Use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine electronic health management information system (eHMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand service delivery adaptations implemented in response. We analyzed eHMIS data for four services , comparing them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown. Additionally, KIIs were used to document adaptations made for continuity of health services. Use of services declined substantially during total lockdown; however, rebounded quickly to earlier observed levels, during the post lockdown for all four services, especially for immunization for children by one year. KIIs identified several health services delivery adaptations. At the community level, these included: community outreaches, training some mothers as community liaisons to encourage others to seek health services, and support from local leaders to create call centers to facilitate clients transport during travel restrictions. Health facilities creatively used space to accommodate social distancing and shifted providers’ roles. District leadership reassigned health workers to facilities closest to their homes, provided vehicle passes to staff, and ambulances to transport pregnant women in critical need. WhatsApp groups facilitated communication at district level and enabled redistribution of supplies. Ministry of Health produced critical guidelines for continuity of health services. Implementing partners provided and redistributed commodities and personal protective equipment, and provided technical support, training and transport. Uganda, like many low-income countries, experience challenges in providing health services, including family planning (FP) and maternal, newborn and child health (MNCH) services. Karamagi et al. described the demand for essential services, access to essential services, quality of care and resilience of the health system as the four capacities of a functional health system . In manyth 2022, Uganda had reported over 165,607 cases and 3,613 confirmed deaths ?’ Actually, they are more effective in those issues of redistribution. So, you could give them commodities and they delivered to health facilities that were in the same direction.”- District commodity store managerQualitative interviewers also asked about key lessons learned and what needs to be done to address challenges and prepare for future challenges to the health system, including pandemics. Maintaining and strengthening community engagement through mobilization, sensitization and increasing outreaches including supporting VHTs to provide house-to-house services was noted. Ensuring health care workers are informed, equipped, and supported financially and emotionally to ensure continued service provision and prevent burnout. Ways to support health care workers included: hiring, training, and supporting additional staff, including VHTs and volunteers during the pandemic; providing training on COVID-19 standard operating procedures and how to provide mental health support for clients. Also noted were improving transport for clients and providers through ensuring availability of ambulances for emergencies, availability of other vehicles including boda bodas, providing vouchers for transport and fuel for emergencies, which would also strengthen the health system beyond pandemic times. Ensuring collaboration with private providers for service provision, commodities, and supervision was noted. Finally, ensuring commodities, PPE and other supplies are available through adequate transport for last-mile delivery, redistribution, and supporting districts to proactively address challenges through better use of service data to make projections, timely requisitions, ensuring budgets included expenses for unplanned situations, buffer stocks at the district and regional levels, bulk ordering, and increased distribution points within the community.This study used routine facility level data from the Ministry of Health collected through the eHMIS to examine changes in key FP and MNCH indicators at the national level before and during the first year of the COVID-19 pandemic. Additionally, we documented service delivery adaptations from multiple perspectives to identify adaptations that supported continuity of health care service provision during this challenging time.Our results show that for all four outcomes, national level monthly total numbers generally increased from 2018 to 2020 demonstrating the Government of Uganda and its partners’ success in increasing uptake of key FP and MNCH services. This is noteworthy as accessing essential services is often reported as the rate limiting factor for a functional health care system Reviewers' comments:Reviewer's Responses to Questions  Comments to the Authorpublication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.  1. Does this manuscript meet PLOS Global Public Health’s Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********  2. Has the statistical analysis been performed appropriately and rigorously?  Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********  3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********  4. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********  5. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: I had a chance to review this study entitled, “Uptake of Reproductive, Maternal and Child Health Services during the First Year of the COVID-19 Pandemic in Uganda.”This study describes that use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda, like many resource-limited countries, is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, among others, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate many of the existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine health management information system (HMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand adaptations in service delivery that were implemented in response to the pandemic. We analyzed HMIS data for four services , and compared them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown.I want to accept this study for publication. However, the authors need to revise it according to my suggestions. The title needs clarity with the design of the main study. I suggest authors revise their titles with better and suitable words. See the below-recommended studies to improve your TTLE and Abstract quality.AbstractFirst, I have some suggestions for the authors to enhance the quality of this innovative study. Please write a high-quality abstract, as it is the main door of the study. I suggest authors add Graphical Abstract in a meaningful way to reflect the whole idea. The abstract should be in a structured format.Introduction sectionThis section needs improvement. Please read these studies, revise your abstract, and cite them in the introduction and literature part. Cite the suggested studies to improve the quality.https://doi.org/10.1186/s12992-020-00654-4Su, Z., McDonnell, D., Wen, J., Kozak, M., Segalo, S., Li, X., Ahmad, J., Cheshmehzangi, A., Cai, Y., Yang, L., & Xiang, Y. T. . Mental health consequences of COVID-19 media coverage: the need for effective crisis communication practices. Global Health, 17(1), 4. Azadi, N. A., Ziapour, A., Lebni, J. Y., Irandoost, S. F., & Chaboksavar, F. (2021). The effect of education based on health belief model on promoting preventive behaviors of hypertensive disease in staff of the Iran University of Medical Sciences. Archives of Public Health, 79(1), 69. doi:10.1186/s13690-021-00594-4https://doi.org/https://doi.org/10.1016/j.crbeha.2020.100011Maqsood, A., Rehman, G., & Mubeen, R. . The paradigm shift for educational system continuance in the advent of COVID-19 pandemic: Mental health challenges and reflections. Current Research in Behavioral Sciences, 2, 100011. https://doi.org/10.24869/psyd.2020.472Abbas, J. (2020). The Impact of Coronavirus (SARS-CoV2) Epidemic on Individuals Mental Health: The Protective Measures of Pakistan in Managing and Sustaining Transmissible Disease. Psychiatr Danub, 32(3-4), 472-477. LiteratureIn the emergence of the COVID-19 pandemic, healthcare systems have faced a tremendous pressure worldwide. This pandemic has affected all lifestyles. The study investigated an interesting research topic. The study offers interesting information and provides useful insight. I suggest authors cite latest literature related to COVID-19 pandemic effects to support the study. The suggested studies are;Zeidabadi, S., Abbas, J., Mangolian Shahrbabaki, P., & Dehghan, M. (2022). The Effect of Foot Reflexology on the Quality of Sexual Life in Hemodialysis Patients: A Randomized Controlled Clinical Trial. Sexuality and Disability, 41(1), 1-12. doi:10.1007/s11195-022-09747-xRahmat, T. E., Raza, S., Zahid, H., Mohd Sobri, F., & Sidiki, S. (2022). Nexus between integrating technology readiness 2.0 index and students’ e-library services adoption amid the COVID-19 challenges: Implications based on the theory of planned behavior. J Educ Health Promot, 11(1), 50. doi:10.4103/jehp.jehp_508_21https://doi.org/10.1007/s10389-020-01407-8NeJhaddadgar, N., Ziapour, A., Zakkipour, G., Abolfathi, M., & Shabani, M. . Effectiveness of telephone-based screening and triage during COVID-19 outbreak in the promoted primary healthcare system: a case study in Ardabil province, Iran. Z Gesundh Wiss, 1-6. https://doi.org/10.1177/0020764020939984Yoosefi Lebni, J., Moradi, F., Salahshoor, M. R., Chaboksavar, F., Irandoost, S. F., Nezhaddadgar, N., & Ziapour, A. . How the COVID-19 pandemic effected economic, social, political, and cultural factors: A lesson from Iran. Int J Soc Psychiatry, 20764020939984. Su, Z., McDonnell, D., Cheshmehzangi, A., Li, X., & Cai, Y. (2021). The promise and perils of Unit 731 data to advance COVID-19 research. BMJ Global Health, 6(4).Methods and ResultsPlease read the suggested studies and improve your method design and result sections. Cite these studies in methods and results to support the literature.Li, Zhenhuan , Dake Wang, Kaifeng Duan, and R. Mubeen. 2021. "Social media efficacy in crisis management: Effectiveness of non-pharmaceutical interventions to manage the COVID-19 challenges." Front Psychiatry 12 (1099):626134. doi: 10.3389/fpsyt.2021.626134.Jiakui, C., Abbas, J., Najam, H., Liu, J., & Abbas, J. (2022). Green technological innovation, green finance, and financial development and their role in green total factor productivity: Empirical insights from China. Journal of Cleaner Production(381), 135131. doi:10.1016/j.jclepro.2022.135131http://www.mdpi.com/2071-1050/11/6/1683Abbas, J., Aman, J., Nurunnabi, M., & Bano, S. (2019). The Impact of Social Media on Learning Behavior for Sustainable Education: Evidence of Students from Selected Universities in Pakistan. Sustainability, 11(6), 1683. Aqeel, M., Rehna, T., Shuja, K. H. (2022). Comparison of Students' Mental Wellbeing, Anxiety, Depression, and Quality of Life During COVID-19's Full and Partial (Smart) Lockdowns: A Follow-Up Study at a 5-Month Interval. Front Psychiatry, 13, 835585. doi:10.3389/fpsyt.2022.835585Farzadfar, F., Naghavi, M., Sepanlou, S. G., Saeedi Moghaddam, S., Dangel, W. J., Davis Weaver, N., . . . Larijani, B. (2022). Health system performance in Iran: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. doi:10.1016/s0140-6736(21)02751-3DiscussionDiscussion is explained well. Check grammar errors in this section.https://fui.edu.pk/fjs/index.php/fujbe/article/view/551Aqeel, M., Raza, S., & Aman, J. (2021). Portraying the multifaceted interplay between sexual harassment, job stress, social support and employees turnover intension amid COVID-19: A Multilevel Moderating Model. Foundation University Journal of Business & Economics, 6(2), 1-17. doi:Zhuang, D., Abbas, J., Al-Sulaiti, K., Fahlevi, M., Aljuaid, M., & Saniuk, S. (2022). Land-use and food security in energy transition: Role of food supply. Frontiers in Sustainable Food Systems, 6. doi:10.3389/fsufs.2022.1053031Schmidt, C. A., Cromwell, E. A., Hill, E., Donkers, K. M., Schipp, M. F., Johnson, K. B., . . . Hay, S. I. (2022). The prevalence of onchocerciasis in Africa and Yemen, 2000-2018: a geospatial analysis. BMC Med, 20(1), 293. doi:10.1186/s12916-022-02486-yGeng, J., Ul Haq, S., Ye, H., Shahbaz, P., Abbas, A., & Cai, Y. (2022). Survival in Pandemic Times: Managing Energy Efficiency, Food Diversity, and Sustainable Practices of Nutrient Intake amid COVID-19 Crisis. Frontiers in Environmental Science, 13, 945774. doi:10.3389/fenvs.2022.945774Yu, S., Draghici, A., Negulescu, O. H., & Ain, N. U. (2022). Social Media Application as a New Paradigm for Business Communication: The Role of COVID-19 Knowledge, Social Distancing, and Preventive Attitudes. Frontiers in Psychology, 13. doi:10.3389/fpsyg.2022.903082ImplicationsExplain this section effectively. It needs a better presentation related to the study topic.LimitationsDiscuss study’s limitations with a separate heading and discuss it briefly.Policy recommendationsPolicy recommendations are not sufficient at this stage of the manuscript. The authors must add a separate section for policy recommendations in the conclusion section. Also, add some exciting limitations regarding political factors for future studies.ConclusionThe conclusion section needs improvement and authors need to expand it as it will improve the quality of this study. The English level needs some improvement to reach a satisfactory level, specifically the grammar. It should sufficiently meet quality to reach scientific merit for publication. I recommend that the authors describe the study's scientific contribution to the existing body of knowledge in the discussion section. How does this study’s implications provide useful information for the scientific readership? I endorse this manuscript for publication after minor corrections, as suggested.Reviewer #2: The manuscript was done in excellent way. It addressed the issue under study very well. The comparison made during periods of pre-covid, partial lack down, total lock down and post lock down was clearly shown and stated. It was compared, analyzed and discussed satisfactorily. The figures and tables are self-explanatory and easy to grasp and understand. The statistical analysis done was great. The conclusion derived matched the exact finding of the result. The recommendations forwarded were in agreement with the result and they will have of great contribution. The study was ethically sound. Utilizing mixed methods of the quantitative and qualitative gives the paper better credit.I am really excited to see such high quality, well-prepared and well-done large scale study.There are only few minor points I need to forward.1. Objective or the aim of the study should clearly be stated. Can you describe concisely what the research tries to achieve?2. Would you mention the study period for the qualitative study (KII) that you did?3. Try to write out all abbreviations in full as introduced in the text the first time, such as WHO (line 59 and 121), ICT (line 308) and IUD (line 339).4. The methodology was discussed in all-inclusive way.o However, it is unclear about how many health facilities were included in this study. Better also to explain the types of health facilities in which the secondary data were obtained; from hospitals, MCHs, clinics or health centers?o Can you explain health facilities in Uganda providing those services  at national level? Or at least general information about how and where those services are provided, so that the readers can understand and have full image of the scope of the study.o Were all health facilities in Uganda included in the study or they were just sampled? Would you briefly mention this? Let you be clear, specific and comprehensive. Can you very briefly describe about the administrative districts or states in Uganda too?o You mentioned that you did pretest. Can you explain where the pretest was done and if any modifications made? (Line 178)Reviewer #3: This mixed method research has provided a good sense about the situation of essential services affected by Covid 19. In the method section, qualitative data analysis should be well explained. Please illustrate how privacy during interview and anonymity of the research participants were maintained. Data management also needs to be clear.The quantitative analysis of data is well narrated. But, qualitative data analysis require further elaborations especially difference between high performing and low performing districts and the challenges. The discussion section well captured challenges that should be described well in results section.Conclusion looks good.**********  6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.Privacy Policy.  For information about this choice, including consent withdrawal, please see our Reviewer #1: NoReviewer #2: NoReviewer #3: No**********https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  30 Jan 2023AttachmentResponse to reviewers 27-01-2023.docxSubmitted filename: Click here for additional data file. 3 Apr 2023Uptake of Reproductive, Maternal and Child Health Services during the First Year of the COVID-19 Pandemic in Uganda: A Mixed Methods StudyPGPH-D-22-01760R1  Kibira  ,Dear Dr. We are pleased to inform you that your manuscript 'Uptake of Reproductive, Maternal and Child Health Services during the First Year of the COVID-19 Pandemic in Uganda: A Mixed Methods Study' has been provisionally accepted for publication in PLOS Global Public Health.Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.globalpubhealth@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.Best regards,Palash Chandra Banik, MPhilAcademic EditorPLOS Global Public Health***********************************************************Reviewer Comments :Reviewer's Responses to Questions  Comments to the Author  1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #2: All comments have been addressed**********  2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.  Reviewer #2: Yes**********  3. Has the statistical analysis been performed appropriately and rigorously?  Reviewer #2: Yes**********  4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #2: Yes**********  5. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #2: Yes**********  6. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #2: Great work. Well done. All comments were satisfactorily addressed.**********  7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.Privacy Policy.  For information about this choice, including consent withdrawal, please see our Reviewer #2: No**********


The virtual escape room is a didactic activity for emergency medicine residents .Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement.By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experienceEmergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred.Sixty-three participants composed of residents , advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills.Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills .Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools.Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals. Learner Audience:Interns, Junior Residents, Senior Residents, Advanced Practice Provider Trainees, FacultyWhile the level of learners was not documented, there were sixty-three participants in total. There was a total of 57 residents , 2 advanced practice practitioner trainees (EM), and 2 faculty member participants (FMP).Time Required for Implementation:https://deck.toys/a/XkDiDc2IK). The actual didactic session can be tailored to 60 to 75-minute sessions depending on the learner’s technical ability and familiarity with the content. Ten minutes should be allotted to activity introduction, 15–30 minutes for learners to complete the escape room depending on learner’s familiarity with content, 5 minutes for a short debrief session, and 30 minutes for topic presentation and discussion.The Deck.Toys platform will take approximately 1–5 hours prior to the session based on user experience and familiarity with the platform as well as ability to formulate puzzles and develop content. Time can be saved by accessing the premade Deck Toy template utilized in this exercise and making changes to the activities as desired  for each 4 to 6-member small group can be incorporated to oversee each virtual breakout room. These additional volunteers do not need background knowledge in emergency management of burn and smoke inhalation injuries. Volunteers were not utilized in our exercise, but are advised.Topics:Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.Objectives:By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experienceObjective eight (communicate and collaborate), nine (task-switching and leadership skills) and ten  is evident throughout the activity. Team members must communicate and use each other's knowledge and resourcefulness to arrive at solutions to each challenge. Participants must utilize task-switching skills to pay attention to comments made by team members while looking up information, complete tasks and activities whole communicating new solutions or hints during the exercise, and actively communicate with team members while analyzing each puzzle. Participants must utilize leadership skills in order to effectively operate in a team. Team collaboration and communication was apparent during the activity (see Activity 1 below). Additionally, students are asked to evaluate their experience at the end of the activity. Each of the remaining activities (1–7) are achieved in activities in the virtual escape room.Knowledge is solidified during the answer and explanation session following the activity.The instructor should have moderate background knowledge of emergency management of burn and smoke inhalation injuries . The instructor should be familiar with Small Group Exercise Activity Answers & Pearls section of this document, which details the explanations/answers for each activity/challenge in the Deck.Toys platform. The information provided in the aforementioned should be sufficient. If more background information on the topic selected in this case is desired, the following would be helpful:https://emcrit.org/emcrit/critical-burn-patients-in-the-ed/Scott Weingart. EMCrit RACC Podcast 219 – Critical Burn Patients in the ED/ICU – Part I with Dennis Djogovic. EMCrit Blog. Published on March 5, 2018. Accessed on May 21st 2019. Available at J of Burn Care and Research. Jan–Feb 2008;29(1):257–266.Pham TN, Cancio LC, Gibran NS. American Burn Association Practice Guidelines: Burn Shock Resuscitation. Nat Rev Dis Primers. 2020;6(1):11. Published 2020 Feb 13. doi:10.1038/s41572-020-0145-5Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn Injury. http://www.emdocs.net/wpcontent/uploads/2018/03/Educator-Download-Burn.pdfKoyfman A. The EM Educator Series: why is my burn patient so sick? emDocs. Published March 15, 2018. Activity PowerPoint:○ Introduction Slides and Overview for discussion and wrap upDeckToy Activity○ DeckToy platform in learner and teacher formatSmall Group Activity Exercise Answers & Pearls (below)○ For facilitator to review with students if questionsAlthough not necessary, learners may benefit from the following resources if pre-preparation or pre-reading is desired:emDocs. 2015, April, 26. http://www.emdocs.net/carbon-monoxide-poisoning/Radwine Z. Carbon Monoxide Poisoning. emDocs. 2020, July, 17. http://www.emdocs.net/em3am-cyanide-toxicity/Bridwell R, Cibrario A. EM@3AM: Cyanide Toxicity. mDocs. 2018, Mar, 15. http://www.emdocs.net/wpcontent/uploads/2018/03/Educator-Download-Burn.pdfKoyfman A. The EM Educator Series: Why is my burn patient so sick? eSmall group application exercise: Since there are multiple challenges in this didactic, they are explained in detail below:Instructor EquipmentDeck.Toys Membership (free)Electronic device Video Conferencing Application (Zoom)Learner EquipmentParticipants were required to have an electronic device with internet capabilities.https://deck.toys/Join Deck.Toys as an instructor/teacher: https://deck.toys/a/XkDiDc2IKAccess the instructor’s version and review: You may embed media gif images as desiredReview the PowerPoint and personalize slides as neededReview reading materialsPresent PowerPoint’s introductory slides in 10 minutes (Slides 1–8)Separate attendees into groups of 4–6 members, each group with an effort to preserve an equal distribution of learner experience based on level of training. Select a team leader for each group. . Start Breakout Session for 15 minutes.Return to large group and announce winner (Slide 9)Debrief for 5 minutes (Slide 10). During this time, you can ask “How was the experience? What went well? What did not?”Deliver topic content over 30 minutes. (Slides 11–35)Deliver survey (Slide 36)Nitrogen Dioxide: a highly poisonous reddish-brown gasCyanide: a highly poisonous gas or volatile liquid that smells like bitter almondsCarbon Monoxide: an odorless, colorless and tasteless gas commonly found in fuels or wood that decreases oxygen-carrying capacity of hemoglobinPhosgene: a colorless poisonous gas that smells like new-mown hay; used in chemical warfareHazardous chemicals associated with house firesNitrogen Dioxide: a highly poisonous reddish-brown gas, typically produced from the combustion of fabric. Formation of nitric oxide, a potent vasodilator, leads to increased bronchial blood flow, decreased hypoxic pulmonary vasoconstriction in poorly ventilated lung spaces, and finally hypoxia from V/Q mismatch.16Cyanide: a highly poisonous gas or volatile liquid that is developed from an incomplete combustion of any material containing nitrogen such as plastic, vinyl, wool, or silk. The gaseous form smells like bitter almonds.12Carbon Monoxide: an odorless, colorless and tasteless gas commonly found in fuels or wood that decreases oxygen-carrying capacity of hemoglobin and is the main toxic compound in fire deaths.11Phosgene: a colorless poisonous gas that smells like new-mown hay that is usually caused from burning of plastics or pesticides; used in chemical warfare.16Lactate: Elevation in what lab result will make you consider cyanide toxicity?Co-oximetry: Necessary order to evaluate for smoke inhalation toxicity?Amyl nitrite: Which medication of the cyanide antidote kit is delivered via inhalation?Oxygen: Treatment for carbon monoxide toxicity?Hydroxocobalamin: What is the cyanokit ingredient?Vitamin B12: Hydroxocobalamin will detoxify cyanide by binding with it to what?Carbon monoxide (CO) poisoning laboratory features and treatment.Carbon monoxide (CO) poisoning may manifest with non-specific symptoms, persistent neurologic symptoms or even as cardiac arrest.11Workup:○ Pulse oximetry: Readings will be falsely normal○ Co-oximetry: measures carboxyhemoglobin which is carbon monoxide bound to hemoglobin○ ABG: PaO2 and % hemoglobin saturation unaffected but an “oxygen saturation gap,” which is the difference between the calculated oxygen saturation from a standard blood gas and the reading from a pulse oximeter may be present.17○ Order a carboxyhemoglobin level. Subtract the carboxyhemoglobin level from the pulse oximetry level to determine true oxygen saturation.■ Non-smokers: up to 1% normal■ Smokers: 4–6% common■ Any reading >10% = concern for significant exposureTreatment: Administer 100% O2. May use hyperbaric oxygen in very severe cases such as if there is loss of consciousness at the scene, new neurological deficits, mental status change, end-organ ischemia, or if patient is pregnant.18Cyanide (CN) poisoning laboratory features and treatment.Workup:○ Pulse oximetry: hypoxia○ ABG: Anion gap metabolic acidosis with severely elevated lactateTreatment:○ Administer100% O2 therapy○ Administer hydroxocobalamin, with consideration for sodium thiosulfate (slower mechanism of action).■ Note: The commercially available cyanokit contains hydroxocobalamin. Cyanide binds to hydroxocobalamin, forming cyanocobalamin (vitamin B12) which is renally excreted. The traditional cyanide antidotes include inhaled amyl nitrite, sodium nitrite, and sodium thiosulfate. Sodium nitrite forms methemoglobin from hemoglobin, for which cyanide has enormous affinity. Cyanide leaves the cytochrome, setting the mitochondria free, forming cyanmethemoglobin. This is transformed to thiocyanate by an enzyme (rhodanese) and renally excreted.RESCUE, ALARM, CONFINE, EXTINGUISH/EVACUATE.PULL, AIM, SQUEEZE, SWEEP.Actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)R.A.C.E.○ An acronym that hospital personnel use to remember their duties in case of fire○ It stands for RESCUE, ALARM, CONFINE, EXTINGUISH/EVACUATE.P.A.S.S.○ An acronym that hospital personnel use to remember their duties for discharging a fire extinguisher.○ It stands for PULL, AIM, SQUEEZE, SWEEP.A 53-year-old male presents to hospital after suffering a burn to his hand from his stove. On examination of his skin, it appears dry, pale and has a sluggish capillary refill. Some pale areas of his burn have no significant pain. How would you classify this burn? C: Deep Partial ThicknessA 5-year-old boy presents to the emergency department after burning his hand from spilled soup. He appears well. When you examine his skin, it appears erythematous with a brisk capillary refill. Three hours after his injury, you noticed that the area of erythema is starting to disappear. How would you classify this burn? A. Superficial ThicknessAll should be performed on a burn except: C. apply silver sulfadiazine dressings to the wound to promote healing All are acceptable medications to take/use for burn complications except: D. FlammazineClassification of burn injury according to depth, extent and severity based on established standards.19Indications for consultation to burn center: Full thickness burn, Partial thickness burns > 10%, Burns to hands, Emotional or social need, burn to genitaliaNon-indications for burn center: Superficial burn > 50%, Burn to chest wall, Low voltage electrical injury, all pediatric patientsIndications for referral to burn centerhttp://www.ameriburn.org/BurnCenterReferralCriteria.pdf. Accessed July 30, 2013.American Burn Association. Burn center referral criteria. What is the urine output goal in cc/hr for a 20kg child (input the answer in the lock)? 20.Fluid resuscitation in burn patients.Remember: do not include first degree burns in the calculation of % TBSA.○ 2–4mL x kg body weight x % TBSA burn = volume of Lactated Ringer’s required for adult resuscitation (formula adjusted to 3–4mL x kg body weight x % TBSA burn for pediatric patients).Half of the total resuscitation volume is given over the first 8 hours, with administration of the remaining half titrated to patient response .All resuscitation measures should be guided by perfusion pressure and urine output:○ Target a MAP of 60 mmHg, and urine output of 0.5–1.0ml/kg/hr for adults and 1mL/kg/h for pediatric patients.A total of three Virtual Escape Room sessions were held at two academic institutions during the month of April 2020, one during an emergency medicine (EM) didactic, one during family medicine (FM) didactics, and the last for a joint family medicine and emergency-family medicine (EM/FM) didactic session. Each session was led by one instructor who conducted the introductory session, small group facilitation, debriefing and content overview. There was a total of 63 participants composed of residents , advanced practice practitioner trainees (2 EM), and faculty participants (4 FMP), all of whom participated as equal team members within the group. Participants all signed into a Zoom video conferencing room, and attendance was tracked through Zoom registration so that room assignments could be randomized. The instructor randomly divided attendees into groups of four to six members during each didactic session with an attempt to assure an equal distribution of learner experience based on level of training. Four to six members was an ideal group size, allowing for small group interaction. Each group should be assigned a team lead, with the role of sharing their screen and inputting team answers into each learning activity. The team lead accessed the Deck.Toys link  and screen-shared the activity for all team members to see and engage. Other team members were not provided with predetermined roles or task designations. All participants were separated into 4-to-6-member small groups via Zoom breakout rooms. The instructor entered each room periodically to answer urgent questions and observe team behaviors without directly participating in the activity or answering topic content-related or knowledge-based questions. Ideally, to reduce the duties of the instructor and be more effective, each team would have a faculty volunteer to perform these tasks. Question format varied from multiple choice questions that did not have to be answered correctly but informed residents of correct answers to cross-word puzzles and matching games in order to mimic the in-person escape room experience and encourage brainstorming, thinking out loud, and teamwork see . During At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency. We adapted pre-existing survey instruments to assess resident satisfaction, motivation, learning, and skills. We used items adapted from Kinio et al, Meterissian et al, and Jambhekar et al.A majority (16/18 = 88.9%) of participants enjoyed the virtual escape room, with 94.4% (17 out of 18) rating the activity as fun. Five out of 18 (38.9%) rated the activity as stressful. None of the participants preferred traditional didactics over the virtual escape room activity, and 72.2% were either just as or equally as satisfied with virtual compared to in-person escape rooms.Engagement was high, with all categories receiving the nearly 100%. They found the challenges interesting, engaging, and interactive (94.4%).As a learning platform, participants felt that the game was helpful in increasing (88.9%) and retaining (72.2%) clinical information. Learners either agreed or strongly agreed (88.89%) that the format helped them identify knowledge gaps. Most of the participants (94.4%) gained new knowledge while 77.8% felt that they will apply what they’ve learned in the future.Collaboration was the most encouraged skill during the activity, with 94.4% either agreeing or strongly agreeing that the activity encouraged the skill’s use. Communication skills were also encouraged (88.9%). Greater than two thirds of participants agreed that it encouraged task-switching and leadership skills.


Meloidogyne spp.) are obligate sedentary endoparasites, considered severe crop-damaging taxa among all plant-parasitic nematodes globally. Their attacks through parasitic proteins alter the physiology and machinery of the host cells to favour parasitism and reduction in crop yield. Currently, the use of excessive pesticides as a fast remedy to manage this pest is hazardous for both the environment and humans. Keeping this view in mind, there is an urgent need for developing efficient eco-friendly strategies. Bio-control as an eco-friendly is considered the best approach to manage nematodes without disturbing non-target microbes. In bio-control, living agents such as fungi and bacteria are the natural enemies of nematodes and the best substitute for pesticides. Fungi, including nematode-trapping fungi, can sense host signals and produce special trapping devices viz., constricting rings and adhesive knobs/loops, to capture nematodes and kill them. Whereas, endo-parasitic fungi kill nematodes by enzymatic secretions and spore adhesion through their hyphae. Bacteria can also control nematodes by producing antibiotic compounds, competing for nutrients and rhizosphere, production of hydrolytic enzymes viz., chitinases, proteases, lipases, and induction of systemic resistance (ISR) in host plants. Scientists throughout the world are trying to evolve environmentally benign methods that sustain agricultural production and keep nematodes below a threshold level. Whatever methods evolve, in the future the focus should be on important aspects like green approaches for managing nematodes without disturbing human health and the environment.Root-knot nematodes ( •Plant-parasitic root-knot nematodes are the major soil-borne pests for agricultural production.•Biocontrol mechanisms as eco-friendly against such pests become the emerging approaches.•In bio-control mechanisms living agents and their products stimulate the resistance genes in plants without disturbing beneficial soil microbes.•Biocontrol agents and their metabolic products also stimulate systemic resistance in plants. According to nematologists, the top 10 PPNs can significantly damaging global agriculture production; these are root-knot nematodes (Meloidogyne spp.), root lesion nematode (Pratylenchus spp.), cyst nematodes (Heterodera and Globodera), pine wilt nematode (Bursaphelenchus xylophilus), burrowing nematode (Radopholus similis), rice white tip nematode (Aphelenchoides besseyi), reniform nematode (Rotylenchulus reniformis), stem and bulb nematode (Ditylenchus dipsaci), dagger nematode (Xiphinema index-the virus vector nematode) and false root-knot nematode (Nacobbus aberrans) [Meloidogyne spp.) are the most important and dangerous soil-borne pathogen among all PPNs .The rhizosphere is the residence of several microbes that interact with each other and the plant roots. Some of them are advantageous for plants and soil microbes while others are deleterious. Such deleterious microbes are considered pests that incite biotic stress and lower the productivity of affected crops . Plant-psoybeans ,5. The iberrans) . However2viz., RKNs, acquire their nutrition from the host plant and cause the weakening and killing of host cells [viz., proteins, genes, sugars and lipopolysaccharides. Such stimuli obtain from pathogens are responsible for the severity of infection and pathogenicity which is determined by the pathogen's ability to colonize the plant cell [Biotic stress is the response of phytopathogenic infection, especially root-knot nematodes (RKNs), fungi, and bacteria that bring down productivity and crop yield . Such hast cells . Plants'ant cell .3Meloidogyne spp.) are major biotic stress-causing agents for several crops globally. It belongs to the order of Tylenchida, ubiquitous in nature and sedentary endoparasites that depend on the host for completing their life cycle [viz., M. javanica, M. incognita, M. hapla and M. arenaria are major and harmful, causing more damage up to 90 % to the plants and making them more susceptible to other pathogens [M. incognita is one of the more damaging species among all, causing major loss and reduction in vegetables yield and quality viz., tomato, okra, eggplant, cauliflower, cabbage and spinach [viz., M. graminicola, M. javanica, and M. arenaria are also pathogenic and common [M. hapla is restricted to temperate/cooler areas [RKNs  but this period is changed due to soil moisture (lesser extent), soil temperature (widely) and availability of a suitable host [RKNs exhibited sexual dimorphisms, i.e., the females are pear-shaped and the males are free-living while second-stage juveniles (J2s) are infective. The life cycle of the RKNs is completed in 25–28 days at 27 °C temperature and divided into different stages viz., eggble host . Embryogble host . By usinble host . During ble host . GCs areble host . They poble host  Fig. 2)viz., egg5viz., parasitic proteins-host proteins also suppress and weaken the defence and defence-related genes of the host [Effector proteins of RKNs are pathogenic in nature that parasitize the host plant by changing the metabolism and physiology of the host cell. Parasitism and manipulation of host cellular mechanisms are favoured by the interactions of effector proteins with certain host proteins. Such interactions the host . During the host . Howeverthe host . Effectothe host ,38 , ethylene, jasmonic acid (JA), cytokinin and salicylic acid (SA) play an important role in the growth and development of plants. Several functions like cell differentiation, elongation, cell expansion and response to various biotic and abiotic stresses are mediated by ethylene and auxin . Such host plant . Recentlst plant . Anotherthe host .5.1.2viz., MiMsp40 from M. incognita suppress the immune system viz., effector-triggered immunity (ETI) and pathogen-triggered immunity (PTI) of the host plant and enhance nematode parasitism [Arabidopsis thaliana [Few effector proteins rasitism . Mi-CRT thaliana .5.1.3Meloidogyne graminicola is a very harmful nematode for rice growth and brings down rice production. An important effector protein, Mg16820 obtained from M. graminicola, reacts as a suppressor of the immune system of the host cell and shows an effective role in nematode parasitism. Furthermore, Mg16820 inhibits flg22-induced reactive oxygen species (ROS) in the rice plant that participate in the stress response and also suppress the R2/Avr2-and Mi-1.2-induced hypersensitive response [M. incognita Profilin 3) was obtained from J2s of M. incognita. MiPFN3 is inoculated within the host plant through the stylet of M. incognita where it favours and stimulates nematode parasitism [M. incognita IDA – like 1 effector) a potent effector protein of M. incognita that mimic with functional IDA (Inflorescence deficient in abscission) or IDA like genes of Arabidopsis for favouring parasitism in Arabidopsis plant in the form of root galls [M. javanica that speeds up parasitism by attacking the ferredoxin/thioredoxin system of the host.response . One morrasitism . MiIDL1 ot galls . Lin et ot galls , found a5.1.4GCs formation in host roots by RKNs influence the metabolic mechanisms of the host plant because such cells act as feeder cells and source of nutrients and metabolites for developing nematodes. Few cells in the vicinity of GCs also become large due to the accumulation of huge amounts of nutrients. Such neighbouring cells provide a direct approach for food to RKNs. Eloh et al.  observedBy examining these all changes in the host's cell physiology and metabolism, including translation it has been necessary to develop effective eco-friendly management strategies against RKNs.6Trichoderma spp.) and bacteria are considered potent bioagents against RKNs and other PPNs. Besides whole microbes sometimes derivatives viz., microbial metabolites and their products can also utilize as BCAs [The intensity for selecting microbes as bio-control agents (BCAs) has grown day by day due to their pest-managing proprieties becoming a key factor in integrated nematode management (INM) on crops . The rhi as BCAs ,70.7Trichoderma spp. well-known individuals recognized as important BCAs against RKNs, parasitize the infective juveniles and inhibit root penetration by nematodes also enhance the growth and yield of crops [Trichoderma spp. must be applied in the soil before crop planting because it completely colonizes the roots [Trichoderma [viz., nematophagous and arbuscular fungi also possess nematicidal activity against RKNs. The bio-control activity of BCAs depends on the nematode species, host plant, its exudates, and other rotation crops [Fungi and their metabolites are found to be control the population of PPNs, which are detrimental to plant health. of crops . To prevhe roots . Howeverchoderma . Other gon crops .7.1Arthrobotrys oligospora and Drechslerella sp., (ii) endoparasitic fungi (obligate parasites of nematodes) parasitize nematodes either by direct ingestion or attaching to their surface followed by growth, germination, and killing of nematodes, eg., Drechmeria coniospora, (iii) nematode's eggs and female parasitic fungi, which as facultative parasites of sedentary stages of nematodes such as cysts and eggs, eg. Pochonia chlamydosporia (Metacordyceps chlamydosporia), P. rubescens and Paecilomyces lilacinus and (iv) toxins producing fungi inhibit the nematodes mobility before hyphae penetrate the nematode cuticle, eg. Pleurotus ostreatus [i.e., taking their nutrition from dead and decaying organic matter in the absence of nematodes, and therefore organic matter rich soil boost their existence [Fungi that feed on PPNs are considered as nematophagous fungi. These fungi are classified into four groups based on the mechanisms of action against nematodes: (i) predatory (nematode trapping) fungi make extensive constricting rings and hyphal networks as trapping tools for capturing nematodes, eg., streatus ,76. Howexistence .7.1.1A. oligospora is an important and most common nematophagous fungus. This fungus traps nematode juveniles facultatively for its nitrogen requirement. It also obtains carbon and energy-rich foods from dead and decomposed organic matter [In vitro experiment shows the high efficiency of A. oligospora in the killing and capturing of M. incognita J2s. The microscopic study also revealed that the J2s of RKNs were trapped by adhesive loops of A. oligospora [A. oligospora treatment significantly reduces the disease development caused by RKNs on tomato plants and shows 74 % predation against M. incognita in comparison to 36 % of the control (having only sterilized distilled water without A. oligospora) [c matter . In vitrigospora . Moreovegospora) .7.1.2D. coniospora infects nematodes with their spores (zoospores or conidia) via the attachment of conidia to the nematode cuticle and inserting the hyphae in nematode epidermis and killing them [Cephalenchus sp., Pratylenchus penetrans, Heterodera schachtii, and Ditylenchus spp. but the attachment of spores to any nematode species does not favour its killing and infection [Fungus ing them . Howevernfection ,80.7.1.3P. chlamydosporia, P. lilacinus, and L. psalliotae are considered as potent BCAs among all female and egg parasitic fungi of RKNs and cyst nematode. These fungi mainly attack nematode females and their eggs because these are the main targets. However, J2s of RKNs inside egg masses can also be attacked by P. chlamydosporia [P. chlamydosporia also stimulate the defence in tomato plants by activation of the salicylic acid (SA) pathway against M. incognita. It has been observed that co-inoculation of both fungus and nematode in tomato plants revealed the expression of defence-related protein 1 (PR1), lipoxygenase (LoxD) genes, pathways viz., jasmonic acid (JA) and SA pathways which provide resistance against M. incognita. In this co-inoculation experiment, fungal chlamydospores were inoculated in the soil just one week before the inoculation of M. incognita J2s [P. lilacinus is another nematode egg parasitic fungus, used as BCAs against RKNs [P. lilacinus strain 251 (PL251) in tomato field infested with M. incognita reduces the egg masses by 74 %, root galling by 66 % and the population of nematodes by 71 % compared to untreated control. However, P. lilacinus directly infect eggs and sedentary stages of nematodes by producing few nematicidal proteins viz., chitinases, leucinotoxins, acetic acid, and proteases [dosporia ,82. A fenita J2s . P. lilanst RKNs . Accordinst RKNs , inocularoteases .7.1.4P. ostreatus (oyster mushroom) as a toxin-producing fungus having the ability to kill nematodes by paralyzing them. This fungus feeds on nematodes for their N2 requirement under low nutrient conditions. However, current studies show that P. ostreatus kill nematodes by increasing calcium (Ca) influx and necrosis in the neuromuscular system of Caenorhabditis elegans through nematode sensory cilia [P. ostreatus against PPNs including root-knot nematode, M. incognita and sugar beet nematode, Heterodera schachtii in cowpea [ry cilia ,87. A fen cowpea ,89 , T. virens, T. harzianum (strain MZ025966), T. koningii, T. longibrachiatum, T. asperellum, and T. polysporum which have a significant impact on disease development caused by RKNs.zosphere . They grzosphere . They enzosphere . Trichod as well . The attspecific . The mos7.2.1Trichoderma spp. also shows antagonistic activity against harmful fungi [Trichoderma induced resistance in plants against other biotic pathogens viz., bacteria, fungi, and viruses are unknown [Trichoderma mediated resistance in plants may play an impressive role in reducing the infection caused by RKNs and other harmful pathogens [Trichoderma spp. changes the metabolism and physiology of the host plant, resulting in the production of several secondary metabolites (SMs) that function as defense responses against RKNs [In addition to competition for food and shelter with RKNs, ul fungi  possessiul fungi ,97. Howe unknown . Althougathogens ,99. Rootnst RKNs ,101.7.2.2T. herzianum and RKNs simultaneously, compared with RKNs infested roots [Reactive oxygen species (ROS) are continuously formed in plants but RKN infection increases ROS production ,102. Exced roots . To normed roots .7.2.3viz., phenols, flavonoids, lignin, and cellulose act as antioxidants to increase resistance and protect host plants from RKNs infection [T. herzianum treated tomato plants infested with RKNs compared to the untreated plants. Ahmad et al. [T. harzianum with fly ash improved the SMs profile and defence-related genes in chili (Capsicum annum) against RKNs.Secondary metabolism plays an important role in the production of antioxidants and SMs required for defence and to lower the high level of ROS under unfavourable conditions. Importantly, several SMs nfection ,106,107.nfection , found ad et al.  also fin7.2.4Trichoderma harzianum treated plants showed an increased level of enzymes that participated in secondary metabolisms to provide resistance against PPNs. Key enzymes such as cinnamyl alcohol dehydrogenase (CAD), glucose-6-phosphate dehydrogenase (G6PDH), phenylalanine ammonia-lyase (PAL), polyphenol oxidase (PPO), shikimate dehydrogenase (SKDH), guaiacol peroxidase (G-POD), 4-coumarate CoA ligase (4CL), and caffeic acid peroxidase (CA-POD) involved in secondary metabolisms in treated tomato plants compared to untreated control [viz., CAD, cinnamate-4-hydroxylase (C4H), and PAL in the regulation of the plant defence and phenylpropanoid pathway against RKNs [In vitro observations suggest these enzymes damage the major parts of the nematode cuticle, and eggshell and ultimately lead to death [ control . Many stnst RKNs ,109. Patnst RKNs ,110,111.to death .7.2.5Trichoderma-induced resistance against RKNs, it is necessary to modify the SA and JA contents in the tomato roots by inoculating Trichoderma in the roots. However, a high level of both SA and JA was found in RKN-infected plant roots compared to non-infected plants  at 100 and 50 ppm doses to fulfil their nitrogen requirement for normal growth and development of plants. Besides, the utilization of nitrogenous explosives as a nitrogen source, Trichoderma spp. also has the ability to degrade unwanted hydrocarbons from the aquatic ecosystem and bio-remediate them [T. harzianum strain T22, for the biodegradation of diesel fuel, allowing it to be used as a source of carbon [Trichoderma into the soil increases plant productivity, nutritional quality, and reproductive and vegetative development. The overall role and application of different species of Trichoderma make it as potent BCAs, and soil nutrient mobilizer, improving the yield and quality of the crops  in host plants. Among these, antibiosis is the most widely used mechanism involving the production of volatile organic compounds (VOCs), toxins, and some antibiotics against nematodes.8.18.1.1It involves the production of toxic compounds by microorganisms harmful to other microbes. During the trophophase of the cell cycle, the development of bacterial cells is ideally higher however the metabolites and antibiotic compounds are formed during the idiophase when the nutrients become drained and the cell has expanded extensively . Such co8.1.2Competition for food and space between pathogenic and non-pathogenic microorganisms in the rhizosphere is known as rhizospheric competition. Rhizospheric competence also promotes the population of beneficial microbes in the vicinity of plant roots. However, these beneficial soil microbes protect plants by root colonization and deplete all the resources from the rhizosphere that are available and accessible to RKNs' growth and development. Such an important relationship between microbes and plants found in the rhizosphere enhances plant health or helps the plant overcome abiotic or biotic stress .8.1.3Bacillus spp. produces various types of enzymes and enzyme complexes viz., chitinases, proteases, lipases, and collagenases. These enzymes affect various stages of PPNs and kill them. Chitinases enzyme produced by the bacterial species, B. pumilus, Serratia marcescens, and B. subtilis degrade cuticle and the outer surface of eggs and J2s of RKNs [B. cereus against the J2s of M. javanica [Pseudomonas against M. incognita [Production of hydrolytic enzymes by rhizobacteria is also an important approach to controlling RKNs and other harmful pathogens effectively. Few  of RKNs ,135. Coljavanica . Some otncognita .8.1.4B. pasteurii, B. subtilis, B. cereus, B. pumilus, B. amyloliquefaciens, P. putida, S. marcescens, P. fluorescence, and Rhizobium leguminosarum can provoke ISR [M. javanica and M. graminicola by fluorescent pseudomonads has been well documented [ISR is one of the possible modes of action that induces resistance in host plants by activating the nematicidal compounds and preventing infection by nematodes. Several bacterial genera like voke ISR . ISR agacumented ,138. Thecumented ,140. How8.28.2.1Bacillus spp. acts as an important bio-pesticide to control RKNs and improve plant growth. Antinemic action of Bacillus spp. based on their enzymes, toxic proteins, and antibiotic compounds they possess for example, antibiotics production by B. subtilis, and B. cereus, toxic proteins production namely Cry proteins by B. thuringiensis and enzymatic action by B. firmus [B. cereus (strain BCM2) in tomato plants reduces the damage and population of M. incognita by 67.1 % compared to untreated plants. Few other strains viz., B. cereus (strain Jdm1) enhance the growth of tomato plants by inhibiting egg hatching, root galling (43 %), and the number of M. incognita J2s in vivo [B. pumilus (strain L1) is another example with anti-RKNs potential, produces chitinases and protease enzymes that degrade and digest the cuticle of M. arenaria [B. amyloliquefaciens (strain Y1) were evaluated to control M. incognita by inhibiting egg hatching and increasing J2s mortality both in vivo and in vitro on tomato plants [Several studies suggested that . firmus . Accordi. firmus , the app in vivo . B. pumiarenaria . Cultureo plants .B. thuringiensis (Bt) that includes the formation of Cry protein or crystal protein . It has been found that several crystal proteins obtain from transgenic plants and their application to protect plants from RKNs [Bio-control of RKNs and other PPNs attributed to rom RKNs . Presentrom RKNs . Cry5 is8.2.2Pasteuria penetrans is an endospore-forming bacterium, that parasitizes the J2s of RKNs [ of RKNs . J2s wit of RKNs . Bacteri8.3viz., Pseudomonas, Bacillus, Lactobacillus, and actinobacteria are involved in plant growth promotion [Herbaspirillum, Azospirillum, Acetobacter, Serratia, Paenibacillus, Burkholderia, and Rhodococcus have also been found to increase crop growth and production [viz., B. pumilis and B. amyloliquefaciens demonstrated in vitro plant growth-promoting attributes, like siderophores production, phosphate solubilization, Indole-3-acetic acid (IAA) production and antagonisms against RKNs. Such strains also favour an increment in the growth and yield of tea crops in terms of root and shoot biomass and the number of leaves in the field conditions [Plant growth-promoting bacteria (PGPB) includes a diverse group of microorganisms that represent a broad range of genera. Few genera romotion . They peromotion . Furtheroduction . Accordioduction , rhizobanditions . Sideropnditions ,164. Besnditions ,166. It nditions ,168.9Agriculture is an important part of the economy in many countries. Most of the human population depends on crops for their food. However, several crops (vegetables and fruits) are severely attacked by RKNs. When evaluating the significant damage caused by RKNs and the limitations made by the government for the use of pesticides, it is necessary to scientists and researchers to invent novel eco-friendly approaches to control RKNs. According to previous studies on nematode management, it has been found that the excessive use of chemicals polluted the environment, soil, and water, and also influences human health. Therefore, by considering these all problems, microbial bio-control emerged as a potent substitute for chemicals.viz., collagenases, proteases, lipases, and chitinases), and induction of systemic resistance. Besides bio-control mechanisms, fungi, and bacteria also enhances plant growth and yield by increasing nutrient (N and P) uptake from the soil and nitrogen fixation as well.Several microbes such as fungi, and bacteria with their different strains have great nematicidal action. Fungi possess various modes of action against nematodes such as digestion and absorption of nematode cuticle and their penetration, rhizospheric colonization, and induction of resistance in plants. Whereas, bacteria counter-attack the RKNs parasitism through antibiosis (production of toxic compounds), rhizospheric competition with nematodes, production of several lytic enzymes , National Research Institute for Agronomic Research , and the Phytopathology Unit of the Ecole Nationale d'Agrioculture de Meknès under SIRAM project .Not applicable.Amir Khan: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft. Mohammad Haris: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft. Touseef Hussain: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing. Abrar Ahmad Khan: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Salah-Eddine Laasli: Conceptualization, Data curation, Formal analysis, Investigation, Writing – review & editing. Fouad Mokrini: Conceptualization, Formal analysis, Writing – review & editing. Rachid Lahlali: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Previous studies achieved low microbial detection rates in lymphoma patients with interstitial pneumonia (IP) after chemotherapy. However, the metagenomic next-generation sequencing (mNGS) is a comprehensive approach that is expected to improve the pathogen identification rate. Thus far, reports on the use of mNGS in lymphoma patients with chemotherapy-related IP remain scarce. In this study, we summarized the microbial detection outcomes of lymphoma patients with chemotherapy-related IP through mNGS testing of bronchoalveolar lavage fluid (BALF).Fifteen lymphoma patients with chemotherapy-related IP were tested for traditional laboratory microbiology, along with the mNGS of BALF. Then, the results of mNGS and traditional laboratory microbiology were compared.Pneumocystis jirovecii , Cytomegalovirus , and Epstein-Barr virus . Mixed infections were detected in 10 cases. Five patients recovered after the treatment with antibiotics alone without glucocorticoids.Of the 15 enrolled patients, 11 received rituximab and 8 were administered doxorubicin hydrochloride liposome. The overall microbial yield was 93.3% (14/15) for mNGS versus 13.3% (2/15) for traditional culture methods (P ≤ 0.05). The most frequently detected pathogens were Pneumocystis jirovecii. The application of mNGS in patients with chemotherapy-related IP was more sensitive.Our findings obtained through mNGS testing of BALF suggested a high microbial detection rate in lymphoma patients with IP after chemotherapy. Notably, there was an especially high detection rate of The online version contains supplementary material available at 10.1186/s13027-023-00556-1. Pneumocystis jirovecii (P. jirovecii) or fungi) [P. jirovecii [P. jirovecii is effective against P. jirovecii infection [Interstitial pneumonia (IP) is a severe adverse effect of chemotherapy in lymphoma patients. It may result in fever, dyspnea, respiratory failure, and death . Additior fungi) , 10. Manirovecii –13. Furtnfection . Howevernfection  retrospeStreptococcus species, Haemophilus species and Pseudomonas species in eight of 22 stable patients with idiopathic pulmonary fibrosis. However, it is uncertain whether the IP caused by bacterial infection or the bacterial infection is secondary to IP. Other bacteria detected in BALF of idiopathic pulmonary fibrosis patients including Neisseria, and Veillonella [P. jirovecii and Aspergillus were detected as factors associated with IP [P. jirovecii was usually identified by quantitative real-time PCR or toluidine blue ‘O’ staining on respiratory specimen [Aspergillus [Despite less data on chemotherapy-related IP, the role of infection has been well-studied in other types of interstitial lung diseases. Research efforts thus far have shown that viruses are most associated with interstitial lung diseases. The most frequently identified virus appears to be Epstein-Barr virus (EBV), and other viruses including Cytomegalovirus (CMV), and hepatitis C virus . Virus dllonella . Fungus  with IP –20. P. jspecimen . CultureMetagenomic next-generation sequencing (mNGS) is a recently developed detection method that is independent of pathogen culture, which can help to provide rapid and objective pathogenic diagnosis. This technology can simultaneously detect known or unknown bacteria, fungi and viruses, and has been proven to significantly improve the pathogen detection rate in systemic infections, artificial joint infections, pleural infections and respiratory infections –26. At pThe study protocol was approved by the Ethical Review Committee of Ningbo Medical Treatment Center Li Huili Hospital . Informed consent to publish the information was obtained from the personal patient.Pneumocystis treatment with trimethoprim-sulfamethoxazole (TMP-SMX); (IV) had incomplete documentation. IP was diagnosed based on radiologic findings, clinical symptoms, physical examination, laboratory tests, lung function, arterial gas analysis, bronchoalveolar lavage and pathologic results [All lymphoma patients who were treated in Ningbo Medical Treatment Centre Li Huili Hospital between January 2016 to February 2022 were retrospectively reviewed. The included study participants were a consecutive series of all patients satisfying the inclusion criteria. The patient eligibility criteria were as follows: (I) ≥ 18 years of age; (II) had a histological diagnosis of lymphoma; (III) received at least one course of chemotherapy; (IV) developed IP after chemotherapy; (V)underwent bronchoscopy and mNGS test of BALF was performed when developed IP. Patients were excluded if they (I)had no BALF culture result; (II) had simultaneous infections of other parts other than the lung, such as blood infection and intestinal infection; (III) had previously received prophylactic anti- results , 33. Art results . The nec results , 33, 35.The collection of BALF was performed by experienced bronchoscopists according to standard procedures : Prior tLegionella pneumophila, Mycoplasma pneumoniae and Chlamydia pneumoniae. Unfortunately, due to the limitations of our laboratory, toluidine blue ‘O’ staining on BALF or sputum cannot be performed.BALF samples from all patients were examined by traditional microbiological methods including smears and cultures for general bacteria and fungi and acid-fast staining for mycobacteria. The following microbiological methods were performed according to the clinician’s discretion: real-time PCR for EBV and CMV from the blood samples, serum BDG assay and serum galactomannan (GM) assay for fungi, serum antibodies for indirect immunofluorescence assay for respiratory syncytial virus, influenza A/B virus, parainfluenza virus, adenovirus, Total nucleic acid was extracted from 5 ml of BALF. DNA or RNA sequencing libraries were constructed for each patient. An Agilent 2100 instrument was used to assess the quality of the libraries. Then, DNA or RNA libraries were constructed through DNA-fragmentation, end-repair, adapter-ligation, reverse transcription (for RNA) and PCR amplification. High-quality sequencing data were generated by removing low-quality and short (length < 35 bp) reads, followed by computational subtraction of human host sequences mapped to the human reference genome (hg19) using Burrows-Wheeler Alignment. The remaining data by removal of low-complexity reads were classified by simultaneously aligning to four Microbial Genome Databases, consisting of viruses, bacteria, fungi, and parasites. The performers and readers of mNGS company were blinded to patient information, including the symptoms and diagnosis.We used the following criteria to define clinically significant microbes in this study, which were derived and revised from prior literature , 37, 38.SPSS 22.0 software was employed for data analysis. The categorical variables were presented as frequency and percentage, and the continuous variables were analyzed using descriptive statistical methods (median and range). The comparison between enumeration data was performed by the chi-square test. P < 0.05 was considered as indicative of statistical significance.During about 6-year study period, 659 lymphoma patients received at least one course of chemotherapy and 38 (5.77%) of these patients developed IP. In total, 15 patients were eligible for this study Fig. . The cliThe patients’ clinical symptoms, characteristic CT findings and laboratory test results were listed in Table The most common predominant CT patterns were diffuse ground-glass opacities (GGO) in 13 of 15 patients and most of them were symmetric and with no zonal predominance. The other CT manifestations included diffuse patchy exudation and thickening of the interlobular septa. The figures of these CT scans were uploaded as supplement materials.All patients had elevated C-reactive protein (CRP) , and 40% (6/15) patients had elevated absolute neutrophils . Serum BDG and GM assays were performed in 13 patients. Four patients had elevated serum BDG assays, and the GM assays were negative in all 13 patients. PCR tests for EBV were performed in 11 patients and were all negative. PCR for CMV was performed in 9 patients, and 1 patient was positive (P 6). Serum antibodies for indirect immunofluorescence assay for respiratory pathogens were performed in 6 patients and were all negative.Klebsiella pneumoniae and Staphylococcus aureus detected, respectively.The outcomes of BALF staining and culture were also listed in Table P. jirovecii was detected in 12 patients  by this method. Among the patients with P. jirovecii, 4 patients had single P. jirovecii infection, while the other 8 patients had mixed infections of P. jirovecii with other pathogens. CMV and EBV were detected in 4 patients  and 3 patients , respectively. Other infrequently detected pathogens were Campylobacter mucosa, Pseudostreptococcus pneumoniae, Candida albicans, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli. The most common mixed infections were P. jirovecii together with CMV or EBV. The identified pathogens and copathogens were listed in Fig. Pathogens were detected in 14 of 15 93.3%) patients by mNGS Table . It is w.3% patieP ≤ 0.05). The pathogens detected by traditional culture methods were different from those detected by mNGS. Klebsiella pneumoniae and Staphylococcus aureus were respectively identified in P4 and P12 by culture of BALF, but not identified by mNGS. In the 4 patients with positive BDG assay, P. jirovecii was detected by mNGS, but no other fungal infection was identified.The overall microbial yield was 93.3% (14 of 15 patients) for mNGS versus 13.3% (2 of 15 patients) for traditional culture methods, with significant difference  occurred in 70–80% of AIDS patients [P. jirovecii were those suffering from underlying hematological malignancy [P. jirovecii was reported to be responsible for 61.2% of confirmed pneumonia in immunocompromised patients [P. jirovecii with high sensitivity and specificity. In this study, the enrolled patients suffered severe immunosuppression. It is reasonable to speculate that the P. jirovecii detected by mNGS was pathogen causing IP but not merely commensal.patients . A natiolignancy . The dialignancy –44. Durilignancy . Recentlpatients . Meanwhipatients , 46. TheP. jirovecii was detected by mNGS but no other fungal infection was identified in the 4 patients. This result suggests that BDG assay has good specificity in the detection of P. jirovecii in chemotherapy-related IP.Serum BDG assay and GM assay are helpful for the diagnosis of invasive fungal disease . A meta-P. jirovecii infection is often associated with T cell dysfunction. Rituximab, on the other hand, can affect CD4 + T cell production by affecting B cells, leading to an increased risk of P. jirovecii infection [Pneumocystis treatment with TMP-SMX decreased the incidence of IP in patients with B-cell lymphoma and receiving chemotherapy [P. jirovecii infection plays an important role in the pathogenesis of chemotherapy-related IP. In addition, the clinical manifestations of PJP patients are non-specific, so rapid and accurate diagnosis of PJP patients is very important for clinical prognosis. A recent retrospective study showed that in non-HIV-infected patients, the sensitivity of mNGS to diagnose PJP reached 100%, and the specificity of mNGS (96.3%) significantly exceeded that of BDG [nfection , 52. Sevnfection , 43. No nfection . Jiang enfection  showed iotherapy , 55. Thet of BDG . In thisP. jirovecii detected, diffuse GGO was observed in 92.3% (12/13) of cases, which met the characteristics of PJP.PJP and drug-induced IP may have a similar imaging presentation of diffuse pulmonary interstitial infiltration. Several studies tried to describe the different characteristics of them. Diffuse GGO or diffuse interstitial infiltration was frequent in patients with PJP , 57, 58;CMV infections were the most frequently reported in patients after allo-HSCT , but theP. jirovecii detected in 3 patients. In addition, of the four CMV-positive patients, only two patients received ganciclovir antiviral therapy, and the other two patients who did not receive treatment eventually recovered. This may be because CMV-specific T cell responses are intact when CMV is reactivated, and the host may eventually control viral replication without developing CMV pneumonia [Cytomegalovirus infection is the most common in patients after allogeneic hematopoietic stem cell transplantation , but lesneumonia , 63. Forneumonia . Previouneumonia . Similarneumonia . The 4 CKlebsiella pneumoniae and Staphylococcus aureus were respectively identified in P4 and P12 by culture of BALF, but not identified by mNGS. One possible reason may be the contamination during culture. Another possible reason may be associated with the false negative of mNGS. Several reports suggested that the sensitivity of mNGS is not superior to that of culture for recognizing common bacteria (excluding MTB and anaerobes) [We also found some discordance between mNGS versus culture results. aerobes) , 66. TheP.jirovecii infection is potentially the major factor in the pathogenesis of IP.Of the 15 enrolled patients, 5 patients recovered after receiving antimicrobial treatments alone without using glucocorticoids, indicating that the cause of interstitial pneumonia in these patients may be opportunistic infections instead of lung damage. From our results, we confer that the previous view of drug-induced lung injury rather than infection being the main pathogenesis of IP after lymphoma chemotherapy  is debatable. Instead, opportunistic infections, especially P.jirovecii and the BALF-GM or BALF-BGD tests were not performed. Thirdly, the sample size of the enrolled population was small and controls were lacking. Finally, it was difficult to distinguish pathogens from colonization to infection due to the unbiased detection of mNGS without a unified standard. In the future, we will conduct prospective studies and further expand the sample size, and explore the feasibility of guiding treatment options in line with the mNGS results.This study has certain shortcomings. Firstly, as a retrospective study, there were selection bias and recall bias which was inevitable. Secondly, the toluidine blue ‘O’ staining and PCR assay for P. jirovecii. We should be more alert to P. jirovecii infection in chemotherapy-related IP.In this study, we found that using mNGS test of BALF, the pathogen detection rate was much higher than that of traditional methods in lymphoma patients with chemotherapy-related IP. Notably, there was an especially high detection rate of Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


VEGFA) gene is an important angiogenic gene and its polymorphisms have been reported to be associated with PTB development. Therefore, we conducted a case-control study to evaluate the association between VEGFA rs699947, rs2010963, and rs3025039 polymorphisms and PTB in Korean women. A total of 271 subjects (116 patients with PTB and 155 women at ≥38 weeks of gestation) were analyzed in this study. The genotyping of VEGFA gene polymorphisms was performed using polymerase chain reaction–restriction fragment length polymorphism. No significant association between the patients with PTB and the control groups was confirmed. In the combination analysis, we found a significant association between PTB and VEGFA rs699947 CC-rs2010963 GG-rs3025039 CC combination . The VEGFA rs699947, rs2010963, and rs3025039 polymorphisms might have no genetic association with the pathogenesis of PTB in Korean women. However, the combination analysis indicates the possibility that VEGFA acts in PTB pathophysiology. Therefore, larger sample sets and replication studies are required to further elucidate our findings.Preterm birth (PTB), a pregnancy-related disease, is defined as a birth before 37 weeks of gestation. It is a major cause of maternal mortality and morbidity worldwide, and its incidence rate is steadily increasing. Various genetic factors can contribute to the etiology of PTB. Vascular endothelial growth factor A ( Preterm birth (PTB) refers to pregnancy-related disorders that are delivered before 37 weeks of gestation ,2. PTB iin vivo model systems showed that VEGF could regulate circulating progesterone levels .-32.VEGFAragments . The resragments  and 3.https://www.quantitativeskills.com/sisa/) to compare the genotype or allele frequencies between groups through a 2 × r table and to calculate odds ratio (OR) with 95% confidence intervals (CIs) using a 2 × 2 table. Based on genotype data, linkage disequilibrium (LD) was estimated using the HaploView 4.2. Haplotype analysis was performed to compare haplotype frequencies between the patients with preterm and control groups by HAPSTAT software v.3.0. In addition, combination analyses of genotype frequency were performed using the SNPstats web-based tool . A p-value of <0.05 was considered statistically significant. Bonferroni correction was applied to adjust for multiple comparisons [A test of cross tabulation analysis was performed using the SPSS 26 Statistics . The chi-squared tests were used to assess the Hardy-Weinberg equilibrium. We used SISA  were analyzed. The mean values of age, height, weight, pre- and post-pregnancy weight, systolic blood pressure, and diastolic blood pressure were insignificantly different between the patients with PTB and control groups (p > 0.05). However, a significant difference was found in birth weight and gestational age between patients with PTB and control groups (p < 0.05) .VEGFA gene polymorphisms for the 116 patients with PTB and 155 controls are presented in Genotype and allele distributions of 2 = 1.0)  . Therefo2 = 1.0) .In the genotype combination analysis of the three gene polymorphisms , we found a significant association with PTB from rs699947 CC-rs2010963 GG-rs3025039 CC combination  .VEGFA polymorphisms are associated with altered VEGF production [VEGFA genetically controls VEGF protein expression [VEGFA rs699947, rs2010963, and rs3025039 polymorphisms and PTB in Korean women.The VEGF protein levels increase during late pregnancy and peak during the time of cervical ripening . It is roduction . Among toduction . Moreoveoduction . Since Vpression -38. We aVEGFA gene polymorphisms on PTB has been inconsistent to date, possibly because of ethnic heterogeneity [VEGFA rs2010963 G allele was significantly associated with PTB in the Malaysian population [2 = 1.0) [VEGFA for PTB, further studies need to be examined in different populations. Also, in the results of VEGFA rs699947 and rs3025039, no significant association in the Korean population (p > 0.05) , Europe, and South Asia population   and 4. Tulations . Also, rpulation . MAFs fopulation . Also, eogeneity  reportedogenesis . TherefoVEGFA rs2010963, rs699947, and rs3025039 by LD analysis  for clinical studies . Nonethehenotype . AnalysiVEGFA gene polymorphisms and PTB in Korean women. Conclusively, our study could not confirm genetic relationships between the VEGFA rs699947, rs2010963, and rs3025039 polymorphisms, and PTB pathogenesis. Therefore, current evidence does not support using the VEGFA to predict risk or as a marker for therapeutic intervention in Korea. Replication studies with larger sample sizes and different populations are still needed to elucidate the genetic relationship between the VEGFA gene polymorphisms and the pathogenesis of PTB.Despite these limitations, this study is the first analysis of the association between