Among IgG-positive HCWs, there was no statistical difference in vaccine uptake regarding those with previous negative, positive, and unsure opinions about vaccination (p = 0.498). In multivariate analysis, independent factors associated with uptake were being female , age of 30–59 years, previously vaccine-unsure , and those with previous positive vaccine attitudes , while nurses were less likely to become vaccinated (OR = 0.39 95% CI: 0.20–0.75) These findings indicate a positive change in attitudes of HCWs towards COVID-19 vaccination.Healthcare workers (HCWs) are at higher risk of developing COVID-19 due to their professional exposition to the SARS-CoV-2 virus. This study assesses the intention of vaccination against COVID-19 before the vaccines were approved, and the rate of vaccine uptake during the first nine months of immunization among HCWs. A cross-sectional seroprevalence study was carried out during July 2020 in University Clinical Hospital Center Bezanijska Kosa in Belgrade, Serbia that included 62.8% of all HCWs. Besides serological testing for IgG antibodies, data about HCWs’ intention to accept COVID-19 vaccination if a vaccine became available were collected. This cohort of HCWs was followed up until the end of October 2021 to assess the number of vaccinated and PCR-positive staff. In the cross-sectional study, 18.3% HCWs had positive SARS-CoV-2 IgG antibodies without difference with IgG-negative HCWs regarding age, gender, profession type, and years of service. Before vaccines became available, a significantly higher percentage of IgG-positive HCWs compared to IgG-negative HCWs was unsure whether to be vaccinated (62.5% vs. 49.0%), and significantly fewer stated that they would not be vaccinated (16.7% vs. 25.1%). When the vaccines became available in Serbia, among IgG-negative HCWs, those who stated clear positive (yes) and clear negative (no) attitude toward vaccination before the immunization period had begun were vaccinated at 28% and 20%, respectively, while 51% of unsure HCWs received a vaccine ( Healthcare workers (HCWs) are at higher risk of becoming infected and developing COVID-19 due to their professional close and long contact with patients and exposure to the SARS-CoV-2 virus. According to WHO data, between 80,000 and 180,000 HCWs died from COVID-19 between January 2020 and May 2021 . AccordiThe vaccination of health workers is of twofold importance. On the one hand, they play a key role in raising public awareness of the importance of vaccination. On the other hand, vaccinated HCWs benefit from relieving individual symptoms and severe disease, and reduce the transmission of infections to patients. Even if vaccinated people transmit the virus like unvaccinated people, they can clear the virus faster, meaning that SARS-CoV-2 is present for less time in the upper nasopharynx of vaccinated people .Health professionals are often expected to have a positive attitude towards vaccination, but this is not always the case. A positive attitude towards vaccination against COVID-19 was in the range of 60–90% among physicians and about 40–60% among nurses in the prevaccine era ,9,10. A Recognizing the importance of vaccination in disease prevention, Serbia was the first country in the region that ordered more types of vaccines from different manufacturers and the World Health Organization (WHO) COVAX program . On 24 DThe aims of this study were: (a) assessing the intention of vaccination against COVID-19 before vaccines were approved; (b) assessing the actual uptake of vaccination; and (c) investigating factors associated with vaccine uptake after its implementation among HCWs.A cross-sectional seroprevalence study was carried out at the end of June 2020 in University Clinical Hospital Center Bezanijska Kosa in Belgrade, Serbia. The hospital was then in a non-COVID-19 regime. All presently working HCWs were invited to participate in the study without exclusion criteria. Out of 916 employees working at the hospital at the time of the study, 575 entered the study voluntarily. Written informed consent was obtained, and participants donated blood for serological testing for IgG antibodies. The infection-control staff administered the questionnaire to people involved in the study. During the entire time of filling in the questionnaire, the staff was available for all questions and concerns.Besides sociodemographic data about age, sex, occupation, and length of employment, they answered questions “will you be vaccinated if a vaccine against COVID-19 would be available” and “do you think that there is a great likelihood of catching COVID-19 if you would not be vaccinated?” Possible responses for both questions were “no”, “not sure”, and “yes”. Additional analysis showed that the group unwilling to be vaccinated against COVID-19 and the vaccine-unsure group were not homogeneous. Therefore, the two above-mentioned variables (questions) were split into three categories: no, unsure, and yes.When the respondents had finished filling out the questionnaire, the trained nurse collected about 5 mL of venous blood under aseptic precautions for serological analysis. The determination of IgG antibodies against SARS-CoV-2 was performed using indirect ELISA SARS-CoV-2 IgG. The test was created at the Institute for Application for Nuclear Energy , and the was CE labeled and registered as the IVD at the Serbian Agency for Drugs and Medical Devices (ALIMS). Results are expressed semiquantitatively as a relative index to the reference calibrator sample. Cut-off values for IgG were established on the basis of ROC curve analysis. For antibody indices higher than 20, the IgG test was considered to be positive.A cross-sectional study was converted into a prospective cohort study. The cohort of HCWs that entered the seroprevalence study was followed for nine months from January to the end of September 2021.The endpoint of this study was willingness to be vaccinated before the vaccination was available, and later COVID-19 vaccine uptake.During the following period, the hospital was transformed into a COVID-19-dedicated hospital and remained in that status until May 2021. Due to the smaller number of COVID-19 patients in the country during the summer months, the hospital was only not in the COVID-19 regime in the period of July–August. In September, due to the increased number of patients, the hospital was retransformed into a COVID-19-dedicated facility. Since January 2021, vaccination has been organized for all staff of that hospital.Serbia re-engineered the vaccine approval process by building AI-powered software that sped up each phase three times while taking citizens’ preferences into account. The country also implemented a new digital platform to schedule vaccine deliveries called the System for Immunization Management of the Republic of Serbia, which enables the real-time monitoring of the immunization of each citizen. Serbia adopted an approval mechanism for COVID-19 vaccinations that gives citizens the option to choose which one of the offered vaccines they preferred and in which location they wanted to be vaccinated. At the hospital level, a specific place and time for the vaccination of employees were organized. If one of the employees was vaccinated outside of that, they were obliged to show a certificate of vaccination to the infection-control team responsible for collecting data from vaccinated persons. In this way, there was double control of the data on vaccinated HCWs.An HCW was considered to have been tested for COVID-19 if they had had SARS-CoV-2 RT-PCR at least once regardless of the reason for testing. Diagnosis of COVID-19 was based on laboratory-confirmed COVID-19 infection or a clinical diagnosis of COVID-19 according to imaging techniques. Data of RT-PCR testing results from some referent virology laboratories in the city were obligatorily entered into the electronic system of the national COVID-19 database. Each RT-PCR-tested employee is obliged to submit the test data to the occupational health department (OHD) of the hospital and the infection-control team, which can check the data in the national COVID-19 electronic database using the employee’s personal identification number. In addition, the OHD is in charge of keeping records of hospitalized HCWs. The infection-control team contacts all hospitalized HCWs or their relatives for further surveillance details. Thus, variable hospitalization was dichotomous (yes/no) for all HCWs.Descriptive and analytical statistical methods were used in data processing. Data are presented as mean ± SD and number (percentage) for categorical variables. A chi-squared test was used to analyze categorical data, and an independent t-test was used for continuous variables. Univariate logistic regression analyses were performed to identify predictors for vaccination against COVID-19 as an outcome. The multivariable logistic regression model with backward Wald as a method was performed to identify independent factors associated with vaccination against COVID-19. Variables that were significantly associated with these outcomes at significance level <0.1 in univariate logistic regression analysis were entered into the multivariable logistic regression model. Odds ratios (OR) with 95% confidence intervals (CIs) were computed, and the Hosmer–Lemeshow goodness-of-fit test was performed to assess overall model fit. Statistical analysis was performed using SPSS version 26.0 software .The study was organized according to the principles of the Declaration of Helsinki of 1975, as revised in 2008, and approved by the ethics committee in the hospital.Out of all healthcare workers in the hospital, 575 (62.8%) decided to participate in the cross-sectional study. The demographic characteristics of participants are shown in One-fifth of the respondents (20.7%) thought that there was a great likelihood of catching COVID-19 if they would not be vaccinated, while 41.4% of them were uncertain about this issue without a difference regarding serological status .p < 0.001)  of participants were vaccinated with one of four COVID-19 vaccines available in Serbia from the end of 2020: 81.2% (311/383) were IgG-antibody-negative and 18.8% (72/383) were IgG-antibody-positive HCWs at the cross-sectional study. Of our cohort, 47.3% received the Sinopharm (Beijing) BBIBP-CorV (Vero Cells) vaccine, 38.9% the Pfizer–BioNTech (Comirnaty) vaccine, and 13.8% the Sputnik V (Gam-COVID-Vac) vaccine . Nobody < 0.001) .p = 0.006). There was no significant difference in vaccination rate according to the previous attitude toward vaccination among IgG-positive HCWs (p = 0.498) . Among IgG-negative HCWs, only 28% and 20% of those who stated clear positive (yes) and clear negative (no) attitude toward vaccination before the immunization period had begun were vaccinated, respectively, while 51% of unsure HCWs received a vaccine (= 0.498) .Predictors of healthcare workers’ COVID-19 vaccine uptake are presented in This study showed that, before vaccines were approved, less than one-quarter of participating HCWs had reported willingness to be vaccinated against COVID-19, with a higher percentage of negative SARS-CoV2 IgG antibodies. In a study conducted in France during a similar period, 77% of participants expressed their willingness to be vaccinated if a vaccine against COVID-19 was available . A recenThe higher percentage of unsure HCWs with positive IgG antibodies found in our study may be explained by the lack of knowledge at the time when the cross-sectional study was conducted regarding possible reinfection and the need to vaccinate persons who had already had COVID-19.Repeated cross-sectional surveys in Hong Kong during the first and third waves of the local COVID-19 epidemic that included different job professions showed increased willingness for COVID-19 vaccination during the three waves of the current pandemic . Our stuIn our study, independent factors that influenced the COVID-19 vaccine acceptance were gender, older age, occupation, and unsure and positive attitudes about vaccination. Females were 1.8 times more likely to receive vaccination than males were, which is contrary to obtained findings in the systematic review and meta-analysis of cross-sectional studies among HCWs  and the As in many studies ,16,25, wAccording to our results, nurses were less likely to be vaccinated against COVID-19, although they have longer and closer contact with patients . These fIn this study, HCWs who had a positive attitude towards COVID-19 vaccination before vaccines became available were vaccinated 2.5 times more than workers with a negative attitude. Further, a significant change of mind about vaccination among unsure HCWs was observed, i.e., those who had not yet decided to receive the COVID-19 vaccine were 1.8 times more vaccinated than those who were against vaccination. Indecisive people are a group that can change their minds if they obtain more information about the effectiveness of the vaccine, its safety, and the fact that, if vaccinated, it protects both themselves and those who may have wanted but could not be vaccinated against disease . The speThe limitation of our study is that it was conducted in a single center using a cross-sectional design in the first part of the study. However, this hospital is a university facility that is composed of all departments except pediatrics. A large number of capital residents gravitate for treatment to it. The limitation of a cross-sectional study including sampling i.e., voluntary enrollment, may have resulted in selection bias. The majority of similar studies that revealed HCWs’ attitudes and willingness to accept COVID-19 vaccination were mainly carried on through online recruitment. The strength of our study is that it was conducted using paper questionnaires as a preferred way for data collection . CompletThe results of our study indicate a positive change in attitudes of HCWs towards COVID-19 vaccination. Independent predictors of HCW attitudes toward COVID-19 vaccination were the female sex, age >30 years, physician occupation, and unsure and positive attitudes about vaccination. The results of this and many similar studies are important, as they can affect the future willingness rate of HCWs and the overall population to become vaccinated against COVID-19.


To evaluate if digital breast tomosynthesis spot compression view (DBT-SCV) could be an additional projection to confirm or deny architectural distortions (ADs) detected by digital breast tomosynthesis (DBT) while assessing the average glandular radiation dose.This is a retrospective cohort study enrolling 8864 DBT exams, of which only cases detecting primary AD and with BI-RADS 2–5 score were considered. Seventy-one AD cases examined with DBT-SCV, US and MRI were evaluated for correlation in terms of BI-RADS score; variables among exams were assessed for inter-relationships.p < 0.05); the NPV of DBT-SCV was 94%. The difference between DBT and DBT-SCV in the detection of benign ADs was statistically significant (p < 0.05). AD without US or MRI confirmation was less likely to represent malignancy (p < 0.05). In detecting malignant cases of ADs, both DBT and DBT-SCV were strongly correlated with US and RM (Kappa > 0.90). In identifying benign cases of ADs, DBT-SCV was poorly/moderately correlated with US and RM (Kappa 0.25 and 0.66); DBT was negatively correlated with US and MRI.Of all ADs identified at DBT, biopsy yielded malignancy in only 38%. PPV in identifying malignancy of ADs was higher for DBT-SCV than DBT (DBT-SCV could be useful to better characterize AD firstly identified by DBT, keeping dose levels within the reference limits. If AD is detected by DBT without an US or MRI correlate, that is not confirmed by DBT-SCV, a “wait and see” approach can be applied to reduce unnecessary biopsy. Architectural distortion (AD) is the third most commonly missed mammographic presentation of non-palpable breast cancer, accounting for almost 6% of the abnormalities detected by screening mammography . CompareAlthough digital mammography currently represents the standard breast imaging technique for the detection of breast neoplasms, it has the big limit of incurring false positives and/or negatives due to tissue overlapping . MoreoveThe main question that arose following the use of tomosynthesis is whether the quantity of radiation dose is acceptable. According to the European Protocol for the Quality Control of Physical and Technical Aspects of Mammographic Screening , a valueThe purpose of this study was to assess if in the architectural distortion detected by DBT, DBT-SCV could be an additional projection to confirm the alteration.Another aim of the study was to determine the negative predictive value (NPV) of DBT-SCV and the positive predictive value (PPV) of DBT-SCV and DBT. Additionally, we wanted to evaluate associations between DBT, DBT-SCV, US and MR imaging, in terms of BI-RADS score, and histopathologic features of AD. Lastly, we analyzed the radiation dosimetry of DBT, underlining its advantages in relation to the use of the C-view software capable of processing 2D synthetic images.The key point of the study was to propose a management work flow of architectural distortions that can be easily applied in clinical practice.This was a single-center retrospective database analysis of patients who underwent DBT. Between December 2018 and December 2021, 8864 DBT exams were performed in the University-affiliated clinic European Hospital of Rome. Written informed consent was obtained from all patients, and the study was compliant with the Health Insurance Portability and Accountability Act. We evaluated 186 consecutive cases of AD detected by DBT as primary architectural distortions that arose within the breast de novo, without an underlying identifiable cause. The cases of AD that were also appreciable in two-dimensional synthesized mammography were excluded from the study. Secondary architectural distortions were excluded, and these take into account causes that are known to distort breast tissues, such as breast surgeries including lumpectomy/excision or cosmetic surgeries such as reduction mammoplasty, as well as known traumatic injuries to the breast and invasive breast infections. All AD cases detected by DBT that were not explainable by identifiable cause have undergone additional DBT-SCV to exclude apparent architectural distortions secondary to the overlap phenomenon of normal breast tissue. Only patients who also performed US and MRI examination as well as histological analysis were included in the study  and mid-lateral-oblique (MLO) projections with Hologic Selenia TM Dimensions System, using C-View software for interpretation –12. The DBT image acquisition was performed in a step‐and‐shoot mode, with less than 10 s acquisition time for each breast. Image reconstruction was performed immediately after image acquisition with a slice thickness of 0.5 mm and a reconstruction time less than 15 s. Patient‐related data, such as age, projection orientation (CC or MLO), compressed breast thickness, compression force, exposure factors, target/filter combination, ESD and AGD, were retrieved directly from the images. The use of tomosynthesis projections only with the synthetic 2D images reconstructed through the C-view software together with the use of DBT and DBT-SCV has led our exams to have average glandular radiation dose values within the allowed limits, according to the protocol for quality control of the physical and technical aspects of mammography screening.Two expert breast radiologists with ten years of experience each, blinded and individually, reviewed DBT images using the BI-RADS system before and after the DBT-SCV.BI-RADS 4–5 for AD with evident tissue attraction, focal retraction, deformation, radiating thin straight lines or spiculations, straightening or thickening of Cooper ligaments and crookedness of the glandular architecture or associated with another finding including asymmetry, microcalcifications and altered mammographic density.BI-RADS 3 in case of AD with blurred morphology, blurring of normal tissue planes such as the fat-fibroglandular junction and compression of tissue around, in the absence of evident tissue attraction or deformation or any other associated anomalies.BI-RADS 2 in case of morphological distortion and geometric changes or distortion disappearance.BI-RADS was assigned as follows:According to the BI-RADS system, each identified specimen is assigned in categories expressing the probability of malignancy . InstrumThe average AGD and ESD for each side and projection were calculated, and for analytical simplicity, the patients were divided into six groups  according to the compressed breast thickness. The reported ESD and AGD values were verified during regular quality assurance measurements, using conversion coefficients reported in the literature .p values less than 0.05 were considered statistically significant. Cohen’s kappa statistics was calculated for breast radiologists’ correlation degree and for inter-relationships between DBT, DBT-SCV, US and MRI.All data were analyzed with a spreadsheet software program . Data analysis was performed using statistics software SAS Enterprise, version 4.2, SAS Institute. Statistical significance was determined with the Chi-square test for categorical variables or the unpaired t test for continuous variables; Baseline characteristics, radiological parameters and histopathological results of the included patients are listed in Table Of the 71 AD cases found at DBT, core biopsy yielded malignant pathology in 27 38%) tissue samples: 13 ductal invasive carcinomas , and in two cases of carcinoma, in situ DBT-SCV BI-RADS score was 2 and 3 . Thirty-eight ADs that resulted to be benign lesions at histology were assigned DBT-SCV BI-RADS 2 or 3, compared to DBT BI-RADS 3 or 4. However, in five benign ADs, DBT-SCV highlighted a BI-RADS score of 4 in agreement with DBT, and score of 5 in one AD that was considered BI-RADS 4 on DBT (Table p < 0.05). The NPV of architectural distortion for malignancy on DBT-SCV was 94%.The PPV of architectural distortion for malignancy at DBT was 38.5%, while on DBT-SCV was 64%, highlighting a statistically significant result (p < 0.05), while it was not significant in the detection of malignant ADs (p > 0.05).Importantly, the difference between DBT and DBT-SCV in the detection of benign ADs was statistically significant , while BI-RADS at DBT-SCV differed from US in only four cases  (Table p < 0.05), in fact, benign AD was significantly associated with MRI-negative correlation (p < 0.05).On the other hand, in case of benignity, only 14 BI-RADS cases detected at DBT-SCV correlated with MRI , while 15 BI-RADS cases detected at DBT-SCV correlated with US  ; additionally, a very strong correlation is appreciable between DBT-SCV, US and MRI  and between US and MRI (0.91) Table .Table 4COn the other hand, in ADs with benign histology, in the analysis of Cohen’s kappa statistics for inter-relationships, DBT is weakly correlated with DBT-SCV (0.40), and negatively correlated with US and MRI (< 0); a poor correlation is appreciable between DBT-SCV, US and MRI ; lastly, a very strong correlation is highlighted between US and MRI (0.85)  that consider AD to be suspicious or suggestive of malignancy are slightly different compared to what reported by Bahl M. et al. (0.2%) . The smaThe use of focused compression performed with tomosynthesis can make the distortion more evident , owing tOur study shows that of the 27 ADs having malignant histology, 25 received a BI-RADS 4 or 5 at DBT-SCV (vs 21 on DBT), while of the 44 benign ADs, only six received BI-RADS score of 4 or 5 on DBT-SCV (vs 32 cases on DBT). Therefore, the calculated PPV of architectural distortion for malignancy at DBT was 38.5%, in agreement with the PPV of 34.6% reported by Choudhery et al. . Also thIncreased PPV and high NPV of DBT-SCV represents an encouraging result to promote the use of the DBT-SCV in clinical practice. In our study, the 71 patients were then subjected to complementary ultrasound to check if there was a morphological correlation to DBT and MRI examination, in order to check for the presence of any pathological contrast enhancement and for biopsy sampling guidance  for adequate diagnosis of nature. While on the one hand, DBT-SCV, US and MRI strongly correlated with assessing ADs with malignant histology, on the other hand, regarding ADs with benign histology, no correlation was seen between DBT, US and MRI (< 0), while a moderate correlation was appreciable between DBT-SCV, US and MRI  (Table p < 0.05); sonographic [In our study, architectural distortion without a US/MRI correlate was less likely to represent malignancy than AD with a correlate  reduced the dose approximately by half to a level that was roughly comparable to that of FFDM , 29. Alln = 179) to 2.56 mGy (n = 300) [In our study, we analyzed AGD as an expression of the absorbed breast dose considering the glandular component as the most radiosensitive tissue of the breast and ESD in correlation with the different breast thicknesses. The use of DBT-SCV remained within the dose limits set by the European Protocol for the Screening and Diagnosis of Breast Cancer proving to be advantageous . Our stun = 300) , 30, 32.n = 300) .Study limitations include the narrow population of patients and the retrospective origin of the study. Secondly, results were obtained in a single center and using a single mammographer, Hologic Selenia TM Dimensions System. Future studies are encouraged to extend the population sample analyzed in addition to implementing different mammography manufacturers.This study showed that DBT-SCV has a high NPV and a statistically significant higher PPV compared to DBT alone, hence could be useful in the daily practice workflow as an additional projection to better characterize the architectural distortions identified with DBT and improve the management accordingly within the radiation dose limits.In summary, if a tomosynthesis-detected architectural distortion, without US or MRI correlate, that is neither confirmed nor changed by DBT-SCV, other options such as “wait and see” approach can be taken into consideration in order to reduce unnecessary biopsy.


Conclusions: Mainland Chinese in Canada who were over 25, in poor financial/health status, or with perceived/experienced discrimination were at a higher risk for COVID-19-related psychological distress. The health inequity across these factors would inform the services to mitigate mental health risk in minority groups.The COVID-19 pandemic has exacerbated health inequalities, with a potentially heightened mental health risk for Mainland Chinese in Canada, given the rising anti-Chinese discrimination, and barriers in assessing health services. In this context, this study aimed to assess non-pathological psychological distress towards COVID-19 and identify its sociodemographic risk factors among Mainland Chinese in Canada at the early stages of the pandemic. Methods: A sample of 731 Mainland Chinese aged 16 or older completed an on-line survey to examine their attitudes, behavioural, and psychological responses towards COVID-19. Non-pathological psychological distress was assessed with a 7-item self-report scale to capture common emotional reactions towards COVID-19. Results: A factor analysis revealed a single-factor structure of the 7-item COVID-19 psychological distress scale (Eigen λ = 3.79). A composite psychological distress index (PDI) score was calculated from these items and used as the outcome variable. Multivariate regression models identified age, financial satisfaction, health status, and perceived/experienced discrimination as significant predictors of psychological distress ( The coronavirus COVID-19) pandemic has been spreading widely in Canada 9 pandemi. In thisIt is reasonable to expect that the mental health risk will be heightened in visible minority populations, especially among Chinese migrants, considering their experiences with cultural, language, and social barriers in accessing healthcare services ,12,13. FThe COVID-19 outbreak has a detrimental impact on psychological wellbeing across the world ,7. A sysIn the process of adapting to Western life, Mainland Chinese in Canada may face numerous obstacles such as social, cultural, and language barriers, as well as racial discrimination . These oA few sociodemographic variables have been identified as being linked to psychological distress during the pandemic. For example, young (aged 18 to 30 years old) and older adults (aged 65 years old and over) showed significantly higher levels of psychological distress relative to other age groups . Women tDespite the possibly heightened risk of psychological distress in Mainland Chinese, there is a scarcity in Canadian research on the psychological impact of COVID-19 among this minority population, particularly at the initial outbreak stage of the pandemic. As a rapid response to the pandemic outbreak, the current study aimed to fill this gap to have a brief assessment of non-pathological psychological distress towards COVID-19 pandemic and identify related sociodemographic predictors among Mainland Chinese in Canada at the early stages of the pandemic. This is important given the time-sensitive behavior measures implemented at that time. The results will shed light on future public health policies and measures to best mitigate psychological distress or mental health issues at the initial stages of the pandemic outbreak.Therefore, this study addressed a specific and explorative research question: whether higher psychological distress of Mainland Chinese in Canada at the initial outbreak stage of the pandemic was predicated by their sociodemographic profiles ? In light of the previous findings reported in the literature ,31,32,33Participants were primarily recruited through a snowball sampling approach via WeChat , including private and group chat forums and moment posts, as well as other online platforms such as emails (to the collaborative Chinese community organizations) and websites, participating the lab contacts and the website of The Centre for New Immigrant Well-being (CNIW) in parallel. A total of 764 individuals responded to the survey, in which 731 completed the informed consent and met the inclusion criterion: Mainland Chinese aged 16 or older who had lived in or would live in Canada for at least 6 months. Compared to the 2016 Canadian census results on Mainland Chinese immigrants  , women . Participation was anonymous and voluntary, and informed consent was obtained before participation. No incentive was provided for participation. Identifying information  was removed before analysis. The survey is composed of two sections. The first section gathers general sociodemographic information about participants and the second section collects information on psychological, cognitive, and behavioral responses towards COVID-19. In light of previous findings [The COVID-19-induced non-pathological psychological distress was assessed with a 7-item self-report scale that captures commonly reported emotions  in response to COVID-19. The items read as “please rate to which degree you feel at ease/fearful/anxious/depressed/stressed/indecisive/confused about the current COVID-19 pandemic?” respectively for each emotional response. Participants rated how each item described themselves based on a 5-point Likert Scale from 1  to 5 (very much). To minimize habitual or robot responses, one item was worded in a positive valence  and, thus the score was reverse coded to index “uneasy”.n = 481), with listwise deletion of missing value cases. The Pearson inter-item correlation analysis showed consistent positive correlations among all these items . The principal component factor analysis extracted a single-factor component . The seven items heavily loaded on this component (0.53–0.84). Thus, a composite psychological distress index (PDI) score was calculated as the average across the seven items, with missing values being replaced with the average score for each participant. Furthermore, the PDI level was defined by categorizing scores larger than the scale median point  as “high-distress” (50.48%), and the remaining as “low-distress”.The rating scores showed a high reliability (Cronbach’s α = 0.85) across the seven items  level category see . Group d2χs ≥ 3.99, ps < 0.05). Young adults (aged < 25), those who were financially satisfied, healthy, with little to no perceived or experienced discrimination, or without exposure or experience of the symptoms, were less likely to be in the “high-distress” category. Additionally, the independent samples t-tests or one-way ANOVA (ps ≤ 0.017). Specifically, young adults reported less distress than middle-aged adults. Women reported higher distress than men. Those who were financially dissatisfied, in poor health, and with perceived or experienced anti-Chinese discrimination reported differentially higher distress. Taken together, the Chi-square and group difference tests suggested a higher psychological distress reported by women, those aged over 25, financially dissatisfied, in poor health, with perceived and experienced discrimination, or experiencing flu-like symptoms.Pearson Chi-square analyses  showed tay ANOVA  on the cA multivariate linear regression model was conducted on the continuous PDI score and a multivariate logistic regression model was conducted on the categorial PDI level score to identify significant sociodemographic predictors for PDI see . All theThis study addressed an explorative research question to assess non-pathological psychological distress towards COVID−19 among Mainland Chinese in Canada and identify its sociodemographic predictors at the initial outbreak stage of the pandemic. The results showed that distress level is lower for young adults (aged < 25), and higher for those in poor financial/health condition or who perceived or experienced discrimination. These results are discussed below in light of the literature.The finding of lower psychological distress risk in young Chinese relative to other age groups was not fully consistent with the literature. It has been reported that both young adults aged 18–30) and the elderly (aged above 60) in Mainland China reported the highest level of psychological distress related to COVID−19 –30 and t,38. But Our results suggest that individuals who are unsatisfied with their financial or health conditions reported higher level of psychological distress, a result consistent with the commonly reported associations between socioeconomic status (SES) and mental health ,43. The Consistent with the available COVID-19 literature , other sIn light of the research question of this study to assess the non-pathological psychological distress towards COVID-19 and identify its sociodemographic predictors among Mainland Chinese in Canada, we found that over half of the sample scored in the “high-distress” category (50.48%) at the early pandemic outbreak stage. Furthermore, the results identified age, financial/health status, and discrimination as significant risk predictors for psychological distress in this population. Specifically, the distress level was lower for young adults (aged < 25), and higher for those in poor financial/health condition or those who perceived or experienced anti-Chinese discrimination.Cultural integration, conceptualized as the adoption of the host and the origin cultures, has been linked with better subjective wellbeing compared to immigrants who have assimilated entirely to the host culture . The lacNonetheless, this study provided critical information on psychological responses to the initial pandemic outbreak among Mainland Chinese in Canada. The results generally identified older age (middle-aged and older adults relative to young adults), poor financial and health status, and perceived anti-Chinese discrimination as significant risk factors for higher psychological distress among this vulnerable population.Given the well-reported health inequalities among racialized individuals in Canada , and the


Following the global COVID-19 pandemic, nanotechnology has been at the forefront of research efforts and enables the fast development of diagnostic tools, vaccines and antiviral treatment for this novel virus (SARS-CoV-2). In this review, we first summarize nanotechnology with regard to the detection of SARS-CoV-2, including nanoparticle-based techniques such as rapid antigen testing, and nanopore-based sequencing and sensing techniques. Then we investigate nanotechnology as it applies to the development of COVID-19 vaccines and anti-SARS-CoV-2 nanomaterials. We also highlight nanotechnology for the post-pandemic era, by providing tools for the battle with SARS-CoV-2 variants and for enhancing the global distribution of vaccines. Nanotechnology not only contributes to the management of the ongoing COVID-19 pandemic but also provides platforms for the prevention, rapid diagnosis, vaccines and antiviral drugs of possible future virus outbreaks. This review highlights how nanotechnology helps us in the management of COVID-19 by providing detection methods, vaccines and antiviral treatments during the pandemic and in the post-pandemic era. The current global coronavirus disease 2019 (COVID-19) pandemic caused by the novel coronavirus  that began in 2019 has greatly changed the world. According to the World Health Organization (WHO), the number of confirmed cases has exceeded 418 million, with over 5.8 million deaths across over 200 countries and territories (as of February 2022) ,1110,11]To detect the SARS-CoV-2 virus in an LFA, the primary targets are the spike (S) protein, the nucleocapsid (N) protein of the virus, the antibodies or the viral nucleic acid . N prote5 times compared to RT-PCR, and by 103 times for cell culture assays [RAT has been deployed on a massive scale in many countries, and the cost per test is low. The trade-off for RAT is that it is less sensitive than expensive laboratory assays, by a factor of 10e assays . One wayNanopore sequencing allows real-time analysis of long DNA or RNA fragments by using voltage-biased nanoscale pores in a membrane ,17. By eet al. evaluated the analytical performance of nanopore sequencing for COVID-19 using the sequencing devices from Oxford Nanopore Technologies, and specimens from SARS-CoV-2-positive patients  and synthetic RNA controls. The results showed highly accurate consensus-level sequence determination, with >99% sensitivity and >99% precision with regard to single nucleotide variants detected above a minimum ∼60-fold coverage depth. This study demonstrates the value of nanopore sequencing for SARS-CoV-2 genome analysis. However, it was also reported that this technique failed to detect variants at low read-count frequencies accurately [et al. combined real-time nanopore sequencing with targeted amplification methods for the detection of SARS-CoV-2. Within 6–10 hours, this approach can detect and categorize SARS-CoV-2 variants and other respiratory viruses. Clinical diagnostic tests have validated this technique [Bull curately . Likewisechnique . 000 copies/mL for SARS-CoV-2, and 1 pfu/mL for human adenovirus  and decorated it with the porphyrin, H2TMP (as a sensitizer for sensors) and achieved a detection limit of 5 nM for the SARS-CoV-2 spike antigen [Sensors based on nanomaterials, especially porous nanomaterials, have been developed for the direct detection of infectious virions of SARS-CoV-2. DNA aptamers, which bind intact infectious virions (but not non-infectious virions), have been incorporated into solid-state nano-sized pores. This allows the nanomaterial to strongly bind and confine the virus, which increases the sensitivity and lowers the detection limit down to 10 antigen . This prIn addition to single-plexed detection, multiplexed sensing of SARS-CoV-2 has also been recently developed based on nanomaterials. Gao and his group designed a multiplexed and wireless electrochemical platform based on graphene for ultra-rapid detection of COVID-19 ,25. ThisVaccines remain the most efficient strategy for protection against viral infections. An appropriate vaccine will generate antibodies and memory T cells as well as sensitized cytotoxic cells. Vaccine design includes the identification of antigens and adjuvants, as well as an appropriate delivery method to deliver the antigens and trigger proper immune reactions. Nanotechnology provides powerful tools to deliver the antigens and present them to the immune system, and also acts like adjuvants to elicit stronger immune responses. During this pandemic, the Pfizer and Moderna mRNA vaccines are using lipid nanoparticles to deliver the mRNA that encodes for the spike protein of SARS-CoV-2, and these represent a milestone for both nanotechnology and the mRNA technique. The mRNA induces the expression of the spike protein, triggering the host immune response. Both the Pfizer and Moderna mRNA vaccines have a reported efficacy of around 95% for preventing hospitalizations caused by laboratory-confirmed COVID-19 in people aged 16 or older who have not been previously infected with SARS-CoV-2 .As shown in Fig. In addition to lipid nanoparticles, other types of nanoparticles can be used as nanocarriers to deliver nucleic acids for vaccines, including PEG-lipid functionalized dendrimer nanoparticles, cationic peptides, cationic polymer nanoparticles and polyethyleneimine nanoparticles ,34.Nanoparticles can possess their own immunogenic properties, which can stimulate protective immune responses against coronaviruses and other viruses . RelevanIn addition to serving as a delivery system, nanoparticles can also be used as adjuvants, to boost the overall efficiency of the immune response generated by vaccines. Adjuvants also reduce the required antigen dose . Of the Vaccination using protein subunits also involves nanotechnology. These protein subunits comprise various external structural components of the SARS-CoV-2 virus and are combined with adjuvants to increase the extent of stimulation of the immune response . An examNanoparticles can be potent adjuvants in vaccines because of their immune-stimulating activity. They also have modifiable surface chemistry ,43. As aUnlike traditional therapeutics, which tend to target a specific viral species and may lose their efficacy as the virus accumulates mutations, antiviral nanomaterials can target many types of viruses, because of their customized chemical and physical properties. DNA-based nanostructures can trap viruses, while modified polymers can serve as cell membrane decoys. Other nanomaterials can disrupt viral envelopes. Using such approaches may offer advantages in the context of countermeasures in a pandemic, as they can be formulated rapidly Fig. .Although SARS-CoV-2 can be transmitted readily by droplets and aerosols, contact transmission is an important additional route, via contaminated inanimate surfaces and poor hand hygiene . The virGiven the importance of respiratory protection via surgical respirators for health care workers during the pandemic, there has been interest in using such composite nanomaterials to coat the fibres within the respirators, or on the outer surface of the filtering facepiece. Study has demonstrated that a silver nanocluster/silica composite coated respirator has an effect against SARS-CoV-2 , with th2 photocatalyst can inactivate SARS-CoV-2 on the surface when there is exposure to light [A further method for providing a smart antimicrobial surface is to use nanomaterials that are light responsive , to achito light . Nanotecto light . Severalet al. prepared silica nanoparticles with 5 to 10 nm spikes, which could be inserted into the surface glycoproteins of the influenza A virus and neutralize them [Nanomaterials can target different stages of SARS-CoV-2 viral infection, such as fusion of the virus with the host cell membrane, internalization, viral genome transcription, translation and replication. Nanomaterials can be designed to trap and neutralize SARS-CoV-2 with high efficiency. For example, Nie ize them . It is let al. have described PEG-carbon nano-horns tagged by an antibody that specifically targets the T7 bacteriophage, and binds the nano-horns to the virus [2 for 10 min), the temperature rose to 55°C, and this inactivated 99.99% of type-1 herpes simplex virus [Photothermal antiviral actions can be achieved rapidly when nanoparticles absorb near-infrared light, and the resulting heat causes photothermal disinfection . The heahe virus . Irradiahe virus . Anotherex virus ,70.A further photothermal process uses gold nanorods that have been functionalized with angiotensin-converting enzyme-2, which will bind SARS-CoV-2. These particles can be activated by near-infrared laser irradiation (798 nm), to achieve selective elimination of SARS-CoV-2. This type of approach may have value when patients are hospitalized with severe pulmonary infections . SeveralCompared to traditional antiviral drugs, which usually work only for specific viruses, nanomaterials may provide broader targeted virus ranges as the antiviral effects are mainly from their chemical and physical properties. For example, the spiky silica nanoparticles may work for the mutations of the viruses as well as bind to the glycoproteins of the virus with their nano-topography . NanomatNanomaterials can be used as smart carriers in targeted drug delivery systems for antiviral medicines. This leverages their distinct properties, including large surface area, good biocompatibility and ease of surface modification, all of which can be customized during design . Using aInorganic nanoparticles with small size (1 to 100 nm) such as metal nanoparticles can be synthesized, and the corresponding increase in the surface area gives them a high loading capacity for antiviral agents . Severalin vivo, and to improve efficiency [Potential concerns with metal nanoparticles include poor biodegradability, with attendant risks of accumulation within organs. Lipid-based nanoparticles are attractive for clinical use because of their good biocompatibility and biodegradability. Lipid nanoparticles have been used as nanocarriers for antiviral agents, for treating hepatitis C and B, herpes simplex and HIV ,88. Lipoficiency .Polymeric nanoparticles have attracted interest because of the considerable flexibility of their design and ease of modification. Poly (lactic-co-glycolic acid) (PLGA) nanocarriers have been shown to boost the antiviral actions of dyphylline in H1N1 influenza infections, because of the sustained release of the drug in the lung. Optimized PEGylation of these nanoparticles prevented activation of macrophages in the lung for four weeks ,92. SuchPolymeric nanoparticles can be loaded with corticosteroids and inhaled. This approach has been used to treat asthma and severe chronic obstructive pulmonary disease, but could also be applied to SARS-CoV-2 infection in patients experiencing severe illness because of a cytokine storm. Multifunctional polymeric nano-delivery systems have considerable potential for clinical application, and with emergency or expedited approval could be deployed in the current COVID-19 pandemic .Dendrimers are synthetic nanostructures with a well-defined branching architecture. They have good biocompatibility, high solubility and are effective for drug encapsulation. Previous works have shown their efficiency as a delivery system in the context of herpes simplex virus type-2, HIV and influenza , and denWith several highly effective COVID-19 vaccines deployed at scale in many countries, an important question is whether the use of nanotechnology in vaccines provides the necessary ability to rapidly redesign vaccines when concerning variants appear that are more virulent. Outlined below are the major advantages of mRNA delivered in lipid nano-carriers.As SARS-CoV-2 continues to mutate, new variants of concern are being generated with altered virulence and transmissibility, resulting in altered levels of protection from existing vaccines . The OmiLipid nanoparticles that contain mRNA have been proven to be an efficient method for developing immunity. Low or ultra-low temperature storage of these lipid nanoparticle-mRNA vaccine formulations (−20 or −80°C) is not convenient for shipping, storage and distribution, especially in developing countries and in remote areas. A new thermostable lipid-nanoparticle-encapsulated mRNA (mRNA-LNP) vaccine, known as ARCoV, has been developed by a modified fabrication process. ARCoV was manufactured through rapid mixing of mRNA in an aqueous solution and a mixture of lipids in ethanol, followed by tangential flow filtration to remove ethanol and concentrate the solution. ARCoV particles are solid spheres without an aqueous core and can be stored at room temperature for at least one week without losing activity. The mRNA encodes the receptor-binding domain (RBD) of SARS-CoV-2. ARCoV is currently being evaluated in phase one clinical trials .Another nanotechnology approach of interest is the so-called ‘nano patch’. This comprises arrays of densely packed projections with a defined geometry, which can penetrate through the epidermis painlessly. Using a patch rather than an injection delivers the vaccines to thousands of antigen-presenting cells in the dermis and epidermis. A nano patch vaccine can be kept at room temperature without needing to be refrigerated. This approach overcomes storage issues and also avoids the need for injections, tackling two barriers at the same time.The widespread use of lipid nanoparticles to deliver mRNA vaccines has increased the awareness of this platform. The relative ease of production makes this appealing for ‘first response’ vaccines for future influenza or coronavirus pandemics. Lipid nanoparticles could also be used to deliver DNA gene therapies and CRISPR gene-editing therapies.In addition, other polymer nanoparticles, protein-based nanoparticles, inorganic nanoparticles and exosomes are also worth considering as vehicles for future vaccines.et al. prepared ‘nanosponges’ that displayed the same protein receptors as human cells and showed that these can bind to and neutralize the SARS-CoV-2 virus, preventing it from infecting cells. This nanosponge approach is not expected to be affected by viral mutations [As already discussed, nanoparticles can deliver antiviral medicines and can also, in some cases, exert their own antiviral actions against multiple viruses. This makes them rather different from traditional antiviral agents, which have a limited range of targets. Many viruses, including SARS-CoV-2, rely on glycoproteins on their surface to bind to and then enter host cells. Nanomaterials can be designed to mimic binding sites. As an example, Zhang utations .Nanotechnology has empowered the global response to the COVID-19 pandemic, through powerful tools for prevention, diagnosis and treatment. Detection systems based on nanoparticles and nanopores have enabled rapid and inexpensive detection of the virus, and have informed public health measures. One lesson we have learned during this COVID-19 pandemic is that rapid, large-scale virus detection can greatly help disease control and requires the development of virus detection methods that are simple to use, and have high accuracy and low cost. The power of nanotechnology-driven detection such as the LFA and nanopore sequence can be further explored to manage COVID-19 and other potential virus diseases.During this pandemic, lipid nanoparticles for delivering mRNA in vaccines have played a major role in population-level vaccination strategies, and will likely play an increasing role in the future, both as a platform for the rapid development of vaccines, and for updating vaccines to address viral mutations. New nanoparticles with higher antigen-delivery efficiency, better stability, especially thermal stability, and target delivery are desired for vaccines. This ability to adjust to the challenges posed by a rapidly mutating virus is a major advantage of nanotechnology. Nanomaterials that have potent antiviral actions also have considerable promise.In the long term, nanotechnology will serve as a technological foundation for the prevention and management of future viral-infection pandemics. Appreciation of the opportunities that nanotechnologies offer is necessary for effective collaboration between scientists, policymakers and health care professionals when addressing the long-term challenges caused by SARS-CoV-2 and potential virus outbreaks.


The fifth wave of the COVID-19 pandemic has caused an unprecedented toll on Hong Kong. As more countries are starting to lift COVID-19 restrictions, it would be important to understand the public attitudes towards lifting COVID-19 restrictions and to identify its associated factors. The present study examined the level of support towards the living with the virus (LWV) policy for COVID-19 among the public in Hong Kong and to identify the associations between resilient coping, self-efficacy and emotional distress with support towards the LWV policy. A random population-based telephone survey was conducted among 500 Hong Kong Chinese adults from 7 March to 19 April 2022, i.e., during the fifth wave of COVID-19 outbreak. Of the respondents, 39.6% showed a supportive attitude towards the LWV policy. Results from the structural equational modeling showed a positive correlation between resilient coping and self-efficacy. Resilient coping was associated with support towards the LWV policy directly and indirectly through a lower level of emotional distress. Self-efficacy had a direct association with support towards the LWV policy but its indirect association through emotional distress was not significant. Interventions that foster resilient coping and self-efficacy would be effective in reducing public emotional distress and promoting their positive view towards the LWV policy. The COVID-19 pandemic has resulted in an unprecedented impact worldwide. As the economic and social costs caused by the pandemic have been substantial . These pAfter three years of numerous waves of the COVID-19 pandemic, pandemic fatigue has been reported in various populations ,7. At thSince the beginning of the pandemic, Hong Kong has adopted the zero-virus policy pursued by mainland China. In contrast to the LWV policy, the zero-virus policy involves using numerous public health measures, including mass testing, contact tracing and social restriction measures to stop the community transmission of COVID-19 as soon as it is detected, with the goal of completely eliminating infections and maintaining normal economic and social activities. Following the zero-virus policy, numerous social distancing measures have been introduced to restrict individuals’ movements and activities in Hong Kong. For example, travelers going to Hong Kong need to undergo compulsory quarantine and flights from high-risk countries have been suspended. Individuals who are tested positive or are in close contact with COVID-19 patients need to undergo mandatory confinement in isolation facilities. Schools were suspended and social and public venues, such as gymnasiums, swimming pools, parks and cinemas were closed. The operating time of restaurants has also been significantly restricted. These measures have curbed the spread of the virus significantly in the early phase of the pandemic. There were only a total of 12,649 COVID-19 positive cases in Hong Kong as of 31 December 2021 .However, a drastic change in the pandemic was observed since the highly infectious variant, Omicron, was detected in Hong Kong in January 2022. Cases of COVID-19 started to surge. Between 1 March to 15 March 2022, 409,254 new COVID-19-positive cases were found, which was more than 30 times of the total number of COVID-19 cases since the beginning of the pandemic . The surSeemingly, increasing public support has been given to the LWV strategy to deal with the pandemic and individuals were increasingly willing to bear the potential costs incurred by the strategy. This is supported by a public survey that has documented a significant decrease in public support on quarantine policy during the fifth wave of the pandemic in Hong Kong. For example, the number of people who supported quarantining anyone who has been in contact with an infected individual dropped from 59% in December 2021 to 45% in April 2022, and those who supported quarantining any location that an infected individual has been in dropped from 45% in December 2021 to 32% in April 2022 . As HongThe government’s pandemic mitigation strategies have raised many opinions due to its significant effect on people’s life. Maintaining public confidence and support towards government policy is imperative during a pandemic, as trust and confidence towards the government’s pandemic mitigation measures were related to increased compliance with COVID-19 public health measures ,18. PrevThere is extensive evidence that perceptions and experiences of the disease, personality and psychological factors can help explain individuals’ attitudes towards a health initiative during a pandemic ,23. CurrThe COVID-19 pandemic is an adverse situation that evokes intense negative emotions. Resilience, which refers to the ability to bounce back from adversity, is an important concept for adaptation to the pandemic . ResilieSelf-efficacy refers to individual’s belief in his or her capacity to perform behaviors necessary to overcome challenges or produce specific results . It servFurthermore, self-efficacy can be considered an important dimension of dispositional pattern of resilience, which refers to physical and ego-related psychosocial attributes that serve as protective factors . AccordiThe importance of emotional factors in pandemic control has been widely demonstrated in the literature. Mental distress is related to poorer adherence to health behaviors, avoidance and lower perceptions of control in face of pandemic ,40,41. HThe present study examined the level of support towards the LWV policy for COVID-19 among the public in Hong Kong to identify the associations between resilient coping, self-efficacy, emotional distress and support towards the LWV policy. It was hypothesized that resilient coping would be correlated with self-efficacy and both of which would be associated with support towards the LWV policy, directly and indirectly through lower levels of emotional distress. The mediation effects of the association between resilient coping and support towards the LWV policy via self-efficacy/emotional distress were hence tested in the present study. In addition, invariance testing via multi-group SEM was conducted to see if the direction/strength of the structural/indirect paths differed according to COVID-19 ever-infected status.A random population-based telephone survey was conducted among Hong Kong Chinese adults aged ≥18 years from 7 March to 19 April 2022, i.e., during the 5th wave of COVID-19 outbreak. By the time of the survey, Hong Kong was still adopting the zero-COVID strategy despite the sharp increase in the number of COVID-19 infections. Household telephone numbers were randomly drawn from the updated landline telephone directories. As this would only be able to reach working individuals after working hours, the 15 min interviews were made by experienced interviewers from 5 pm to 10 pm, in order to avoid over-sampling non-working individuals. The household member whose birthday was closest to the interview date was invited to join the study. Unanswered telephone calls were given at least three attempts before being classified as invalid numbers. Unavailable eligible participants were contacted again by appointments. No incentives were given to the participants. Verbal informed consent was obtained from the participants; the interviewers were asked to sign a form pledging that they had completed the required consent procedures. The ethics approval was obtained from the Survey and Behavioral Research Ethics Committee of the corresponding author’s affiliated institution (No. SBRE-21-0555A).A total of 500 valid interviews were conducted. The response rate, defined as the number of completed interviews (n = 500) divided by the number of eligible contacts (n = 957), was 52.2%.This information included gender, age (years), educational level, marital status, employment status  and having any diagnosed chronic diseases .One item assessed participants’ levels of support towards the LWV policy based on the current COVID-19 situation in Hong Kong; the LWV policy included lifting the COVID-19 control policies on social distancing, compulsory facemask wearing, free COVID-19 testing, travel restriction and quarantine. The item was rated on a 5-point Likert scale (1 = extremely low to 5 = extremely high), which was recoded into a binary dependent variable [1 = Supportive (high/extremely high) vs. 0 = Unsupportive (moderate/low/extremely low)].This was measured by the 4-item Brief Resilient Coping Scale (BRCS) that aimed to capture the tendency to cope with stress in an effective, flexible and committed ways . The ChiThis was assessed by the item, “I believe I can succeed at most of any endeavours to which I set my mind”, which was selected from the commonly used 7-item General Self-efficacy Scale (GSES) . The iteA two-item scale was used to assess the extent to which the participants felt (a) panicked and (b) anxious due to the current COVID-19 threat in Hong Kong. The items were rated on a 5-point Likert scale (1 = extremely low to 5 = extremely high). The scale has been commonly used in previous studies investigating emotional responses to emerging infectious diseases  . The CroParticipants were asked about whether they have ever had COVID-19 positive results of the Nucleic Acid Amplification Test (NAAT) or Rapid Antigen Test (RAT) (yes or no response options).p value > 0.05 in the Wald test would denote between-group invariance on that tested structural/indirect path. The SEM was conducted by using Mplus 7.0, and the other analyses by using SPSS 23.0. Statistical significance was defined as two-sided p < 0.05.Supportive attitude towards the LWV policy was used as the binary dependent variable in this study. The differences in background variables between those who were supportive and unsupportive towards the LWV policy were examined by using Chi-square test. Pearson correlation coefficients were derived among resilient coping, self-efficacy and emotional distress due to COVID-19. Univariate and multivariate (adjusted for background factors) logistic regression analyses were conducted to test factors of supportive attitude towards the LWV policy; crude odds ratio (ORc), adjusted odds ratio (ORa) and respective 95% confidence intervals (CIs) were generated. Structural equation modeling (SEM) was fit to investigate the mediation effect of emotional distress due to COVID-19 between resilient coping/self-efficacy and the supportive attitude; the Weighted Least Square Mean and Variance (WLSMV) estimator was used. Two latent variables of resilient coping and emotional distress due to COVID-19 were created from the four and two original scale items, respectively. Multigroup SEM by previous COVID-19 infection was further fit to examine the significance of each structural/indirect paths of the above SEM model between those having and not having a previous COVID-19 infection. A series of models, each constraining a specific individual path , were compared to the unconstrained model testing all the paths freely. Of all the participants, 67.0% were female; 69.5% were currently married; 41.2% had a full-time job (41.2%); 25.2% attended college/universities. About one-third aged >60 years (33.4) and had a chronic disease such as hypertension or diabetes (35.8%). The prevalence of having a COVID-19-positive result according to NAAT or RAT was 16.9% .About 40% (39.6%) showed a supportive attitude towards the LWV policy. Those showing a supportive attitude were significantly more likely to be younger (aged 18–30: 20.2% vs. 10.3%), had an educational level of college or above (34.5% vs. 19.0%), in full-time employment (50.5% vs. 35.8%), had a history of COVID-19 infection (23.2% vs. 12.6%) and were less likely to be married (63.6% vs. 73.3%) than those with an unsupportive attitude. No significant between-group differences were found in gender and chronic disease status .r = 0.49, p < 0.001) and negatively correlated with emotional distress due to COVID-19 . The correlation between self-efficacy and emotional distress was statistically non-significant  (See Resilient coping was positively correlated with self-efficacy (378) See .Consistent with the results of univariate logistic regression analyses, with adjustment of the background factors, multivariate logistic regression analyses showed that resilient coping  and self-efficacy  were positively associated with supportive attitude towards the LWV policy, while emotional distress due to COVID-19 was negatively associated with the supportive attitude . See 2/df = 111.24/82 = 1.36 (p of χ2 = 0.018); CFI = 0.99; TLI = 0.99; RMSEA = 0.03) with factor loadings of the two latent variables ranging from 0.77 to 0.94 .β = 0.07; p < 0.001), i.e., resilient coping was negatively associated with emotional distress due to COVID-19 , which was in turn negatively associated with the supportive attitude ; the mediation effect size was 31.7%. Furthermore, the direct effect of resilient coping on the supportive attitude was significant , indicating a partial mediation between resilient coping and support towards the LWV policy via emotional distress due to COVID-19. In addition, self-efficacy had a significant direct effect on supportive attitude towards the LWV policy , but its indirect effect via emotional distress due to COVID-19 was statistically non-significant , indicating a full mediation effect.It is seen from All the directions and magnitude of the paths shown The pandemic of COVID-19 has disrupted lives across the globe. The implementation of restrictions to reduce the spread of the COVID-19 has sparked considerable debates. As more people are exposed to the less severe Omicron variant, which has become the dominant COVID-19 variant, a shift in public attitudes towards lifting restrictions and living with COVID-19 and calls to ease restrictions and eliminating physical distancing measures have been observed in many countries. However, research on people’s attitudes towards easing COVID-19 restrictions remains scarce.It is worthwhile to note that a substantial proportion 39%) of the participants showed support towards the LWV policy. The continual mitigation strategies to restrict movements and detection and isolation of those tested positive might have caused tremendous stress and disruption to people’s lives 9% of the,5. GivenPrevious studies on resilient coping have been focused on health outcomes ,33,34. TSelf-efficacy is an important dispositional dimension of resilience that would promote positive adaptation. While the relationship between self-efficacy and positive health outcomes has been established in the literature ,37, findDespite the extensive discussions on the mental impact of pandemic mitigation measures (such as lockdown policies) ,49, how It is possible that the COVID-19 pandemic will continue and various kinds of pandemic control strategies may continue to be in place. Some countries might have to reinstall some removed measures if more infectious/severe variants emerge. The present study is one of the few studies in understanding the level of public support towards the LWV policy. Findings on the public’s view towards the easing of COVID-19 restrictions could inform the policymakers to design effective control and health communication strategies in response to further COVID-19 and other outbreaks.The present study has provided a more nuanced understanding of the role of psychological factors on policy support and its findings have underscored the importance of promoting resilient coping and self-efficacy as means to reduce emotional distress and stimulate public support towards the LWV policy during the pandemic. Indeed, promoting resilience and self-efficacy have been regarded as one of the 10 considerations for effectively managing the COVID-19 transition . It is aFurthermore, interventions should also empower the general public by promoting their self-efficacy during the pandemic. Public health interventions should address the general public’s confidence and belief that they have the ability to prevent themselves from the infection and cope with the stressors caused by the pandemic. Social modeling is also another effective way to improve self-efficacy as it allows individuals to observe and learn strategies for overcoming obstacles from others ,53. StudThe present study is subject to several limitations. The study was cross-sectional in nature so no causality could be assumed. Compared to the Hong Kong general population , the ageThe present study revealed that during the fifth wave of the COVID-19 pandemic, more than one-third of the general public in Hong Kong were supportive of the LWV policy and their support was motivated by resilient coping, self-efficacy and lower level of emotional distress. Knowing the view of the general public and factors associated with their support will inform government of the feasibility of a similar policy for infection outbreak. Interventions that foster resilient coping and self-efficacy would be effective in reducing public emotional distress and promoting their positive view towards the LWV policy.


This study was aimed to investigate the characteristics of the amplitude of low-frequency fluctuation (ALFF) at specific frequencies in severe obstructive sleep apnea (OSA) patients. A comparison was made between pre-CPAP treatment and one night after continuous positive airway pressure (CPAP) treatment.30 severe OSA patients and 19 healthy controls (HC) were recruited. The ALFF method was used to assess the local features of spontaneous brain activity and calculated at different bands (slow-5 and slow-4). A correlation analysis was performed to evaluate the relationship between the changes of the ALFF and polysomnography data.r = 0.4933, p = 0.0056). The left cerebellum 6 slow-5 band change was positively correlated with the duration of the REM sleep change , and the left cerebellum 6 slow-4 band change was also positively correlated with the mean blood oxygen change in the REM  and NREM sleep .Compared with HC, in slow-5 frequency band, OSA patients showed significantly decreased ALFF in the left inferior temporal gyrus, and significantly increased ALFF in the left middle frontal gyrus, left inferior frontal gyrus, triangular part, right superior frontal gyrus, dorsolateral and right middle temporal gyrus. In slow-4 frequency, there was significantly decreased ALFF in the right inferior temporal gyrus, and significantly increased ALFF in the left precuneus, right posterior cingulate gyrus and right median cingulate besides the slow-5 difference band showed. Compared with pre-CPAP, we found that after CPAP treatment, ALFF signals in the left insula in slow-5 and left caudate in slow-4 increased, but the calcarine in slow-4 significantly reduced. Correlation analysis showed that the left angular slow-4 band change was positively correlated with the slow wave sleep change (We found that the use of slow-4 was more specific in OSA studies. These results suggested that the severe OSA patients have frequency-related abnormal spontaneous neural activity, which may contribute to a better understanding of the pathological basis of OSA-related diseases and provide a potential therapeutic target for OSA patients. Obstructive sleep apnea syndrome (OSA) is a common sleep disorder characterized by frequent upper airway collapse during sleep, leading to intermittent hypoxemia, sleep fragmentation and changes in sleep structure , 2. OSA Non-invasive neuroimaging techniques have been widely used to explore the pathophysiological mechanisms of various diseases, such as neurological and psychiatric disorders. Different neuroimaging techniques have been used to explore related structural, functional, and metabolic alterations in OSA patients –9. Many To date, most rs-fMRI studies have detected spontaneous low-frequency oscillatory (LFO) activity in a specific frequency band of 0.01–0.08 Hz. It is proposed that neural oscillations with different frequencies in the human brain may be sensitive to activity in different regions and can be used to reflect different physiological functions of brain activity . The rs-Continuous positive airway pressure (CPAP) is the gold standard treatment for moderate/severe OSA patients . PreviouHowever, after one-night CPAP treatment, the proportion of slow wave sleep and REM sleep in severe OSA patients increased, the arouse index and apnea-hypopnea index (AHI) decreased significantly, and the blood oxygen saturation improved significantly. Furthermore, the next day, most patients' daytime sleepiness was alleviated and their attention and responsiveness improved significantly . HoweverThirty newly diagnosed, untreated male OSA patients and nineteen healthy controls (HC) were recruited for this study from the Sleep Medicine Center of West China Hospital, Sichuan University. In this study, all subjects were recruited based on the following criteria: (1) male, (2) OSA patients with AHI>30, HC AHI <5, (3) age 20-60 years. In addition, the following characteristics were excluded: (1) non-right-handed. (2) A history of neurological or psychiatric diseases  or other sleep disorders (such as insomnia); (3) MRI contraindications ; (4) shift work; (5) abuse of illicit drugs. All subjects underwent Epworth sleepiness scale (ESS) assessments before undergoing polysomnography (PSG). All subjects signed written informed consent forms for this study before data acquisition and the study protocol was approved by the Human Research Ethics Committee of West China Hospital, Sichuan University.2) and body position were recorded. The subjects' tests were recorded by infrared cameras and continuously monitored by an experienced sleep technologist.All subjects were required to undergo PSG evaluation . According to the American Academy of Sleep Medicine guidelines, electroencephalography (EEG), electromyogram (EMG), electrooculography (EOG), electrocardiogram (ECG), oral and nasal airflow, snoring, thoracic and abdomen breathing movement, oxygen saturation  after PSG evaluation. The treatment pressure of the ventilator was set at 4–20 cm HAll participants had functional and structural MRI images collected in our hospital using a 3.0 T MRI scanner . MRI scans were performed the following day at 7:30–8:30 am after PSG or CPAP monitoring, so the patients underwent two scans and the controls only had one scan. Rs-fMRI data were acquired using an echo planar imaging (EPI) sequence with the following parameters: repetition time (TR) = 2,000 ms, echo time (TE) = 30 ms, flip angle = 90°, thickness = 5.0 mm, gap = 0.5 mm, field of view (FOV) = 240 × 240, matrix size = 64 × 64, slices = 30; a total of 6,000 rs-fMRI images were recorded. High-resolution T1-weighted MRI images of brain structures were obtained using a sagittal three-dimensional T1-weighted magnetization prepared rapid acquisition gradient echo (MPRAGR) sequence: TR = 1,900 ms, TE = 2.34 ms, inversion recovery Time (TI) = 900 ms, flip angle = 90°, thickness = 1.0 mm, gap = 0.5 mm, FOV = 256 × 256, matrix = 256 × 256, layers = 176.http://rfmri.org/DPARSF) and SPM12 (https://www.fil.ion.ucl.ac.uk/) based on MATLAB2018b  were used to preprocess the fMRI data: (1) File format conversion from DICOM to NIFTI; (2) removal of the first 10 volumes; (3) slice timing and head motion correction; (4) T1 segmentation with the Diffeomorphic Anatomical Registration Through Exponentiated Lie algebra (DARTEL) spatial normalization into the Montreal Neurological Institute (MNI); (5) regression of nuisance covariates including linear trend, white matter signals, cerebral spinal fluid signal, and Friston-24 parameters of head motions; (6) smoothing with a 6-mm full width at half maximum Gaussian kernel.We also evaluated the fMRI data for imaging or head motion-related artifacts before data preprocessing. Prior to ALFF analysis, DPARSFA , and slow-4 band (0.027–0.073 Hz)]. All ALFF maps were converted to z-maps by subtracting the global mean and dividing by the standard deviation. Subsequent statistical and correlation analyses were based on normalized ALFF plots.t-tests were performed to assess between-group differences on demographical and sleep data that were normally distributed. Mann–Whitney U-test was performed to assess between-group differences in variables that were not normally distributed.Data were assessed for normality (Shapiro–Wilk test), and Student t-test. Age, education level and head motion were imported as covariates. Whole-brain ALFF before and after CPAP treatment (slow-5 and slow-4) were tested using paired samples t-test. Head motion was imported as a covariate.Whole-brain ALFF (slow-5 and slow-4) were compared between the OSA group and the control group using an independent sample Whole-brain ALFF before and after CPAP treatment were correlated with sleep-related data, respectively, and regions with significant correlation results were selected as regions of interest (ROIs) and extracted (the results were presented in the 2 (blood oxygen saturation) of REM sleep, NREM sleep and TST, slow wave sleep (SWS) compared with HC. After one-night CPAP treatment, the time of REM sleep, SWS, the mean SaO2 of REM sleep, NREM sleep and TST increased significantly. AHI and the time of NREM sleep decreased significantly.The demographic and polysomnography data are shown in In the slow-5 frequency band, OSA patients showed significantly decreased ALFF in the left inferior temporal gyrus, and significantly increased ALFF in the left middle frontal gyrus, left inferior frontal gyrus, triangular part, right superior frontal gyrus, dorsolateral, right middle temporal gyrus compared to HC .In the slow-4 frequency band, compared to HC, OSA patients showed significantly decreased ALFF in the bilateral inferior temporal gyrus, and significantly increased ALFF in the left precuneus, right posterior cingulate gyrus, right median cingulate, right middle temporal gyrus, right inferior frontal gyrus, opercular part, left middle frontal gyrus, left inferior frontal gyrus, triangular part .t-tests were used to compare the difference in ALFF between pre-CPAP and post-CPAP OSA patients in the slow-4 and slow-5 frequency bands. Paired sample r = 0.4933, p = 0.0056) and the change of ALFF in left cerebellum 6 of the slow-5 frequency was positively correlated with the change of REM duration  before and after CPAP treatment. Moreover, the change of ALFF in left cerebellum 6 of the slow-4 frequency band was also positively correlated with the change of mean oxygen saturation during REM  and NREM sleep .As shown in For the first time, we used the slow-4 and slow-5 frequency bands of ALFF to analyze the characteristics of resting-state frequency in OSA patients and explored the changes of ALFF values in OSA patients after one-night CPAP treatment. Our study found that there were differences in ALFF between the severe OSA group and the control group in many brain regions. In addition, ALFF changes in brain regions were also found after one-night CPAP treatment. Correlation analysis further revealed the relationship between the changes of ALFF in the brain region and the changes of polysomnography parameters. The above results are more obvious in the slow 4-band.Our study showed that in the slow-5 frequency band, OSA patients showed significantly reduced ALFF in the left inferior temporal gyrus. But in the slow-4 band, the signals of OSA patients were reduced in the bilateral inferior temporal gyrus brain region. The inferior temporal gyrus is related to processing memory and text information, as well as the processing of emotions , 29. PreIn addition, OSA patients were found to have signal increased in the right inferior frontal gyrus and left middle frontal gyrus region by analysis of slow-5 and slow-4 frequency bands compared with HC. Previous studies , 32 idenPosterior cingulate gyrus and precuneus are important nodes of the default network. Our study also found that OSA patients showed increased signal in the right posterior cingulate gyrus, right middle cingulate, and left precuneus brain region in the slow-4 band compared with HC. DMN inactivation in OSA patients was found to be abnormally inactivated during working memory tasks and was significantly positively correlated with behavioral performance . In addiWe found that the signal in the left insula increased in the slow-5 frequency band after CPAP treatment. And in the slow-4, the signal increased in the left caudate area, while the signal reduced in the left calcarine area. The human insula is small but the insular cortex has extensive connections to the frontal, temporal, cerebellum, and limbic regions and is involved in a large number of different functions, cortical regulatory regions of emotion and sensorimotor function . Zhang'sThe function of the caudate nucleus is involved in the regulation of respiration. Binks's research  suggesteThe calcarine cortex change was also found in this article. Only a few studies  had repoAlthough our study found that ALFF changes in brain regions after one-night CPAP treatment were not consistent with those in OSA patients vs. controls. The possible reason is that one-night CPAP treatment can quickly change the function of brain areas that can be improved after a short period of treatment, and these brain areas may be associated with daytime sleepiness and cognitive function, which can be improved after one-night CPAP treatment. However, the differences of OSA patients and controls are more likely to be related to brain dysfunction caused by long-term chronic effects.A correlation analysis was performed to identify the relationship between changes in brain function and polysomnography parameters. Our study showed that there was a significant correlation between the left angular and the SWS of sleep. The proportion of SWS in OSA patients after CPAP treatment increased significantly, suggesting that the angular signal was also enhanced after CPAP treatment. The angular gyrus plays an important role in regulating emotion, consciousness, memory and introspection . There iIn addition, we found that the cerebellum is associated with sleep architecture and blood oxygen saturation. The slow-5 frequency band was positively correlated with the difference in the REM phase, suggesting sleep rebound in the REM phase more affected the slow-5 frequency band signal in the cerebellum. However, the slow-4 frequency band was related to the mean blood oxygen saturation in the REM and NREM phases, and the correlation between blood oxygen saturation in the REM phase was greater. It suggests that the slow-4 frequency band in the cerebellum is more related to the correction of blood oxygen, especially the blood oxygen saturation in the REM phase. The above results suggested that the slow-5 band in the cerebellar region was related to sleep structure, while the slow-4 band was related to blood oxygen. Therefore, sleep fragmentation and intermittent hypoxia significantly affect the function of cerebellar regions. Studies on brain function in patients with heart failure have shown that cerebellar gray matter loss is associated with hypoxia, which further indicates that hypoxia may lead to cerebellar dysfunction. This research supported our findings . RecentlTherefore, we believe that one-night CPAP treatment can also find changes in the brain function of OSA, which is similar to changes in brain function after long-term CPAP treatment. We speculate that brain function changes after one-night CPAP treatment may predict the changes after long-term CPAP treatment, and we also can explore the main areas of acute and chronic brain function damage caused by OSA. These injury areas may be related to the complications of OSA patients, such as cognitive dysfunction and hypertension. These corresponding brain regions intervention studies can be carried out in the future to explore the main mechanisms of dysfunction in OSA patients.There are several limitations in the current study. Only male patients with severe OSA were included in this study, and female and mild-to-moderate OSA patients were not included. The sample size of cases and controls in this study was relatively small.We found that the use of the slow-4 frequency band may be more specific in OSA studies. These results suggest that the severe OSA patients have frequency-related abnormal spontaneous neural activity, which may contribute to a better understanding of the pathological basis of OSA-related diseases and may provide potential therapeutic targets for OSA patients.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Human Research Ethics Committee of West China Hospital, Sichuan University. The patients/participants provided their written informed consent to participate in this study.YS: conceptualization, data curation, methodology, software, investigation, formal analysis, and writing—original draft. MX: methodology, software, and writing—original draft. SY: methodology and writing—review and editing. KZ: resources, supervision, and writing—review and editing. XT: supervision. All authors contributed to the article and approved the submitted version.This work was supported by the Ministry of Science and Technology of the People's Republic of China (2021ZD0201900) and the National Natural Sciences Foundation of China .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.