Acute promyelocytic leukemia (APL) is one of the most curable cancers. However, relapse of the disease is a difficult issue in clinical practice and it remains a great challenge that patients have a poor effect of conventional treatment in the clinic. Therefore, new and more effective therapeutic measures are urgently needed. Herein, we report a case of relapsed and refractory APL harboring a RARA-LBD region mutation successfully treated with venetoclax (VEN).A 37-years-old woman was admitted to our hospital with worsening spontaneous gingival bleeding and skin ecchymosis. Physical examination revealed multiple petechiae and ecchymosis in the extremities.The patient was diagnosed with L-type PML-RARα-positive APL, harboring a RARA-LBD region mutation, low-risk, based on bone marrow cytology, immunophenotypic analysis by flow cytometry, karyotype analysis, and molecular analysis.Complete remission was achieved after the first induction therapy of all-trans retinoic acid (ATRA) combined with arsenic trioxide, but relapse was observed only after 11 months. Reinduction with ATRA and arsenic trioxide combined with anthracycline failed. Therefore, we tried to provide a new treatment with the Bcl-2 inhibitor VEN orally .Clinical symptoms and laboratory indicators improved rapidly with VEN treatment. A complete hematologic response was achieved with VEN-based therapy.Related drug resistance gene monitoring should be performed canonically in relapsed and refractory APL. Some relapsed and refractory APL that failed to respond to conventional treatment were at risk of death. Bcl-2 inhibitors are expected to be an effective salvage therapy for patients with resistance to ATRA, which is worthy of further discussion. APL has now become curable with the great development of all-trans retinoic acid (ATRA). Some patients experienced recurrence, although it has a high cure rate. The poor effect of conventional treatment is a great challenge in clinical practice, and new therapeutic measures need to be developed. Relevant literature has reported that venetoclax (VEN)-based therapy is a feasible rescue therapy for relapsed and refractory nonpromyelocytic AML,–4 but its application in APL has not yet been reported. Herein, we describe a case in which a patient with relapsed and refractory APL failed to undergo treatment with ATRA in combination with arsenic trioxide (ATO) and chemotherapy, but she achieved a complete hematologic response (CHR) with a Bcl-2 inhibitor. This is reported below.Acute promyelocytic leukemia (APL) is a special subtype of acute myelogenous leukemia (AML), which manifests as hemorrhage and hemocytopenia, accounting for 10% to 15% of all AML diagnoses.29/L ; hemoglobin: 124 g/L (120–160 g/L); platelets: 30 × 109/L (100 × 109/L–300 × 109/L); myeloblasts 16.0%. She was diagnosed with L-type PML-RARα-positive APL, low-risk, based on bone marrow cytology, immunophenotypic analysis by flow cytometry, karyotype analysis, and molecular analysis. She achieved CHR after 1 month of induction therapy with ATRA and ATO combined with chemotherapy. Then, 3 consolidation therapies were administered to daunorubicin plus cytarabine, homoharringtonine plus cytarabine, and daunorubicin plus cytarabine successively. Maintenance therapy with ATRA and compound realgar natural indigo tablets was subsequently administered for approximately 3 cycles. She sustained CHR during this period, but no fusion gene monitoring was performed to assess whether molecular remission was achieved. Unfortunately, she experienced a relapse during the maintenance therapy in December 2019, failing to achieve CHR after double induction therapy with ATRA and ATO. She was then administered 1 dose of 40 mg idarubicin, twice that of idarubicin plus cytarabine, and 1 medium dose of 21 g cytarabine chemotherapy, all of which failed. The patient was admitted to our hospital in August 2020 for excessive fatigue and progressive skin and mucosal bleeding. On physical examination, multiple petechiae and ecchymosis were observed in the extremities, and no obvious abnormalities were observed in the rest. The complete blood count results were as follows: white blood cell: 4.73 × 109/L; hemoglobin: 96 g/L; platelets: 19 × 109/L; absolute neutrophil count: 0.09 × 109/L (1.8 × 109/L–6.3 × 109/L); abnormal promyelocytes in peripheral blood account for 78%. The results of the coagulation profile were as follows: prothrombin time: 17.4 seconds (9.0–13.0 seconds); prothrombin time ratio: 1.58 (0.82–1.18); international normalized ratio: 1.60 (0.80–1.20); fibrinogen: 0.32 g/L (2.0–4.0 g/L); thrombin time: 25.9 seconds (14.0–21.0 seconds); d-dimer: 11.56 mg/L (0.00–0.55 mg/L); fibrinogen degradation products: 27.97 mg/L (0.00–5.00 mg/L). Bone marrow aspiration demonstrated relapsed APL with promyelocytes comprising 96% and L-type PML-RARα fusion gene positivity. Color ultrasonography showed right hepatic vein occlusion with possible collateral formation. After admission, we treated her with ATRA combined with ATO double-induction chemotherapy and continuous transfusion of cryoprecipitate, fresh frozen plasma, and platelets. At the same time, drug-resistance genes were tested. Fibrinogen still lasted <0.3 g/L after 8 days of treatment, and the coagulation dysfunction could not be corrected. PML-RARα mutation analysis results were as follows: RARA-LBD area: c.854C>T; p.T285I (high mutation rate), suggesting ATRA resistance, and no ATO resistance-related gene mutation was detected (Fig. 9/L, leaving the blood transfusion treatment. On the 29th day, the patient achieved CHR (Fig. A 37-years-old woman patient visited a local hospital for worsening spontaneous gingival bleeding and skin ecchymosis in December 2018. The complete blood count results were normal in parentheses, as shown below: white blood cell: 2.96 × 103–9 which has become a major factor for failed treatment and death. Some relapsed and refractory APL failed to respond to conventional treatment and were at risk of death due to severe coagulation disorders, including bleeding and thrombosis. This has forced us to search for new, safe, and effective treatment protocols. Studies have shown that Bcl-2 inhibitors can treat cancer by downregulating the expression of antiapoptotic Bcl-2 protein and promoting the apoptosis of malignant tumor cells.,11 As an oral, potent, and selective inhibitor of Bcl-2, VEN has no decisive effect on the survival of platelets and will not cause significant reduction of platelets.,13 Relevant clinical trials reported that treatment with VEN significantly improved the median survival time in chronic lymphocytic leukemia,,15 AML, and relapse or refractory multiple myeloma, but no study has reported its application in APL. A part of relapsed and refractory APL develop resistance to ATRA and/or ATO.–22 Studies have found that resistance to ATRA may be related to the mutations in RARA-LBD region.,23 Goto et al and Zhu et al studied the mutations associated with targeted drugs for leukemia and believed that drug resistance of APL to ATO might be related to the mutation in the PML-B2 domain.APL was once the deadliest subtype of AML. The cure rate of APL has been increasing since the combination therapy of ATRA and ATO. However, the relapse rate of APL can still reach 8% to 30.5%,This case of relapsed and refractory APL failed to conventional treatment when the disease relapsed and had a severe tendency to face the risk of death at any time. Until she was treated with VEN, the clinical symptoms and laboratory indicators improved rapidly, leaving the risk of death and achieving a second CHR. It was well tolerated, with few side effects, using Bcl-2 inhibitors. Unfortunately, the patient eventually died after 4 months.Molecular remission is a necessary condition for the long-term survival of APL, and the greatest deficiency in the initial treatment of this patient is that fusion gene monitoring is not standardized, which neither evaluates whether the disease has achieved molecular remission, nor can timely salvage treatment be carried out when the disease has relapsed. Therefore, related drug-resistance gene monitoring should be carried out in relapsed and refractory APL to avoid delay in treatment. If the APL resistance gene test could be performed in time when this patient relapsed, the attempt of ineffective treatment of ATRA or ATO and the irreversible consequences or even the cost of life because of delayed treatment could be avoided. The patient was well tolerated by VEN and the obtained CHR suggested that the significant effect of VEN on this patient, as well as Bcl-2 inhibitor, is expected to be an effective salvage therapy for patients with resistance to ATRA, which is worthy of further discussion. Meanwhile, Bcl-2 inhibitor monotherapy cannot maintain long-term remission, but can be used as an effective bridging therapy. Hematopoietic stem cell transplantation should be performed as soon as possible after obtaining CHR, so that patients hope for a cure again.4Bcl-2 inhibitor-based therapy is expected to be an effective salvage therapy for relapsed and refractory APL harboring RARA-LBD region mutation, which is worthy of further prospective studies.Data access statementAll relevant data are within the paper and its Supporting Information files. The laboratory indicators data are provide in the Supplementary Files .Conceptualization: Kejie Zhang.Date curation: Youli Li.Funding acquisition: Kejie Zhang.Investigation: Youli Li.Methodology: Kejie Zhang.Project administration: Youli Li.Resources: Jieni Yu, Qinhong Xu, Kejie Zhang.Supervision: Jieni Yu, Qinhong Xu.Visualization: Jieni Yu, Qinhong Xu.Writing – original draft: Youli Li.Writing – review & editing: Kejie Zhang.


Interest revolving around coronavirus disease 2019 (COVID‐19) reinfection is escalating rapidly. By definition, reinfection denotes severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), PCR redetection, and COVID‐19 recurrence within three months of the initial symptoms. The main aim of the current systematic review was to evaluate the features of COVID‐19 relapse patients.For this study, we used a string of terms developed by a skilled librarian and through a systematical search in PubMed, Web of Science, and Embase for eligible studies. Clinical surveys of any type were included from January 2019 to March 2021. Eligible studies consisted of two positive assessments separated by a negative result via RT‐PCR.Fifty‐four studies included 207 cases of COVID‐19 reinfection. Children were less likely to have COVID‐19 relapse. However, the most patients were in the age group of 20–40 years. Asthenia (66.6%), headache (66.6%), and cough (54.7%) were prevalent symptoms in the first SARS‐CoV‐2 infection. Asthenia (62.9%), myalgia (62.9%), and headache (61.1%) were most frequent in the second one. The most common treatment options used in first COVID‐19 infection were lopinavir/ritonavir (80%), oxygen support (69.2%), and oseltamivir (66.6). However, for the treatment of second infection, mostly antibiotics (100%), dexamethasone (100%), and remdesivir (80%) were used. In addition, obesity (32.5%), kidney failure (30.7%), and hypertension (30.1%) were the most common comorbidities. Unfortunately, approximately 4.5% of patients died.We found the potency of COVID‐19 recurrence as an outstanding issue. This feature should be regarded in the COVID‐19 management. Furthermore, the first and second COVID‐19 are similar in clinical features. For clinically practical comparison of the symptoms severity between two epochs of infection, uniform data of both are required. We suggest that future studies undertake a homogenous approach to establish the clinical patterns of the reinfection phenomena. Totally, 1807 studies obtained from PubMed/Medline, Web of Science, and Embase databases. Following the removal of duplicates, the title and abstract of 998 studies were screened to select the studies which report the relapse of COVID‐19 after a negative RT‐PCR test. Finally, among the 152 full‐text articles, 54 studies were found to be eligible for data extraction. Viruses such as severe acute respiratory syndrome coronavirus (SARS‐CoV) and Middle East respiratory syndrome coronavirus (MERS‐CoV) have also been prevalent in recent years.Reinfection, relapse, recurrence, and reactivation are terms used for people infected with coronavirus and have become positive again after a period of negativity.2The present systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statements.2.1We used PubMed/Medline, Web of Science, and Embase for a systematic search from January 1, 2019, to March 7, 2021. The search was based on the following string of terms: (“recurrence” OR “relapse” OR “reinfection” OR “reactivation”) AND (“COVID‐19” OR “severe acute respiratory syndrome coronavirus 2” OR “novel coronavirus” OR “SARS‐CoV‐2” OR “nCoV disease” OR “SARS2” OR “2019‐nCoV” OR “coronavirus disease‐19” OR “coronavirus disease 2019” OR “2019 novel coronavirus” OR “Wuhan coronavirus” OR “Wuhan seafood market pneumonia virus” OR “Wuhan pneumonia”). There was no limitation on language, location, and type of studies.2.2All the studies reported the reactivation or second infection of COVID‐19 were considered in the search. Total records were retrieved and entered into EndNote X9 software (Thomson Reuters). Following duplicate exclusion, a three‐stage screening was carried out to exploit the eligible studies based on title, abstract, and full text. The whole eligible studies reported the patients who were recovered from primary infection, but then developed a secondary COVID‐19 infection. RT‐PCR test was necessary inclusion criteria. Patients with a positive RT‐PCR for the first phase of COVID‐19, a negative RT‐PCR for recovery, and a second positive RT‐PCR for COVID‐19 recurrence were examined in the study. We excluded articles that reported only a serologic diagnosis test, without a nasopharyngeal swab RT‐PCR test, as well as duplicate publication of same studies, congress abstracts, reviews, systematic reviews and meta‐analysis, cellular and molecular studies, and animal studies. All types of manifestations and treatments were regarded without any restriction, and there was no limitation on comorbidities and underlying disorders.2.3The following data were acquired from each article: first author's name, location, publication time, type of study, number of relapsed patients, age, gender, interval between two infections, clinical manifestations, treatment, relative status, comorbidities, and outcome. Two investigators independently extracted the data from full text of 54 included studies. Inconsistencies between reviewers were resolved by consensus. The retrieved data are represented in Table 2.4The critical appraisal checklist provided by the Joanna Briggs Institute (JBI) was used to perform a quality assessment of the studies.33.1N = 3), case reports , and case series . Likewise, in the included studies, RT‐PCR tests were performed to detect both the first and the second infections. Thirteen studies were originated from Europe, 11 from the USA, 9 from China, and 6 from Brazil. These articles reported a total number of 207 patients who developed the second infection of coronavirus after a recovery, which was confirmed by a negative RT‐PCR test. Forty‐six studies reported the clinical features in the first infection; however, seven articles declared no symptoms. Only one study unrecorded the clinical features in the first infection. In addition, 42 investigations implied the medication and intervention.The search strategy yielded 1807 studies from three databases. Following the removal of duplicates, the title and abstract of 998 studies were examined. Among these studies, 152 were selected for full‐text assessment, and other 846 studies were eliminated due to irrelevancy. In all the selected studies, the relapse of coronavirus infection after a negative RT‐PCR test was reported. Among the 152 full‐text studies examined, only 54 studies were found to be eligible for data extraction  studies reported n ≤ 30 or 30 < n < 90 for the recovery duration, and only 11 (22.5%) investigations implied more than 90 days  patients were female, and 85 (41.1%) patients were male. As shown in Table To compare the severity of the first infection with secondary, the reported features and symptoms were reviewed and extracted from the articles. Of 63 patients, 29 presented more severe manifestations, while 25 cases showed an ameliorated status, and 9 other cases indicated similar symptoms in both phases of the infection. Forty‐nine studies recorded the outcome of 199 patients, among whom 190 cases were discharged with an improved status, but 9 cases succumbed in hospital. Indeed, the survival rate is required to be taken into account when determining the potency of coronavirus reactivation.3.3Some clinical signs were most frequent between the two infections, but prevalence was different. Moreover, the most prevalent clinical signs in the first infection were asthenia (66.6%), headache (66.6%), cough (54.7%), fever (52.8%), sore throat (50.0%), and respiratory distress (48.1%). However, in the second infection, asthenia (62.9%), myalgia (62.6%), headache (61.11%), sore throat (52.54%), and dyspnea (48.53%) were the common. Respiratory alkalosis (21.43%), drowsiness (11.11%), and night sweat (11.11%) occurred only in the first infection. The most frequent symptoms observed only in the second infection were as follows: asthenia (62.9%), myalgia (62.9%), and headache (61.1%). COVID‐19 recurrence was manifested with more mild signs in 39.6% of patients, while 46.0% presented with more severe signs, and other 14.3% did not show any prominent change between the two infections.3.4Medications and treatments for the first COVID‐19 infection were reported in 40 studies. Among these treatments, hydroxychloroquine, azithromycin, and oxygen support were reported by 15, 11, and 11 articles, respectively. A total of 37 articles stated treatment for the second COVID‐19 infection. So that, oxygen support (17 studies), azithromycin (9 studies), dexamethasone (8 studies), and remdesivir (8 studies) were mostly reported. The most common treatment options used in first SARS‐CoV‐2 infection were lopinavir/ritonavir (80%), oxygen support (69.2%), and oseltamivir (66.6). However, for the treatment of second SARS‐CoV‐2 infection, mostly antibiotics (100%), dexamethasone (100%), and Remdesivir (80%) were used  and Parkinson's (9.52%) diseases were found as comorbidities  COVID‐19 infection reactivates following a period of dormancy, and (b) COVID‐19 increases the susceptibility to the second coronavirus invasion. Future experimental and clinical researches could examine these hypotheses and finally provide a clear view of COVID‐19 relapse.The authors declare that they have no competing interests.Maryam Koupaei, Mohamad Hosein Mohamadi, Ilya Yashmi, Amir Hossein Shahabi, Amir Hosein Shabani, Mohsen Heidary, and Saeed Khoshnood contributed in revising and final approval of the version to be published. All authors agreed and confirmed the study for publication.Not applicable.Not applicable.


Simple tuning of mode resonant frequenciesand strength is found for each quasi-normal mode, revealing a spectroscopic“fingerprint” for each facet shape, on both truncatedspherical and rhombicuboctahedral nanoparticles. This is applied todetermine the most likely nanoscale morphology of facets hidden beloweach NPoM in experiment, as well as to optimize the constructs fordifferent applications. Simple scaling relations are demonstrated,and an online tool for general use is provided.The optical properties of nanogap plasmonic cavitiesformed bya NanoParticle-on-Mirror  are determined here,across a wide range of geometric parameters including the nanoparticlediameter, gap refractive index, gap thickness, facet size and shape.Full understanding of the confined optical modes allows these nanocavitiesto be utilized in a wide range of experiments across many fields.We show that the gap thickness  Because of thisextreme localization and enhanced light-matter interaction, the spectraltuning and loss of trapped plasmonic modes is a subtle function ofgeometry at the nanometre scale. Understanding this interplay betweennanoresonator geometry and light is vital in accounting for many widelyused applications of plasmonic nanocavities such as enhancing excitonphotoluminescence,6 nonlinear vibrationalpumping,7 sensing, mid-infrared upconversiondetectors,8 or hot-electron emission9 among many others.Confining light to the surface of plasmonicmetals greatly increaseslight–matter interactions.12 This prevents the developmentof deep understanding for many light–matter effects observedexperimentally. For example, simple analytical predictions are evenlacking as to how modes tune when the refractive index in the subwavelengthvolume changes, and how this might vary for differently shaped nanoparticles(NPs).To understand the detailsof light fields in such plasmonic nanocavities,most previous works have relied on more cumbersome simulations ofhighly idealized geometries and, thus, cannot easily account for thebroad inhomogeneous distribution of scattering spectra observed fromeach nominally identical construct.18 Nanoparticles are inevitably faceted19 and thus form NPoMs with a MIM plasmonic nanogap of specific lateralshape. The influence of this nanocavity shape, as well as its materialproperties, are the focus of this work. We investigate structuresconsisting of a 10–200 nm diameter metal nanoparticle (NP)spaced 0.5–10 nm away from a metal mirror separated by a dielectricspacer, which is often of molecules or inorganic layers, but alsopolymers, perovskites, oxides, or other materials.20 Although we focus here on NPoMs with both metal layersbeing Au ,all our findings develop analogously in other plasmonic metals suchas Ag, Al, and TiN. We also do not take into account the atomic facetplane of the Au,22 because it leads to systematicspectral shifts of only a few %, similar to other uncertainties .In this work, we examine several nanocavities formedby a truncatedspherical NP and a rhombicuboctahedron-shaped NP to form a wide rangeof nanocavity shapes. These nanocavities support tightly trapped lightand allow the role of lateral confinement upon their plasmonic modesto be explored. Light can be efficiently and robustly trapped as plasmonsin nanogaps based on metal–insulator–metal (MIM) configurations,and here we take a scalable widely used scheme based on the Nanoparticle-on-Mirror(NPoM) configuration.E field or emitter location, chosen to replicate an experimental systemunder study.23 This however often obscuresthe underlying physics of the system and brings little physical intuition,necessitating a simulation for each experiment. To compensate, severalsemi-analytical models have emerged in recent years which qualitativelyaccount for the dependence on parameters including NP diameter, facetsize, gap refractive index and thickness.26 These howeversuffer from limitations, such as multiple free fitting factors whichare tuned to match the results of experiments carried out over limitedparameter spaces. Additionally, they often only attempt to model thelowest energy NPoM resonance, and poorly account for higher-ordermodes. This is insufficient as higher-order modes are often involvedin excitation or emission (as in the case of photoluminescence). These“dark” modes (which have an inherently higher Q) weakly scatter and play a large role in light–matterstrong coupling27 and lasing,28 despite being typically disregarded. As thesize, material, and shape  significantly influencespectral tuning, isolating their effects in experiments can provedifficult.29Usually, numerical analysis ofplasmonic nanoresonators uses FiniteDifference Time Domain or Finite Element Method simulations, solvingMaxwell’s equations with a specific incident 30 including NPoMs,31 to better understand their optical behavior. These QNMs are eigensolutionsof Maxwell equations, producing a set of modes that are orthogonal,with parameters spanning eigenfrequencies ω̃, qualityfactors Q̃, and mode volumes Ṽ. These parameters of the plasmonic resonators are complex,and since the modes lose substantial energy to Ohmic losses and radiateefficiently to the far-field, these lead to low Q̃ values. Physical quantities such as scattering cross-sections andPurcell enhancements can be constructed from a linear sum of theseeigenmodes.32 Understanding what influencesthese modes and how their relative strengths contribute to physicalphenomena allows for a holistic understanding of the system. Thisis especially powerful when there are few QNMs in a spectral regionof interest that can dominate the response observed,33 but they can also account for systems with many near-degeneratemodes.Recently, the communityhas begun to leverage Quasi-Normal Mode(QNM) decomposition of the electromagnetic response of plasmonic resonators,26 is shown to affect QNMs differently. Finally,the results are compared to experimental measurements of mode positionsto allow unique optical identification of the likely facet shape undereach NP and its size.Here we find the solutions of >2000 QNMs over a varietyof differentgeometric parameters. The results produce general trends that canpredict the spectral position and intensity of the first three lowestorder QNMs for all NPoM configurations and provide a new benchmarkfor any further analytical models, as well as optimization conditionsfor designing nanoplasmonic cavities. Notably, while all modes followthe qualitative trends of past works, they are found to quantitativelyvary widely and distinguishably depending on the shape of the nanoparticlefacet. Additionally, the effect of facet edge rounding, previouslyimplicated as instrumental in the coupling of light out of the gap37 and consists of a sphere of diameter D truncated to produce a circular nanoparticle facet ofdiameter w, separated from a semi-infinite Au substrateby a dielectric gap of thickness t and a refractiveindex n inside a surrounding background refractiveindex of 1  = ∑lmαlm(ω)Elm, where αlm(ω) arefrequency-dependent scattering coefficients.32 These coefficients can be further factored into two parts, αlm = Slm(ω)Olm(ω).The former term accounts for the line shape of the mode scatteringcontribution to each peak at ω = Re[ω̃lm] and has a width proportional to Im[ω̃lm], allowing us to reconstruct the scatteringspectra (with asymmetries that arise from mode Fano interferences).The latter factor is a near nondispersive term that accounts for themode coupling to an incident field .The real part of ω̃lm is thespectral position of the QNM, while the imaginary component κlm gives the rate of the total energy lossfrom the mode (radiative and nonradiative), analogous to the decayrate of an emitter.32 The nonradiativedecay rate can also be independently calculated from the decay rateκMIM of a similar but nonradiative infinite MIM waveguide, for lightat frequency ω = Re[ω̃lm],31 as detailed in Supporting Information, S2. Therefore, for each QNM, the radiativeefficiency can be defined aslm is proportional to the scattering intensity ofeach QNM. The spectral response (|Es(ω)|2) thus takes the form |Slm(ω)|2, scaled by the radiative efficiency.We first explore the TruncatedSphere on Mirror (TSoM), which iscommonly used to simulate NPoM geometriesdex of 1 1a, left.dex of 1  using Film = 10, 11, and20) deliver most of the system’s scattering spectral responsefor λ > 600 nm .This shows that the dimensionality of the problem can be reduced andthat gap refractive index and thickness cannot be distinguished.A parametricsweep is performed for the TSoM geometry using allcombinations of the parameters shown in nDf (asfor microcavities or interferometers), these metal–insulator–metalwaveguides support a plasmon with λeff = πt|Reεm|/n2 for small t. Using a Drude model εm = ε∞ – λ2/λp2 gives the quasi-analytical formula for 10 mode wavelength describedin,20n/t0.5 is expected beyond λ> 600 nm. Clearly, this simple 1D model has to be corrected for2Dconfinement, noncircular facets, and leakage beyond the facet edges,but gives a good intuition of the full simulations.Instead of scaling with optical path 2Supporting Information, S5–S6) on λ10, λ11, and λ20 with f, D, and G as regressors,a minimum residual is found when g = 0.472 ±0.004. Similar behavior is found for square and triangular facetsof the rhombicuboctahedral geometry (described below), resulting inminima at g = 0.467 ± 0.006 and 0.465 ±0.006, respectively. The average of all these, g =0.47, is used throughout the rest of this work. A key conclusion hereis thus that the gap refractive index and thickness cannot be independentlyextracted from spectroscopy.Performingthird degree polynomial regression  has regular facet fraction fr ≃ 0.3 for the triangular facet,while for the square facet, fr ≃ 0.46 .To investigate the effect of facetshape on the QNMs of NPoMs,a rhombicuboctahedral NP is used since it is one of several commonAu nanoparticle shapes observedEz mapsof 10, 11, and 20 modes .For each geometry and combination of parametersin D = 80 nm subset of this datawith polynomialfits . Higher-order modes,such as 22 and 33, whose near-field profiles resemble 2D whisperinggallery modes and are thus localized at the facet edges, also redshiftdisproportionately quickly with increasing f, D. In fact, for large portions of the parameter space, wefind that λ11 > λ22 > λ10 . Subtle changes in λlm betweenthe three facet shapes can be observed, for instance with D = 80nm, f = 0.3, t =1.5nm, n = 1.5 . The weakdependence on f is likely due to the decreasing totalvolume of the NP when truncation increases.The radiative efficiencyη andλ10 3b and is andλ10 3c,d. For circuit 3e24  at shortwavelengths . These observations suggest that the facet edges can be highlyimportant in selecting which modes are possible to couple to. We thusnow explore a further geometrical parameter, the rounding of thisfacet edge.When the 10 plasmonic nanocavity mode frequencycoincides withthis antenna frequency, scattering is maximized. The analysis alsoshows that the 11 mode becomes more radiative for large elengths 3c, becauD = 80 nm, f ≃ 0.3). For all modes, the effect of rounding increases asgap parameter G increases  because the effective sizeof the facet is decreased. This blue-shifting increases with G since the modes are more strongly localized under thefacet edge, increasing its influence. This effect is stronger forthe 11 and 20 modes, as their fields are more localized at the facetedge, with Δω11 > 20% at ρ = 10 nmforhigh G. By contrast, for the 10 mode at high G, Δωρ decreases because thehigh confinement causes the 10 mode profile to retract from the facetedges, outcompeting any rounding effect. The shifts and relative magnitudescaused by increasing ρ correlate with the dependence on decreasing f, Δω11 > Δω20 > Δω10, indicating that the dominant effectof increasing ρ is decreasing the facet area and, as such, iswell accounted for by the facet size f.The rounding radius ρ of the filleted NP bottom(triangular)facet edge is varied  and low-angle(θlow) white-light scattering spectra are taken of17 NPoMs witha biphenylthiol (BPT) gap spacer molecular layer  by angularly separatingthe collected light . Changing D tunes all modes similarly withinreasonable polydispersities (80 ± 10 nm) of our samples and thushas little explanatory power . While n and t may be combined without loss of information into the gap couplingparameter G (t (nm) for easy comprehension.To visualize the information in the cross-correlations of the threemeasured mode positions, the polynomial fits of the 10, 11, and 20mode wavelengths for each facet shape are plotted on 10 versus 11,10 versus 20, and 11 versus 20 graphs (f and vary gap size t (and vice versa), allowingthe set of each NPoM peaks to unambiguously predict a value of  for each geometry. The agreementbetween  for these three correlationsis a measure of how likely this simulated facet shape is the one probedin experiment. The data points coincide at similar parameter valuesfor the triangular facet , we find that most NPoMs have triangular facets,with average D̅ = 82 ± 5 nm and t̅ = 1.4 ± 0.3 nm. This D̅ matches well with the expected 80 nm NP size. Previous ellipsometrymeasurements suggested that similarly prepared BPT SAMs have thickness t = 1.3 nm and refractive index n = 1.45,39 agreeing well with these optimized parameters.By allowing free variation of G ≡ n/t0.47 does not vary from NPoM to NPoM, and n and t are thus fixed to investigate the correlation of f and D . This might be attributed to facet growth/annealing of rhombicuboctahedralfacets (regular rhomboctahedra have fr ≃ 0.3), however, it is more likely from icosahedrawhich consist entirely of triangular facets for which fr = 0.408 or cuboctahedra for which fr = 0.47. This accounts wellfor the prevalence of triangular facets assigned. Typically, all theseshapes of particles can be identified in electron microscope images,as well as less frequent pentagonal bipyramids.40 The inverse correlation between f and D  and experimental spectra. These have previously been causingconfusion in many experimental papers from diverse researchers. Despitepredictions of our analytic analysis, the gap scaling here was notseen in previous simulations because they were not accurate enough,while not being obvious to any intuition.n and width t)can be described entirely in terms of a composite gap parameter G ≡ n/t0.47 and low-order polynomials of D, f, and G. The radiative efficiency of the dominantmode scales in intensity and spectral position as for a classicalantenna, depending only on spectral position and D. Finally, angle-dependent spectroscopy isolates “dark”modes in experimental scattering spectra from NPoMs. Using the lowestthree modes in comparison with simulated results allows likely facetshapes to be assigned as mostly triangular. The insights from thisanalysis support a wide range of experiments, which employ ultralowvolume plasmonic cavities, providing their mode spectrum and its sensitivityto geometry at the nm-scale. This underpins a wide variety of applicationsthat utilize these nanocavities.We show how 3D morphology influences plasmonicnanocavity modes.By employing improved computational methods, detailed informationcan be now extracted about heterogeneous ensembles on a construct-by-constructbasis. More specifically, we show that a handful of QNMs dominatethe spectral response of NPoMs, and these tune widely with geometricalparameters. Their resonant frequency dependence on the gap parameters, which givesthe mode positions and estimated scattering spectrafor any combination of the above parameters, as well as refer to thefull parameter sets in the Supporting Information. Since the three-dimensional nanoparticle shape above the facethas much less effect on the modes (mainly the height controls theantenna resonance λant), this model works for everytypical NPoM shape. The source python code is freely accessible. Wenote that the same QNMs are also found in nanoparticle dimers, butexperimentally the overlap of the two touching facets is uncontrolled,leading to very widely heterogeneous tuning ranges compared to theNPoM (as expected from the influence of above).To aid the reader, we provide an onlineapp (see 24 A multipole Lorentz–Drudemodel was used to model εAu(ω), necessary forthe augmented-field formulation of QNM decomposition.∞ = 6, ε0, ωp,1 = 5.37 × 1015 rad/s, ω0,1 = 0 rad/s, γ1 = 6.216 × 1013 rad/s, ωp,2 = 2.636 × 1015 rad/s, ω0,2 = 4.572 × 1015 rad/s, and γ2 =1.332 × 1015 rad/s. These parameters were obtainedby fitting to Johnson and Christy Au.41 This data and the fit are presented in Supporting Information, S10. Where background fields are required, a TMplane wave incident on the same structure without the NP is simulatedwith periodic boundary conditions.Finite Element Method simulations were performedwith COMSOL adaptingthe QNMEig toolkit.All simulated geometrieshave 5 nm rounding applied to the bottomfacet only. A quarter geometry and appropriate symmetry was used toreduce the computational time for TSoMs. With accurate search regionsfor the QNMs and careful choice of meshing, the full set of simulationstakes a week with 15 cores on COMSOL.42 A biphenyl-4-thiol SAM was formed by submerging the substratein a 1 mM solution in anhydrous ethanol  for 24 h, then rinsing with ethanol. The 80 nm AuNPs (BBI solutions) were then dropcast on the surface.NPoM samples were preparedon template-stripped Au, fabricatedby established methods.xk/k0 = 0 is filtered and dispersed by a150 l/mm grating and collected using an Andor Newton 970 BVF EMCCD.IndividualNPoMs are illuminated with focused incoherent whitelight  at an annular illumination angle of 64–75°with respect to normal incidence, and scattered light with an angleof <64° is collected through a dark-field objective . The scattering pattern from a NPoM is determinedusing the light intensity distribution at the back focal plane ofthe microscope objective. Single NPoM structures are spatially isolatedby spatially filtering the real image plane with a pinhole. The backfocal plane image is demagnified by three times before being imagedon the entrance slit (150 μm wide) of a Triax 320 spectrometer,where a narrow range of the scattering pattern near


ALDH2). Dysfunctional alleles of ALDH2 (ALDH2-deficient variants) are prevalent among East Asians.Alcohol—a risk factor for atrial fibrillation (AF)—is metabolized by aldehyde dehydrogenase 2 , ALDH2 heterozygous-deficient allele (∗1/∗2), and ALDH2 homozygous-deficient allele (∗2/∗2). Multivariate analyses were applied to determine the correlation between ALDH2 genotype and AF.A total of 656 consecutive patients were included in this investigation. ALDH2∗1/∗2 and ALDH2∗2/∗2 carriers who were ALDH2-deficient variant carriers comprised 199 (30.3%) and 27 (4.1%) patients, respectively. Among these patients, the proportions of habitual alcohol consumption were 26.1% and 0%, respectively. Multivariate analysis revealed that ALDH2∗1/∗2 itself was not a risk factor for AF . However, habitual alcohol consumption in ALDH2∗1/∗2 carriers was an independent risk factor of AF . Contrary to expectations, ALDH2∗2/∗2 itself had a lower incidence of AF among other risk factors .ALDH2∗1/∗2 itself was not associated with AF, ALDH2∗1/∗2 carriers with habitual alcohol consumption could experience AF because of slow alcohol metabolism. In contrast, ALDH2∗2/∗2 itself had a lower incidence of AF. This might be related to the absence to habitual alcohol consumption in ALDH2∗2/∗2 carriers because of the negligible activity of ALDH2. Thus, abstaining from alcohol consumption might prevent the development of AF in patients who are ALDH2∗1/∗2 carriers.Although the   The carriers of ALDH2∗1/∗2 and ALDH2∗2/∗2 are ALDH2-deficient variant carriers. Compared with the ALDH2 wild-type, ALDH2∗1/∗2 and ALDH2∗2/∗2 represent reduced and negligible activity of ALDH2, respectively.ALDH2∗1∗2 who habitually consume alcohol is caused by the low metabolic activity and accumulation of toxic acetaldehyde. In contrast, there is decreased prevalence of AF in patients with ALDH2∗2/∗2, because these patients are not able to consume alcohol because of the negligible activity of ALDH2. In this study, we investigated the relationship between ALDH2 genotypes and the prevalence of AF in association with habitual alcohol consumption.Alcohol is metabolized in 2 steps. First, it is metabolized to acetaldehyde by an alcohol dehydrogenase subunit, and second, the acetaldehyde is metabolized to acetic acid by aldehyde dehydrogenase 2  or Holter ECG. In the other patients, new-onset AF was confirmed using surface ECG and by monitoring the ECG during admission. Previously documented AF was confirmed using surface ECG or Holter ECG performed by their primary care doctor. AF was defined by the absence of P waves, presence of fibrillatory waves, and an irregular ventricular rate in patients without conduction disorders that lasted >30 s. Following this, AF was diagnosed by ≥2 cardiologists.ALDH2 was extracted from whole blood using a DNA purification kit . The ALDH2 rs671  genotypes were determined by performing a real-time TaqMan allelic discrimination assay  according to the manufacturer’s protocols (assay no. C_11703892_10). The allele ratio was analyzed using this method.Genomic DNA used for genotyping of ALDH2 genotypes. We defined older age as older than 60 years, because the prevalence of AF increases in individuals above this age.2. Habitual alcohol consumption was defined as ≥3 drinking opportunities per week, according to the Ministry of Health, Labour and Welfare in Japan.The following variables were analyzed: age, sex, hypertension, diabetes mellitus, obesity, alcohol consumption habit, and ALDH2∗2 allele and AF, univariate and multivariate analyses were performed to identify factors associated with AF.To determine the correlation between the ALDH2 genotype. Average alcohol intake volume was obtained from patients’ self-report. The volume was represented in standard drinks per week. One standard drink was defined as 12-g alcohol. According to this definition, alcohol intake volume was divided into the following groups: nondrinkers: 0-1 drinks/week; mild drinkers: 2-7 drinks/week; moderate drinkers: 8-21 drinks/week; and heavy drinkers: ≥22 drinks/week.In addition, we evaluated the relationship between AF and habitual alcohol consumption, based not only on categorical diagnosis, but also with regard to total alcohol consumption in relation to the P value <0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 25 (IBM), except for propensity-score matching, which was performed using R .All continuous data showed a normal distribution according to the Shapiro-Wilk test; continuous data were expressed as mean ± SD. One-way analysis of variance with Tukey’s test was used for multiple comparisons of data. Continuous data that showed a non-normal distribution using the Shapiro-Wilk test were expressed as the median (interquartile range). The Kruskal-Wallis with Steel-Dwass test was used for multiple comparisons of the data. Categorical data were presented as numbers or percentages. Differences between multiple groups were tested using Fisher’s exact test with Bonferroni’s correction. Multiple logistic regression analysis was performed to determine the risk factors for AF. Propensity-score matching and inversed probability treatment weighting analyses were performed to balance the bias of background. Cox regression analysis was performed to determine the risk factors for new-onset AF. A ALDH2∗1/∗1 (ALDH2 wild-type) and ALDH2-deficient variant carriers, which included ALDH2∗1/∗2 and ALDH2∗2/∗2 carriers, were 430, 199, and 27 patients, respectively. This proportion of ADLH2 genotypes was similar to the reports in Japanese and East Asian populations.,Among the 656 patients, the distribution of the genotypes ALDH2 wild-type carriers and ALDH2∗1∗2 and ALDH2∗2/∗2 allele carriers except for left atrial dimensions, drinking habits, and AF. The differences of left atrial dimensions between each genotype were not significantly different. However, prevalence of habitual alcohol consumption in ALDH2∗2/∗2 carriers was significantly less than that of ALDH2 wild-type and ALDH2∗1/∗2 carriers . In addition, prevalence of habitual alcohol consumption in ALDH2∗1/∗2 carriers was significantly less than that of ALDH2 wild-type carriers . Prevalence of ALDH2∗2/∗2 carriers’ history of AF was also significantly less than those of ALDH2 wild-type and ALDH2∗1/∗2 carriers . However, there was no significant difference between ALDH2 wild-type and ALDH2∗1/∗2 carriers.ALDH2 genotypes and type of AF. As shown, the proportion of paroxysmal, persistent, and longstanding persistent AF was not significantly different between each ALDH2 genotype.P < 0.001) and multivariate  analyses.ADLH2 genotypes and AF history, ALDH2∗1/∗2 carriers were not significantly correlated with AF on univariate  and multivariate analyses . Rather, contrary to expectations, ALDH2∗2/∗2 carriers had a lower incidence of AF on univariate  and multivariate analyses .With respect to the relationship between ALDH2 genotypes in regard to habitual alcohol consumption was lacking in this analysis. Therefore, variables in ALDH2 genotypes and habitual alcohol consumption were divided into 5 categories to understand the importance of ALDH2 genotypes and habitual alcohol consumption for the risk of developing AF. These categories were ALDH2 wild-type carriers who did not consume alcohol habitually, ALDH2 wild-type carriers who consumed alcohol habitually, ALDH2∗1/∗2 allele carriers who did not consume alcohol habitually, ALDH2∗1/∗2 allele carriers who consumed alcohol habitually, and ALDH2∗2/∗2 allele carriers . Multivariate analysis was performed as the reference for ALDH2 wild-type carriers who did not consume alcohol habitually by including other variables. P < 0.001), hypertension , being male , ALDH2 wild-type carriers with habitual alcohol consumption , and ALDH2∗1/∗2 allele carriers with habitual alcohol consumption  positively correlated with the risk of AF. Particularly, ALDH2∗1/∗2 allele carriers who consumed alcohol habitually showed the highest OR among these variables. In addition, ALDH2∗2/∗2 allele carriers had a lower incidence of AF .However, the relationship between AF and ALDH2 wild-type and ALDH2∗1/∗2 carriers using propensity-score matching analysis and inversed probability treatment weighting analyses. In this analysis, AF history and habitual alcohol consumption were included in the propensity score model as covariates. The values changed following propensity-score matching, but the overall meaning and significant difference remained the same  and moderate drinkers with the ALDH2∗1/∗2 allele  were positively correlated with AF risk. ALDH2∗1∗2 allele carriers with moderate alcohol consumption showed the highest OR. ORs of heavy drinkers in ALDH2∗1/∗2 allele carriers was not obtained because the proportion of AF was 100%.ALDH2 wild-type carriers, ALDH2∗1/∗2 carriers, and ALDH2∗2/∗2 carriers were 111, 51, and 12, respectively. During follow-up, new-onset AF was observed in only 6 patients . Cox regression analysis did not show the correlation between ALDH2 genotypes and new-onset AF . The number of patients who were onset AF . In addirelation .ALDH2∗2/∗2 carriers (n = 27); therefore, we conducted a power analysis with 27 ALDH2∗2/∗2 carriers and 430 ALDH2 wild-type carriers as control subjects. In this present study, proportion of ALDH2 wild-type carriers with a history of AF was 0.607, and the relative risk of AF in ALDH2∗2/∗2 carriers was 0.32. Under the type I error probability associated with this test of this null hypothesis of 0.05, the calculated power was 0.994. We used Fisher’s exact test to evaluate this null hypothesis. Therefore, we analyzed the data incorporating ALDH2∗2/∗2 carriers as well.There were only a few ALDH2∗1/∗2 allele itself, which leads to the slow metabolism of alcohol, was not a risk factor for AF. However, the ALDH2∗1/∗2 allele carriers with habitual alcohol consumption had the strongest risk factor for AF compared with older age, hypertension, and male sex. Second, with increased alcohol consumption volume, the OR of AF risk increases in both ALDH2 wild-type and ALDH2∗1/∗2 allele carriers. This phenomenon appears prominently in ALDH2∗1/∗2 allele carriers. Third, the ALDH2∗2/∗2 allele itself, which negligibly metabolizes alcohol, correlated with lower incidence of AF.In this present study, we found 3 main findings. First, the In this study, habitual alcohol consumption was one of the risk factors for AF according to the multivariate analysis.,,A mechanism of developing AF based on habitual alcohol consumption may consist of various factors. First, alcohol has 2-sided effect in the atrium associated with AF, including autonomic modulation, represented by increased β-receptor density,ALDH2∗1/∗1 (ALDH2 wild-type) and ALDH2-deficient variant carriers, which included ALDH2∗1/∗2 and ALDH2∗2/∗2 carriers, was 430, 199, and 27 patients, respectively, among all 656 patients. Although the worldwide prevalence of ALDH2∗2 allele carriers is rather small,ALDH2∗1/∗2 and ALDH2∗2/∗2 carriers was similar to past reports in Japanese and East Asian populations.,In this study, the distribution of the genotypes of ALDH2-deficient variant allele has reduced enzyme activity.,ALDH2 activity leads to accumulation of toxic acetaldehyde in ALDH2-deficient variant carriers, causing an alcohol flushing syndrome in ALDH2-deficient variant allele carriers after alcohol consumption.ALDH2-deficient variant allele contributes to cardiovascular disease, diabetes, stroke, and cancer.The ALDH2∗1/∗2 allele itself was not a risk factor for AF. Consistent with the data in this study, Nakano et alALDH2-deficient variant allele itself was negatively associated with AF. However, the study did not focus on habitual alcohol consumption in ALDH2 genotypes. Being an ALDH2∗1/∗2 allele carrier with habitual alcohol consumption was the strongest risk factor for AF in the multivariate analysis in this present study. In addition, increased alcohol consumption volume, increased the OR of AF risk, especially in ALDH2∗1/∗2 allele carriers. It was shown that alcohol induced autonomic effects and atrial electrical remodeling, both of which are associated with the generation of the AF substrate.ALDH2-deficient variant carriers could play an important role for developing AF. It was shown that overdrive pacing fails to induce triggered activity in the presence of ethanol. However, triggered activity was induced by overdrive pacing in the presence of acetaldehyde.In this study, we found that the ALDH2∗2/∗2 allele carriers, symptoms of the alcohol flushing syndrome could be more severe because of the negligible activity of ALDH2 compared with that of ALDH2∗1/∗2 allele carriers. Therefore, ALDH2∗2/∗2 allele carriers cannot consume alcohol.ALDH2 genotypes and AF development. As shown, although small amounts of alcohol did not lead to AF development in ALDH2 wild-type carriers, large amounts of alcohol led to AF development despite, normal ALDH2 metabolism. However, even small amounts of alcohol led to development of AF in ALDH2-deficient variant carriers because of low ALDH2 metabolism activity.With respect to ALDH2∗1/∗2 allele carrier, because both ALDH2 wild-type and ALDH2∗1/∗2 allele carriers can consume alcohol. Symptoms of alcohol flushing syndrome could be a predictor to differentiate between ALDH2 wild-type and ALDH2∗1/∗2 allele carriers, because in the ALDH2∗1/∗2 allele carriers, facial flushing, headache, nausea, and palpitations  have been observed even with small amount of alcohol.Therefore, it might be important to identify whether an individual is an ALDH2 genotype was consistent with that in a previous report, it might not represent the general population.This study’s population only included patients who were admitted to the Cardiovascular Center of Kumamoto University. In addition, the 385 patients of 656 patients underwent catheter ablation for AF. Although the proportion of the ,Although the relationship between AF and sleep apnea syndrome was not evaluated, obesity was not a risk factor of AF in this study. This might be because most patients with the sleep apnea syndrome in the Japanese population develop the condition from having a small jaw and not because of obesity.,Socioeconomics factors, educational attainment, and regional customs demonstrated a close relationship with habitual alcohol consumption.ALDH2 genotypes and new-onset AF was not observed, the follow-up period was short because of retrospective study design. Increasing the follow-up period and patient numbers might clarify this correlation.Although a correlation between ALDH2∗2 allele carriers is extremely rare in EuropeansThe prevalence of ALDH2 genotype. However, the exact starting time of habitual alcohol consumption, especially the starting time of the current drinking volume, was obscure. In addition, some patients were asymptomatic for AF. Therefore, this evaluation could not be conducted.The duration from beginning habitual alcohol consumption to developing AF might be different for each ALDH2∗1/∗2 itself was not associated with AF, ALDH2∗1/∗2 carriers with habitual alcohol consumption might experience AF because of slow alcohol metabolism. In contrast, ALDH2∗2/∗2 carriers had a lower incidence of AF. This might be related to the absence of habitual alcohol consumption in ALDH2∗2/∗2 carriers because of the negligible activity of ALDH2. Thus, abstaining from alcohol consumption could prevent the development of AF in patients who are ALDH2∗1/∗2 allele carriers in the Japanese population.PerspectivesCOMPETENCY IN MEDICAL KNOWLEDGE: Alcohol—a risk factor for AF—is metabolized by ALDH2. Dysfunctional alleles of the ALDH2 (ALDH2-deficient variants) are prevalent among East Asians. In this study, we revealed that habitual alcohol consumption in ALDH2-deficient variant carriers is an independent risk factor for AF because of the presence of slow alcohol metabolism.TRANSLATIONAL OUTLOOK: It should be noted that habitual alcohol consumption in ALDH2-deficient variant carriers is an independent risk factor for AF because of the presence of slow alcohol metabolism. Therefore, abstaining from alcohol consumption, particularly by ALDH2-deficient variant carriers, may suppress AF onset.Although the This work was supported by JSPS KAKENHI Grant Number JP20K22878. Drs Hoshiyama and Kanazawa have received grants from Medtronic Japan, Nihon Kohden, Abbott Medical Japan, Fukuda Denshi, Boston Scientific Japan, Japan Lifeline, Nipro, and Biotronik Japan. Dr Tsujita has received honoraria from Bayer Yakuhin, Daiichi-Sankyo, Kowa, MSD, Sanofi, and Takeda Pharmaceutical; and has received grants from Astellas Pharma, Abbott Vascular Japan, Bayer Yakuhin, Boehringer Ingelheim Japan, Boston Scientific Japan, Bristol Myers, Chugai Pharmaceutical, Daiichi-Sankyo, Goodman, Japan Lifeline, Medtronic Japan, Mitsubishi Tanabe Pharma, MSD, Novartis Pharma, Otsuka Pharmaceutical, Sanofi, Takeda Pharmaceutical, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.


After emerging in China, the novel coronavirus disease 2019 (COVID-19) quickly spread to all parts of the country and became a global public health emergency. The Chinese government immediately took a series of protective and quarantine measures to prevent the spread of the virus, and these measures may have negative effects on behavior and psychological health. This study aimed to examine the associations between factors related to COVID-19 measures and mental health symptoms among Chinese college students in different pandemic areas.An online survey was administered to 14,789 college students from February 4 to 12, 2020. After excluding the participants who did not complete the questionnaire, the quality of the questionnaire was checked. Finally, the sample included 11,787 college students from 16 cities and 21 universities in China. The areas included the city of Wuhan (Area 1), the neighboring province of Hubei (Area 2), first-tier cities , and other provinces (Area 4).χ2 = 25.57 and anxiety: χ2 = 39.42). Coping with COVID-19 partially mediated the associations between some related lifestyle behaviors, anxiety, and depression. The conditional process model analysis results supported our hypotheses that lifestyle health behaviors and coping style were both predictors of anxiety and depression symptoms, and their direct and indirect effects were moderated by sex.The average age of the participants was 20.51 ± 1.88 years. One-third of the participants were men. In total, 25.9 and 17.8% reported depression and anxiety, respectively. We also explored COVID-19-related factors, such as infection risk, perceived resistance to COVID-19 (or susceptibility to COVID-19 infection), perceived physical symptoms, family or friends, direct or indirect contact with confirmed cases, and having sought psychological counseling, which were significantly associated with anxiety and depression symptoms. Higher screen time, lower physical activity, higher soda and tea beverages , use of alternative medicines or food supplements , and decreased meal frequency were all correlated with higher depression and anxiety symptoms (depression: Compared with the city of Wuhan, other epidemic areas had a lower risk of mental health problems. Lifestyle health behaviors and coping styles alleviated mental health symptoms. COVID-19-related social stressors were positively associated with mental health symptoms.The online version contains supplementary material available at 10.1186/s12889-022-14598-4. After the first confirmed case in December 2019, coronavirus disease 2019 (COVID-19) rapidly spread to many cities in China and became a public health emergency of international concern (PHEIC) . In the − 1 among young adults during the COVID-19 pandemic ”). The Ethics Committee of Anhui Medical University approved this study. All the respondents provided informed consent. Data collection occurred over several days . Participants could withdraw or decline participation at any time during the study.The participants completed the questionnaires using an online survey platform (“Survey Star [i) I know if someone has had pneumonia in the past 14 days and tourism history of Wuhan or Hubei, ii) contact history with COVID-19 patients in the past 14 days, iii) knowledge and concerns about COVID-19, iv) precautionary measures against COVID-19 in the past 14 days, and v) additional information required for COVID-19; (3) lifestyle behaviors with COVID-19; and (4) mental health symptoms. Sociodemographic data were collected on gender, age, grade, student type, and regional and school areas. Lifestyle behaviors related to COVID-19 were measured in the following aspects: ST, PA, SSBs, meal frequency, healthy food, appetite, and vigor.This study examined factors related to the COVID-19 pandemic. The structured questionnaire consisted of questions that covered several aspects: (1) sociodemographic data; (2) COVID-19-related information, such as The ST of participants was evaluated using one question: “How much time do you spend on ST?” . ST was Participants’ PA was measured using the question, “On how many days in the last week did you spend at least an hour (60 minutes) on PA?” ?” The options range from 0 to 7 days ; high leSSB intake of participants were evaluated using two questions: “During the last week, how many soda and tea beverages did you drink per day?” The responses were as follows: “none,” “less than one bottle per day,” “one bottle per day,” “two bottles per day,” “three to four bottles per day,” and “more than four bottles per day.”Meal frequency was evaluated using the following question: “During the last week, did you feel your diet was more regular?” The answers were as follows: “increased,” “unchanged,” and “decreased.”Alternative medicine or food supplements were evaluated using two questions: “During the last week, did you consume Chinese herbal medicines or vitamins?” The possible answers were “yes” and “no.”Appetite and vigor changes were evaluated using two questions: Do you feel worse appetite or vigor than before? The answers were: none, sometimes, half of the day, and all the time.Coping style during COVID-19 was evaluated using the following questions: (1) “Do you usually keep the unhappy memories in mind but never forget them?”; (2) “When you encounter setbacks, do you usually compare them to those of individuals with similar experiences to make sense?”; (3) “In the face of painful events, can it be used to alleviate the pain with positive actions, such as PA?”; and (4) “When you encounter as a sad situation, do you vent anger on others and often lose your temper?” Responses to these questions were based on a four-point scale:1 , 2 , 3 , and 4 (“nearly every day”). Cronbach α was 0.74.The mental health status of college students was measured using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Questionnaire (GAD-7), and the total score was calculated based on previous studies , 28. TheP < 0.05. The associations were presented as regression coefficients and 95% confidence intervals (CIs). Statistical analyses were performed using SPSS Windows software version 23.0 .Descriptive statistics were calculated for the sociodemographic characteristics, ST, and PA. The chi-square test was used to analyze the prevalence of depression and anxiety in the general data and health behaviors. PHQ-9 and GAD-7 scores were expressed as dichotomous variables. We also built a multiple lifestyle health behavior index  to measure the overall behaviors during the pandemic. ST was scored as 1 (> 4 h/d), 2 (2-4 h/d), and 3 (≤ 2 h/d). PA was scored as 1 (< 3 days) or 2 (≥3 days). SSB intake, including soda and tea beverages, were scored as 5 (“none”), 4 (“less than one bottle per day”), 3 (“one bottle per day”), 2 (“two to three bottles per day”), or 1 (“more than four bottles per day”). Meal frequency was scored as 3 (increased), 2 (unchanged), or 1 (decreased). The use of alternative medicines or food supplements, including Chinese herbal medicines and vitamins, was scored as 1 (“yes”) or 2 (“no”). Worse appetite and vigor were scored as 1 (“none”), 2 (“sometimes”), 3 , or 4 . The multiple lifestyle health behavior index was calculated as the sum of the behavioral scores. For coping styles, items 1 and 3 were reverse scoring items, items 2 and 4 were forward scoring items, and the total score of the entries was calculated. Linear regressions were used to calculate the association between sociodemographic characteristics, health behaviors, and mental health, with a significance level of χ2 = 25.57 and anxiety: χ2 = 39.42).This study covers a sample of 11,787 college students from 21 universities in 16 cities. Their mean age was 20.51 ± 1.88 years. One-third of the students were women. The demographic characteristics of the college students are shown in Table χ2 = 196.15, P < 0.001). Lower PA was associated with higher depression symptoms . The students’ daily ST > 4 h/d, 2–4 h/d, and ≤ 2 h/d of depression symptoms were 31.3, 20.3, and 22.0%, and PA < 3 d/w and PA ≥ 3 d/w depression symptoms accounted for 28.2 and 20.1%, respectively. Similar results were also observed for anxiety symptoms. Moreover, the prevalence of sleep rhythmicity decreased, remained unchanged, and increased by 27.9, 58.5, and 13.7%, respectively, and the prevalence of diet rhythmicity decreased, remained unchanged, and increased by 17.5, 66.9, and 15.6%, respectively. Other results and gender differences in health behaviors are shown in Tables The daily ST > 4 h/d, 2–4 h/d and ≤ 2 h/d of the college students were 47.2, 31.6, and 21.3%, respectively, and PA < 3 d/w and PA ≥ 3 d/w accounted for 70.7 and 29.3%, respectively. Of all the college students, 27.2 and 20.5% consumed soda and tea beverages; 11.1 and 19.5% used Chinese herbal medicines and vitamins, respectively; and 13.7 and 15.6% consumed soda and tea beverages, respectively. Some reported worse sleep and diet rhythmicity than previous conditions. The higher the ST, the higher the depressive symptoms .A comparison of health behaviors among regional areas is shown in Table OR = 1.55, 95%CI:1.39–1.73) and anxiety symptoms  compared with daily ST ≤ 2 h/d. Daily 2–4 h/d of ST was negatively correlated with depression  and anxiety symptoms  compared with daily ST ≤ 2 h/d. After adjusting for confounding factors, compared with PA < 3 d/w, weekly PA ≥ 3 d/w was positively correlated with depression  and anxiety symptoms . The students who reported higher consumption of soda and tea beverages, use of Chinese herbal medicines and vitamins, and decreased meal frequency had higher depression and anxiety symptoms.As shown in Table Table In Tables As shown in Table OR = 3.58, 95% CI% = 3.0,4.27); depression: OR = 2.58, 95% CI% = 2.19,3.05); having perceived lower resistance to COVID-19 ; depression: OR = 3.15, 95% CI% = 2.60,3.81), and having family members or friends who had direct or indirect contact with confirmed cases . The same results were also shown for students with family or friends living with them who had any travel or residence history in Wuhan, practiced hand washing measures, suspected that they were infected with COVID-19, and sought psychological counseling.As shown in Fig. − 1 [This large study aim to examine lifestyle behaviors, coping style, COVID-19-related information, and mental health symptoms during the initial epidemic outbreak among college students in China. Our nationwide survey present several main findings. First, approximately half of the ST was more than 4 hours per day, only 21.3% had ST less than 2 hours per day. Simultaneously, some researchers have found the mean ST was 264 min/d in adults and the ST level was also higher , which w− 1 . There i− 1 . These d− 1 . Most pr− 1 , further− 1 . A total− 1 . Second,The COVID-19 pandemic has posed a severe threat to people’s health and daily life . It alsoSome previous studies have also found that high ST may be positively correlated with high level anxiety and depression; therefore, assessing sedentary based ST could also serve as an important factor in measuring health behaviors in young adults , 47. DurOur study also explored soda and tea beverage intake. Previous studies have suggested that SSBs can be linked to mental health problems in different age groups , 63. SomWe also explored the students’ meal frequency. We found that students who reported unchanged or increased meal frequency had better mental health, suggesting that in situations like COVID-19, proper timing of diet habits may be necessary to increase unnecessary panic attacks and negative symptoms .To better understand the effect of behaviors on mental health, we adopted a multiple health index, which aimed to explore possible comprehensive influences, including appetite, vigor, diet rhythmicity, SSBs, ST, and PA. It is well known that clustering of health behaviors is also found among students who engage in one lifestyle behavior and are more likely to engage in other lifestyle behaviors . The curIn this study, nearly 94.7% of students paid close attention to whether they had fever, cough, sneezing, fatigue, etc., and logistic regression showed that perceived physical symptoms  were significantly associated with higher anxiety and depression symptoms. A previous study has also shown that physical symptoms can significantly impact psychological responses , 70. PhyAccording to the results of the regional division at the beginning of the outbreak, the higher the unhealthy lifestyle behaviors of college students in high-risk areas, the higher the mental health symptoms of college students compared with those in the other three regions. The reason may be that college students in high-risk areas, who live locally, will pay close attention to the development of the epidemic, and therefore, they will have more unhealthy lifestyle behaviors, leading to more mental health symptoms , 18; ThiOur study has some limitations. First, this was a cross-sectional study, we could not establish a causal relationship between lifestyle behaviors and mental health outcomes. Second, lifestyle behaviors and mental health were self-reported, and because of the special epidemic situation, we could not meet with the students face to face; therefore, there might have been recall bias. Third, the mechanisms underlying the associations observed in the study have not been directly assessed. Finally, we have not obtain information on mental health conditions or lifestyle behaviors before the outbreak. We couldn’t compare screen time with changes in physical activity and sugary drinks in our own study.Despite these limitations, our study deserves further attention. Firstly, we have a large number of samples, which are representative to a certain extent. Our study includes different endemic areas, which can also be used to compare regional differences. Therefore schools and governments in different places can respond quickly. The second is to grasp the epidemic problems in time to provide some reference for the psychological research of domestic college students, especially the psychological factors research and intervention. Our study is a continuous follow-up study, and a follow-up investigation will be conducted every 6 months for up to 2 year, thus enabling further clarification of the relationship. Third, during the quarantine period, on the one hand, we paid close attention to the epidemic information concerned by college students through research and investigation, which was helpful for further targeted understanding of the adverse effects caused by the current situation of the epidemic. On the other hand, as a result of quarantine, people’s lives and movements have been restricted to different degrees, especially those who have had direct and indirect contact with confirmed cases, and may have different degrees of psychological impact during home quarantine. Therefore, this study takes this as a starting point to conduct a nationwide survey on college students’ mental health .Our study revealed that adopting healthy lifestyle behaviors and timely realization of related COVID-19-influenced factors were negatively associated with mental health. Compared to cities at high risk during the pandemic, the risk of mental health problems in other affected areas is relatively lower and still higher than before. The relevant government departments should also pay attention to the health education of college students with non-medical background and improve the awareness of COVID-19 among college students. These institutions should find methods of making related activities, such as decreasing ST and unhealthy diet patterns and increasing PA and rhythmic rhythm of life more attractive to college students, and increase the knowledge of popular science among this group during the epidemic. Thus, a better understanding of the relationship between healthy lifestyle behaviors and mental health of college students during the epidemic will help school leaders and the Ministry of Education to identify and adopt effective policies and interventions for college students during the outbreak stage, as well as timely control public opinion .Additional file 1: Table S1. List of all the participants. Table S2. The association between health behaviors and mental health among college students. Table S3. Mental health scores stratified by depression, anxiety symptoms. Table S4. The mediation effect of coping style on the relationship between lifestyle health behaviors and mental health symptoms in college students. Table S5. Model characteristics for the conditional process analysis. Table S6. Bootstrapped conditional direct and indirect effects. Fig. S1. The correlation between COVID-19 related related social stressors and mental health.


Papillary thyroid carcinoma is the most frequent endocrine neoplasia and its incidence has tripled over the past 35 years. Although papillary thyroid carcinoma carries a good prognosis, 10%−30% of patients still develop recurrence and metastasis. Some clinical and genetic features are associated with worse prognosis. The most frequent mutation is the BRAF p.V600E, which has been associated with many clinical features of poor prognosis. However, many studies have produced controversial results without any association between BRAF mutation and clinicopathological features of poor prognosis.Since the prognostic value of BRAF mutations remains controversial, this study aims to investigate the importance of this mutation in therapeutic decisions for papillary thyroid carcinoma.Therefore, we evaluated whether the presence of BRAF mutation is associated with features of poor prognosis in 85 patients with papillary thyroid carcinoma older than 45 years treated at A.C. Camargo Cancer Center, from 1980 to 2007. BRAF mutation was evaluated by pyrosequencing. Statistical analysis was performed using SPSS.p  = 0.743), age (p  = 0.236), N-stage (p  = 0.423), vascular and perineural infiltration . Although not statistically significant, the majority of patients with recurrent disease were BRAF positive (9 out of 11) (p  = 0.325). Patients affected by BRAF mutation are associated with tumors larger than 1 cm (p  = 0.034) and with extrathyroidal extension (p  = 0.033).The mean age of patients was 54 years (range: 45 − 77 years), 73 were women (85.8%) and 12 were men (14.2%). Among them, 39 cases (45.9%) presented extrathyroidal extension and 11 cases had recurrent disease. BRAF mutation was detected in 57 (67%) patients. No significant association was observed between BRAF mutation and gender (Although BRAF testing is widely available, there are no consistent data to support improvement in outcomes from incorporating it into therapeutic decision for thyroid cancer. Well-Differentiated Thyroid Carcinoma (DTC) is the most common endocrine malignancy; the incidence has triple over the last 35 years affecting more than 50.000 people in USA in 2018.3In general, PTC has a good prognosis with a 5 year survival rate over 90%, however, some patients are unresponsive to treatment and more accurate prognostic markers are not well established in clinical routine.BRAF mutations frequency ranges from 29%–87% in population (mean of 45%).12Several studies have reported a correlation of BRAF V600E with clinical and pathological features of more aggressive PTC, such as distant or nodal metastases, larger tumor size and advanced stage.However, a series of studies observed no association between BRAF mutation and clinicopathological markers of poor prognosis.This was a retrospective study with a review of patients submitted to total thyroidectomy between January 1980 and December 2007 at the Head and Neck and Otorhinolaryngology Department of AC Camargo Cancer Center (Brazil). We enrolled in this study 85 PTC samples available for DNA extraction from patients with ≥ 45 years. The study was approved by the Institutional Human Research Ethics Committee (Protocol # 1541/11).Clinical data was collected for each patient, including age, sex, risk factors for thyroid cancer and followup . Detection of persistent and recurrent disease was evaluated by ultrasound, serum thyroglobulin measurement in patients without anti-Tg antibodies (with or without rhTSH stimulation), 131I scan, and FNAB according to the ATA guidelines for follow-up .Surgical specimens were properly collected and stored in AC Camargo Cancer Center Tumor Bank, following all legal and ethical requirements. Fresh frozen samples from papillary thyroid carcinomas were obtained from 85 patients undergoing surgical resection. Samples were manually microdissected to achieve at least 70% malignant representation and DNA was extracted using a standard phenol/chloroform-based method. DNA integrity and concentration were verified in gel agarose and NanoDrop .Initially, the region of interest was amplified by PCR (codon 600 of BRAF) with 20 ng of DNA and 0.2 μM of labeled primers  (assay ADS871) and PCR MasterMix (Qiagen). Controls without template, a positive (colon cancer cell linage WiDr) and negative controls  were included in all runs. In order to confirm successful amplifications, the PCR products were electrophoresed in a 1% agarose gel. Pyrosequencing was carried out according to manufactures’ recommendations in PyroMark Q96 ID system . Exchange of nucleotide-T for A in codon 600 in more than 10% of alleles were assumed positive for mutation in BRAF.t-test was used to evaluate the association with continuous variables with normal distribution, whereas the Mann-Whitney U test was used for abnormal distributed continuous variables. Disease free survival curves were analyzed using the Kaplan-Meier method, assessing significance of the statistical difference between BRAF-positive and BRAF-negative patients with the log-rank test. Finally, Cox regression analysis of recurrence-free survival time was performed, including BRAF status and all variables associated with recurrence at the univariate analysis. Statistical significance was considered for p < 0.05, and confidence intervals were set at 95%. Statistical analysis was performed using SPSS  and Graphpad Prism  software.Association between BRAF mutation and categorical variables was tested with the X2 test or Fisher exact test as appropriate. The Student Among the 85 patients included on this study, 73 were women (85.8%) and 12 were men (14.2%). The mean age was 54 years  and 29 (34%) patients were older than 55 years. All tumors evaluated were papillary thyroid carcinoma: histological variant types were revised by the pathologist and 59 samples were classified as classical (69.4%), 19 were follicular (22.3%) and 6 were rare variant subtypes (8.3%). Extrathyroidal extension was present in 39 cases (45.9%), and vascular and perineural infiltration were detected in seven patients (8.2%). The majority of cases presented single nodules  and 42 (49.4%) patients had thyroid nodules smaller than 1 cm. Median followup period was 92 months.p =  0.743), neither age at diagnosis (p =  0.236). No significant association was observed between BRAF mutation and histologic variant (p =  0.075), N-stage (p =  0.423), vascular and perineural infiltration (p =  0.085), multifocality (p =  1.0) and lymph nodal metastasis (p =  0.423).BRAF mutation was detected in 57 (67%) of 85 patients, and the patients were classified in two groups according to BRAF V600E status (BRAF positive vs. negative) . Gender p =  0.034) and with extrathyroidal extension (p =  0.033). Recurrence of disease was detected in 11 of 85 (13%) patients, nine of them were positive for BRAF mutation. Recurrences were locally and regional in nine patients, whereas two had distant disease. The median followup of patients with recurrence was 34 months. All recurrences had pathologic confirmation (fine needle aspiration biopsy or surgery) or combined imaging and strong biochemical evidence. Although the majority of patients with recurrence were BRAF positive, no statistical significance was found (p =  0.325). Mean time to recurrence was 18 months . Kaplan-Meier analysis for specific disease survival showed no statistically significant association with BRAF mutation (p =  0.272) (Patients affected by BRAF mutation are associated with tumors of more than 1 cm (  0.272) .Figure 1Well-differentiated thyroid carcinomas derived from follicular epithelium are the most frequent carcinoma of endocrinology system and the predominant histological type is the papillary carcinoma, corresponding to 80%−90% of all DTC.24In order to investigate the potential prognostic value of BRAF mutation in Brazilian population, we associated the mutation status with several features of high recurrence risk, including age over 55 years, male gender, multifocality, extrathyroidal extension, histological type, vascular and lymphatic invasion, lymph node metastasis and distant metastasis. Several studies have reported an association between age and mortality rates according to BRAF mutation status.p  = 0.037). BRAF mutations were more prevalent in tumors larger than 1 cm, this association was also described by Li 2012 and Kim 2012.p =  0.423). The lack of correlation between this prognostic feature and BRAF was also observed by other studies. Pelttari et al. reported that BRAF mutation was not significantly associated with lymph node metastasis, tumor size and distant metastasis at the time of disease presentation.p =  0.089, p =  0.433, respectively).In this study, we could observe a significant difference between T-stages and BRAF mutation status (p  = 0.033), however, microscopic or macroscopic extension data are not available because this information was not evaluated at the time of surgical procedures. In addition, many studies have described association of BRAF mutation and multifocal tumors.p =  1.0).Extrathyroidal extension is an important feature of poor prognostic value for PTC and has been associated with increased risk of invasion into cervical structures, local recurrence, and persistence of tumor.p =  0.325), probably due the limited number of patients.Although the risk of recurrence in PTC is relatively low (5%−10%), it may affect the patient’s quality of life, requiring additional therapy, such as reoperation and high cumulative radioiodine dose. Several meta-analysis studies have found an association between BRAF mutation and recurrence.Although this study evaluated a small number of cases, our findings do not support the hypothesis of using the BRAF mutation as a prognostic factor for both disease recurrence and changing the surgical approach to perform prophylactic neck dissection in patients with positive mutation.The authors declare no conflicts of interest.


We hereby inform our readership of the retraction of the article “Méningiome chordoïde extra-axiale: à propos d´un cas” by Mohammed Guini, Mohammed Khoulali, Nabil Raouzi, Noureddine Oulali, and Fayçal Moufid, published in the Pan African Medical Journal 2021;38: 123 (doi: 10.11604/pamj.2021.38.123.20437). Access retracted manuscriptFollowing a complaint of article theft, our investigation concluded that Mohammed Guini, Mohammed Khoulali, Nabil Raouzi, Noureddine Oulali, and Fayçal Moufid are not the real authors of this article. None of them contributed to the management of the patient or wrote the article. This retraction complies with our policy on publishing ethics and integrity and the Committee on Publication Ethics (COPE) guidelines. The retracted article will remain online to maintain the scholarly record, but it will be digitally watermarked on each page as “Retracted”. The PAMJ regrets that this grave violation was not identified before publication and sincerely apologizes to the scientific community.


Identifying the clustering and correlates of physical activity (PA) and sedentary behavior (SB) is very important for developing appropriate lifestyle interventions for children and adolescents. This systematic review (Prospero CRD42018094826) aimed to identify PA and SB cluster patterns and their correlates among boys and girls (0–19 years). The search was carried out in five electronic databases. Cluster characteristics were extracted in accordance with authors’ descriptions by two independent reviewers and a third resolved any disagreements. Seventeen studies met the inclusion criteria and the population age ranged from six to 18 years old. Nine, twelve, and ten cluster types were identified for mixed-sex samples, boys, and girls, respectively. While girls were in clusters characterized by “Low PA Low SB” and “Low PA High SB”, the majority of boys were in clusters defined by “High PA High SB” and “High PA Low SB”. Few associations were found between sociodemographic variables and all cluster types. Boys and girls in “High PA High SB” clusters had higher BMI and obesity in most of the tested associations. In contrast, those in the “High PA Low SB” clusters presented lower BMI, waist circumference, and overweight and obesity. Different cluster patterns of PA and SB were observed in boys and girls. However, in both sexes, a better adiposity profile was found among children and adolescents in “High PA Low SB” clusters. Our results suggest that it is not enough to increase PA to manage the adiposity correlates, it is also necessary to reduce SB in this population.The online version contains supplementary material available at 10.1186/s12889-022-14869-0. Clustering among physical activity (PA) and sedentary behavior (SB) have been linked to important health outcomes  –4. PA anRecent studies have shown that low levels of PA combined with excessive time spent in SB occur repeatedly in children and adolescents –11. PrevThese clusters with distinct characteristics may also correspond to correlates in different ways. Thus, the association between clusters and different sociodemographic, mental and physical health have been explored in children and adolescents , 14, 18.Given the complex inter-relationships summarized above, there is a need to (i) map the characteristics of PA and SB cluster patterns among boys and girls according to the methodological quality of studies; (ii) describe which clusters are most prevalent by sex; and (iii) examine the range of correlates that have been explored. This is necessary because previous reviews on cluster patterns were either not systematic , employeThe aim of the present study is therefore to review systematically the literature that has investigated the clustering patterns of PA and SB in children and adolescents. In particular, we aimed to verify if clusters differ according to sex, and to identify their potential correlates.This systematic review used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) , 31 and Studies were included if they met the following eligibility criteria: (a) included children and/or adolescents ; (b) analyzed simultaneously PA and SB); c) applied exploratory data-based statistical procedures, considering cluster analysis , latent Class/Profile Analysis, and dimensionality reduction techniques ; and (d) be published in English, Portuguese, or Spanish. All correlates reported in the included studies were extracted. Studies were excluded if they involved clinical populations , or included other behaviors or variables  as part of the cluster patterns. Reviews, letters to editor, and conference abstracts were excluded. All studies designs were considered for inclusion. More information about the eligibility criteria can be observed in Supplementary material Table SThe search strategies used five electronic databases  and were carried out in December 2019. Particularities strategy and Boolean operators and truncation symbols  were considered and no restrictions of publication year and study design were applied. The search string can be observed in Supplementary material Table S.Firstly, the titles and abstracts were screened independently by the authors of the first review (GTM/RMC and GTM/MVVL). If the relevance of an article was unclear, it was retained for full text screening by the same peers. Reference lists of included studies and previous reviews were examined as additional searches (RMC and MVVL). More information can be observed in Fig. The methodological quality of the included studies was assessed by the 17-point adapted version of the Quality Assessment Tool for Quantitative Studies of Effective Public Health Practice Project (EPHPP) , in fourData were extracted by (GTM/CB) and discrepancies were resolved by a third person (GM). Extraction elements included: (1) article description ; (2) instruments used to measure PA and SB; behaviors domain and components ; (3) variables used to determine clusters (i.e. cluster input variables) and the resulting cluster types according to mixed-sex samples, boys, girls, children, and adolescents; and (4) all correlates examined and their direction of association.Instruments used to measure PA and SB were classified as: 1) Defined ; 2) Undefined (reported question and/or response option and instrument reference); (3) Undefined-Reproducible (reported question and response options but did not mention the reference); (4) Objective measurement ;  Distinctions in measurements and indicator types of PA and SB; 2) Variability of algorithms used in distinct data-based cluster statistical procedures; and, 3) The different clusters types identified.The results were organized according to the SWiM as follow: a) study characteristics and its risk of bias Table ; b) instThe searches resulted in 11,912 potentially relevant titles, of which 17 (11 from different data set) were identified and included in the review , ranging from 5.9% to 64.7%. Only three studies , 23, 37 n = 11) [n = 13) [The classification of the instruments used to measure PA and SB is available in Table n = 11) , 41, 42,[n = 13) , 38–42. [n = 13) , 38–42 w[n = 13)  study us[n = 13) , 37 usedn = 11 articles [n = 6 articles) [n = 3 articles) [The most used variables for PA were Weekly PA ,rticles) , 25, 35 rticles) , 34, 40.rticles) , 35, 37 rticles) , 37 artirticles) , 25, 39 rticles)  used Musn = 10 studies) [n = 9 studies) [n = 9 studies) [n = 7 studies) [n = 4) [n = 1) [n = 3) [n = 3) [n = 2) [For SB, Weekly Computer Time was the most used variable (studies) , 41, 42 studies) , 41, 42,studies) , 41, 42,studies) , 40–42.  [n = 4) , 41, 42, [n = 1) , Daily T [n = 3) , 16, 26, [n = 3) , 16, 26  [n = 2) , 40. Fin [n = 2) ), Daily  [n = 2) , Daily V [n = 2)  were alsn = 11) [n = 3) [n = 2) [n = 1) [Studies included up to 16 input summary variables in cluster analysis. As presented in Table n = 11) –39, 41 w [n = 3) , 26, 40, [n = 2) , 42 and, [n = 1) . A descr [n = 1) , 37, “Lo [n = 1) , and “Lo [n = 1) .n = 5 studies) [n = 4 studies) and “High PA High SB” (n = 3 studies). Otherwise, the most prevalent cluster types for whole samples were “Low PA Low SB” and “Low PA High/Low SB” and, highlighting that these was the clusters most prevalent in adolescents.Nine cluster types were identified for whole samples (i.e. boys and girls combined) (studies) , 39, 42,n = 12), twelve clusters were identified for boys and ten for girls. The most frequently cluster identified in boys was “High PA High SB” (n = 8 studies) and “Low PA Low SB” (n = 8 studies). Most prevalent cluster among boys were “High PA High SB”, “High PA Low SB”, and Low PA and Low SB. Girls’ most frequently clusters were “Low PA Low SB” (n = 8 studies), “Low PA High SB” (n = 6 studies), and ‘High PA Low SB” (n = 6 studies). Otherwise, the most prevalent clusters were “Low PA Low SB”, “Low PA High SB” and “High PA High SB”. Only one study was realized in children and procedure cluster analysis according to sex, the most prevalent cluster in both sexes were characterized by “Low PA Low SB”.From studies that evaluated clusters according to sex ; “High PA High SB cluster” vs obesity (positive); “High PA Low SB cluster” vs BMI and waist circumference (negative); “Low PA High SB cluster” vs obesity/overweight (positive); vs age and socioeconomic status/poverty (differs); “Low PA Low SB cluster” vs obesity (positive); vs age (differs); and “Low PA High/Low SB cluster” vs overweight (positive); vs age and socioeconomic status/poverty (differs).This systematic review sought to provide comprehensive and up to date evidence on the clustering of SB and PA according to sex (identified using exploratory data-based methods) and their potential correlates. Nine, twelve and ten cluster types were identified for whole samples, boys, and girls, respectively. Boys were mostly allocated to the “High PA/High SB” clusters and girls to the “Low PA Low SB” clusters. Moreover, boys were more likely to accumulate time watching television time, using computer, and playing videogame and girls dedicate more time to paid work or housework , 36, 41.The risk of bias assessment identified methodological weaknesses in the studies, especially for the domains of sample selection and for withdrawal and dropouts. Few studies included samples representative of the target population, or were impacted by participant dropouts. Further, the number of participants who completed the study was often poorly reported across the studies. Having information on study response and dropout rates, as well as their reasons and the participant characteristics, allows a better interpretation of the results and the potential impact of selection bias. Future studies on clustering should therefore report the process of selection of participants, withdrawals and dropouts in a more comprehensive way.Several cluster types with distinct combinations were identified for children and adolescents, and more than 70% of clusters included one negative behavior, corroborating with previous literature , 12, 43.The predominance of unhealthy profiles in youths have been constantly reported in the literature , 14, 43 In relation to the correlates of clusters, most studies included in this review evaluated adiposity indicators , 38, 40 This was the first study to systematically review the clustering of PA and SB, and their associations with a comprehensive range of health correlates, in mixed-sex samples, and in boys and girls, separately. The search strategies were developed based on suggestion of experts on the theme which enabled the identification of many potential studies. This study also was able to identify and describe the behavior variables used to determine clusters. All these points advance the evidence base on clustering because previous reviews on cluster patterns were either not systematic , employeThe findings of this review have implications for future research examining the clustering of PA and SB. First, we emphasize that more studies examining clustering of PA and SB using data-driven exploratory methods should be conducted in children and adolescent populations from lower income countries, as none were found in this review and cluster types have been shown to differ according to socioeconomics variables , 54. SecWe highlight that meta-analysis was not performed due to heterogeneity in measurements, analysis used and clusters types observed between studies. In order to conduct a meta-analysis, the cluster indicators and algorithms used in the clustering procedures would need to be standardized.In summary, the majority of cluster types had at least one unhealthy behavior in PA or SB indicators. Clusters differ in SB components in the profiles between boys and girls and high proportion of boys were allocated in cluster characterized by high PA. These demonstrate that different preventive approaches, tailored to boys and girls, need to be considered to improve children and adolescent lifestyles. Predominantly, clusters were associated with sociodemographic and adiposity correlates. Therefore, a better understanding of the modifiable correlates associated with PA and SB cluster types is needed to plan effective policies and interventions to improve youth lifestyles and subsequent health and wellbeing, and to develop guidelines considering simultaneously between behaviors once they together contribute to unhealthier health correlates.Additional file 1:Table S1. Prisma Checklist. Table S2. SWiM checklist. Table S3. Eligibility criteria. Table S4. Search of all strategy. Table S5. Adapted version of the Quality Assessment Tool for Quantitative Studies of Effective Public Health Practice Project (EPHPP). Table S6. Assessment of the bias risk of studies. Table S7. Clusters variables details before authors classifications. Figure S1. Instrument used and questionnaires classification according to each behavior. Table S8. Clusters detail.