VWF and decreased levels of ADAMTS-13 which suggests endothelial activation, may be considered in the treatment of COVID-19.