Little is known about whether people who use both tobacco and cannabis (co-use) are more or less likely to have mental health disorders than single substance users or non-users. We aimed to examine associations between use of tobacco and/or cannabis with anxiety and depression.We analyzed data from the COVID-19 Citizen Science Study, a digital cohort study, collected via online surveys during 2020–2022 from a convenience sample of 53,843 US adults (≥ 18 years old) nationwide. Past 30-day use of tobacco and cannabis was self-reported at baseline and categorized into four exclusive patterns: tobacco-only use, cannabis-only use, co-use of both substances, and non-use. Anxiety and depression were repeatedly measured in monthly surveys. To account for multiple assessments of mental health outcomes within a participant, we used Generalized Estimating Equations to examine associations between the patterns of tobacco and cannabis use with each outcome.Anxiety: OR = 1.89, 95%CI = 1.64–2.18; Depression: OR = 1.77, 95%CI = 1.46–2.16), followed by cannabis-only use, and tobacco-only use. Compared to tobacco-only use, co-use  and cannabis-only use  were associated with higher adjusted odds for anxiety, but not for depression. Daily use (vs. non-daily use) of cigarettes, e-cigarettes, and cannabis were associated with higher adjusted odds for anxiety and depression.In the total sample , 4.9% reported tobacco-only use, 6.9% cannabis-only use, 1.6% co-use, and 86.6% non-use. Proportions of reporting anxiety and depression were highest for the co-use group  and lowest for the non-use group . Compared to non-use, the adjusted odds of mental health disorders were highest for co-use (Use of tobacco and/or cannabis, particularly co-use of both substances, were associated with poor mental health. Integrating mental health support with tobacco and cannabis cessation may address this co-morbidity. Tobacco and cannabis are among the most commonly used substances worldwide. In the U.S., 22.1% of adults reported using tobacco and 12.4% using cannabis in the past month in 2020 . Amid thUse of either tobacco or cannabis are related to poor mental health –14 with To date, previous research has predominantly examined the association of mental health with use of either tobacco or cannabis. Lacking are studies examining the association between co-use of both substances and mental health. The important gap to address is that whether people who use both substances are more or less likely to have mental health disorders than those who use single substances or neither of these substances. A study in the UK showed that people who used both tobacco and cannabis reported the highest prevalence of mental health treatment compared to those using single substances or not using these substances . LikewisTo address this gap, we analyzed a large dataset from an online cohort of US adults collected during 2020–2022, the COVID-19 Citizen Science Study (CSS) , leveraghttps://covid19.eurekaplatform.org/) [This study analyzed data from the CCS study, a longitudinal cohort study hosted on the Eureka research digital platform (rm.org/) . The CCSThis entirely digital study is hosted on Eureka, a digital research platform that produces mobile applications for clinical research built by investigators and developers at the University of California, San Francisco (UCSF). The Eureka platform is available to anyone who wants to conduct medical or health-related research, including university or other non-profit investigators, industry investigators or others. The app’s elements  can be customized for individual studies. In January 2021, a web version of the CCS study was launched to enable participation options for people without a mobile phone or with concerns about downloading an app.Using a convenience sampling method, participants were recruited through multiple channels, including email invitations to participants in other studies using the Eureka platform, press releases, word-of- mouth, social media sharing, and recruitment through partner organizations nationwide. Participants must be 18 years or older, agree to participate in English, provide consent, and register for a Eureka account. Participants were asked to complete baseline, daily, weekly, and monthly surveys about demographics, medical conditions, medications, and behaviors through the study app or website. Use of tobacco and cannabis was measured only once at baseline, while mental health was measured repeatedly in monthly surveys. There were no monetary incentives for participation in the study. Retention strategies include daily notifications, data visualizations, and intermittent study update blog posts. More details about the study procedures have been described elsewhere .For this analysis, we included data collected between March 2020 (when the CCS study started) and April 2022 . Of 87,984 US participants who completed the baseline survey and provided data on tobacco and cannabis use, 53,843 participants (response rate of 61.2%) who completed at least one monthly survey on mental health were included in this analysis. The study duration for the participants ranged from 1–25 months, with an average length of follow-up of 8.5 ± 6.6 months. Results are reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.All participants provided informed written consent via a dedicated research mobile application to participate in the study. The CCS study was approved by the UCSF Institutional Review Board (IRB #17–21879).Participants were asked about their mental health repeatedly in monthly surveys, and thus, there were multiple assessments of mental health outcomes nested within a participant. While anxiety and depression symptoms frequently co-occur, they have differing but independent effects on functional impairment and disability . Thus, wAnxiety was measured by the 7-item Generalized Anxiety Disorder scale (GAD-7), a brief and validated screening measure for anxiety symptoms used in both clinical and community samples . The GADDepression was measured by the 8-item Patient Health Questionnaire (PHQ-8), a brief and validated screening tool for a major depression episode within the past two weeks . ResponsUse of tobacco and use of cannabis were reported separately in the baseline survey. Participants reported number of days they had used each tobacco product  and number of days they had used any combustible or vaporized cannabis products during the past 30 days. Those reporting 0 days were classified as non-use of tobacco or cannabis. Those reporting 30 days were classified as daily use of a product. Based on their responses, participants were categorized into four groups: tobacco-only use, cannabis-only use, co-use (using both substances in the past 30 days), and non-use of either substance. These groups were created to investigate any potential independent effects of single substance use and joint effects of co-use on mental health disorders.On average, how often have you exercised (enough to breathe heavily and/or sweat) over the past year?” with answer options ranging from “Never of rarely” to “4 or more times a week.” Participants also reported number of alcohol drinks they consumed in the past week. Physical activity and alcohol use were coded as continuous variables, corresponding to greater frequency of physical activity and alcohol consumption.Demographic characteristics and other covariates were collected at baseline. Age at registration was self-reported. Sex assigned at birth was self-reported as male and female. Gender identity was dichotomized into “cisgender”  and “transgender and non-binary gender” . Race and ethnicity were measured by combining two items: race  and ethnicity (Hispanic or not). Responses were categorized into Hispanic, non-Hispanic White, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic Other. Participants reported educational attainment in categories; the variable was recoded into “High school or less,” “Some college or college graduate,” “Postgraduate,” and “Other/Unknown.” Subjective social status was measured by the MacArthur Scale using a 1–10 stepladder with higher score indicating one’s higher perceived status in the social hierarchy . ParticiData were analyzed using STATA 15.0 . Participant characteristics were summarized for the total sample and for each pattern of tobacco and cannabis use. ANOVA tests were used to compare means for continuous variables across patterns of tobacco and cannabis use, nonparametric median tests were used to compare medians for non-normally distributed variables, and chi-square tests were used to compare proportions for categorical variables.To examine the associations between the patterns of tobacco and cannabis use  and mental health outcomes (the binary outcomes), we fit Generalized Estimating Equations (GEE) models to account for the nesting of multiple monthly assessments of anxiety and depression within each participant . ParticiWe also conducted several sensitivity analyses. First, we ran linear mixed-effects models for continuous mental health outcomes  with the four patterns of tobacco and cannabis use. We then checked dose-response relationships by running linear mixed-effects models with continuous independent variables for tobacco and cannabis use  and continuous mental health outcomes .Participants’ baseline characteristics are described in Anxiety: OR 1.89, 95% CI 1.64–2.18; Depression: OR 1.77, 95% CI 1.46–2.16), followed by cannabis-only use , and tobacco-only use .Results from the GEE models are presented in , but not for depression . Likewise, cannabis-only use was associated with higher adjusted odds for anxiety , but not for depression  compared to tobacco-only use. However, there were no significant differences between co-use and cannabis-only use .Compared to tobacco-only use, co-use was associated with higher adjusted odds for anxiety Several covariates were significantly associated with mental health outcomes. Young adults aged 18–29 years (vs. older age), females , and transgender and non-binary gender participants (vs. cisgender peers) had higher odds of reporting anxiety and depression. Conversely, covariates associated with lower odds of having mental health disorders were being non-Hispanic Black, non-Hispanic Asian, or non-Hispanic Other (vs. non-Hispanic White), perceiving higher subjective social status, or having greater frequency of physical activity. Reporting greater alcohol consumption was associated with slightly higher odds of anxiety, but not depression. Across the study years, the odds of reporting anxiety and depression were lower in 2021 and 2020 compared to those in 2020. and e-cigarettes  were associated with higher odds of both anxiety and depression. However, the associations between daily use of other combustible tobacco products and the mental health outcomes were not statistically significant. Daily use of cannabis (vs. non-daily use) was associated with higher odds of anxiety  and depression .Results of the sensitivity analyses were very similar to those of the primary analyses. Compared to non-use, co-use was associated with the highest scores of GAD-7 and PHQ-8, followed by cannabis-only use, and tobacco-only use . Co-use This study examined the extent to which different patterns of tobacco and cannabis use are associated with mental health disorders among US adults enrolled in a digital cohort study. As hypothesized, we found that use of tobacco and/or cannabis was positively associated with self-reported anxiety and depression. Notably, co-use was associated with higher odds of anxiety when compared to tobacco-only use, but not different from cannabis-only use. We also found that daily use of cigarettes, e-cigarettes, and cannabis were associated with the increased odds of reporting anxiety and depression. To our knowledge, this is the first study among the US adult population to evaluate the association of mental health with four mutually exclusive patterns of tobacco and cannabis use, with a focus on co-use of both substances.Consistent with prior studies ,30, our Compared to single substance use, the odds of anxiety for co-use were higher than those for tobacco-only use, but were not significantly different from cannabis-only use. While these findings are suggestive of an additive effect of cannabis use on mental health among people who use tobacco, an additive effect of tobacco use among those who use cannabis use was not certain. This may be related to the large proportion of cannabis-only use in our sample. Indeed, 80.6% of our participants with past 30-day cannabis use reported using cannabis-only, while this proportion was only 8.4% in a population-based sample . It shouIn addition, we found that lower frequency of physical activity was associated with higher odds of anxiety and depression. A review indicates that both tobacco use and low physical activity are lifestyle risk factors for mental health . It shouAs this study is conducted from early (2020) to later periods (2022) in the COVID-19 pandemic, we also found that the odds of reporting anxiety and depression were lower in later years than in 2020. This finding could be partly explained by unprecedented stress, economic hardship, lockdowns, and social isolation early in the pandemic ,42.Our study has implications for clinical practice and public health efforts. The observed associations between use of tobacco and/or cannabis and anxiety and depression call for more attention to the comorbidity of substance use and mental health. This comorbidity is particularly concerning among those who use both tobacco and cannabis. Increased vulnerability to poor mental health in the co-use group may impede successful cessation from tobacco and cannabis . FurtherAs tobacco and cannabis use are common among people with mental health issues, screening for use of tobacco and cannabis should be a priority in mental health treatment settings. In California, universal screening for tobacco use in substance use treatment settings was signed into law in 2021 . In regaFurthermore, despite insufficient evidence regarding therapeutic benefits of cannabis, nearly half of US adults view cannabis as self-medication for treating depression and anxiety symptoms . SimilarThis study has several limitations. As aforementioned, the causal relationships between patterns of tobacco and cannabis use and mental health disorders cannot be elucidated given the study design. Since use of tobacco and cannabis was measured only once at baseline, we could not examine potential effects of changes in substance use on mental health. Longitudinal studies using repeated measures of both substance use and mental health over time are needed to uncover causal and dynamic relationships. Our digital cohort recruited via a convenience sampling method which, although allowing for a large sample size and facilitating data collection during the COVID-19 pandemic, may limit the findings’ generalizability. Since our sample is not a nationally representative population-based sample, cautions should be taken in interpreting the findings to other samples. Of note, we only asked about use of combustible or vaporized cannabis products, and thus, findings may not generalize to other modes of consumption. Self-reported data and non-respondents may be subject to bias. Data on nicotine and cannabis dependence and the purpose of cannabis use  were not collected; thus, we could not examine potential impacts of these factors on mental health.This study provided recent data on positive associations of the mutually exclusive patterns of tobacco and cannabis use with mental health, with a focus on co-use of both substances among US adults. Co-use of tobacco and cannabis and use of cannabis-only were associated with higher odds of anxiety and depression compared to non-use and tobacco-only use. Tobacco-only use was associated with higher odds of anxiety and depression compared to non-use. The findings suggest that coordinating tobacco and cannabis cessation with mental health treatment may be beneficial to address these comorbidities. Specifically, providing mental health support and addressing polysubstance use  among individuals with co-use are needed to facilitate successful cessation from tobacco and cannabis.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Dataset(CSV)Click here for additional data file.


Coronary artery disease (CAD) is a common finding in patients suffering from aortic valve stenosis (AS), with a prevalence of over 50% in patients 70 years of age or older. Transcatheter aortic valve intervention (TAVI) is the standard treatment option for patients with severe AS and at least 75 years of age. Current guidelines recommend percutaneous coronary intervention (PCI) in patients planned for TAVI with stenoses of >70% in the proximal segments of non-left main coronary arteries and in >50% of left main stenoses. While the guidelines on myocardial revascularization clearly recommend functional assessment of coronary artery stenoses of less than 90% in the absence of non-invasive ischemia testing, a statement regarding invasive functional testing in AS patients with concomitant CAD is lacking in the recently published guideline on the management of valvular heart disease. This review aims to provide an overview of the hemodynamic background in AS patients, discusses and summarizes the current evidence of invasive functional testing in patients with severe AS, and gives a future perspective on the ongoing trials on that topic. In pati present . ConversWhile the current guideline for chronic coronary syndrome recommends invasive functional evaluation in all cases of coronary stenoses that do not exceed 90% in the absence of non-invasive ischemia testing , a stateThe aim of this review is to provide an overview of the hemodynamic pathophysiology in AS patients, to summarize the available evidence on functional evaluation in coronary arteries in these patients, both with hyperemic and non-hyperemic indices, and to present a future perspective on ongoing trials dealing with this topic.It is widely known that the mere angiographic assessment of coronary artery stenosis cannot predict its functional impact on coronary perfusion ,11. TherAs adenosine has potential side effects, such as bradycardia, chest discomfort, and/or dyspnea, in more recent years, non-hyperemic pressure indices for functional assessment of coronary artery stenoses were introduced to overcome this issue. The instantaneous wave-free ratio (iFR) is a pressure-derived invasive index parameter registering the pressure in the so-called “wave-free” period during diastole. During this period, coronary microvascular resistance is lowest, and coronary flow and pressure are linearly related . The optCoronary flow reserve (CFR) is defined as the ratio of coronary flow under maximal vasodilation divided by coronary flow during resting conditions  and reflThe index of microvascular resistance (IMR) is derived from the pressure measured at the distal part of the coronary artery divided by flow. Based on studies measuring IMR in a healthy study population, the normal value is below 25 ,24,25. IIn patients with severe aortic stenosis, left ventricular (LV) afterload is typically increased due to the diminished aortic valve area, leading to elevated LV wall stress. As afterload is defined as the product of LV pressure and LV radius divided by LV wall thickness, concentric myocardial hypertrophy is the key mechanism to compensate for the pressure overload and hence increased afterload by normalizing LV wall stress and preserving cardiac output and LV ejection fraction ,27,28. HThe immediate repair of AS by TAVI leads to an acute reduction of afterload and hence LV wall stress with subsequent decompression, especially of the subendocardial vasculature. Several studies investigated the acute changes in coronary hemodynamics in patients with AS immediately after TAVI, both in the presence and absence of CAD. However, these studies yielded conflicting results. Wiegernick et al. assessed intracoronary pressures and flow velocities using the Doppler-derived method in 27 AS patients before and directly after TAVI and compared them with 28 controls without AS . The meap = 0.41), although, at the 12-month follow-up, a significant increase in CFR was detected  [Conversely, Camuglia et al. did not find an improvement in CFR assessed immediately after TAVI via a Doppler-tipped coronary wire in ten patients with high-grade AS with no relevant CAD on visual assessment : The mean change in CFR immediately post-TAVI vs. pre-TAVI was 0.045  . Stoller < 0.01) . Twenty- < 0.01) . In cont < 0.01) .p < 0.001) [In a recently published study, Wada et al. performed serial Doppler-derived measurements (via echocardiography) of CFR before TAVI, one day after TAVI, and at the 12-month follow-up in 59 patients with severe AS . While C< 0.001) . The med< 0.001) . These r< 0.001) .Vendrik et al. investigated resting and hyperemic coronary flow velocities via an invasive Doppler-based approach in 13 AS patients pre-TAVI, immediately after TAVI, and at a six-month follow-up . Like WaIn summary, the majority of studies investigating the effect of TAVI on coronary hemodynamics found an immediate improvement in CFR due to increased hyperemic flow, while the resting flow remained unchanged. This finding was even more pronounced after a certain amount of time had passed, most likely due to regression of LV hypertrophy and the accompanying morphological changes, such as extravascular decompression of the subendocardial microvasculature and remodeling processes. As a limitation, all studies have in common that the sample sizes were small and that a comparison with a matched control cohort was seldom performed. Thus, the results must be interpreted with caution.The current European guidelines recommend invasive functional assessment of coronary artery stenoses below 90% with a class IA grading in the absence of non-invasive testing for ischemia . This rep < 0.001 for all comparisons). This decline was primarily due to increased hyperemic coronary flow velocities and underscores that the vasodilatory capacity of the microvasculature improves in the short term, most probably due to the immediate reduction of afterload right after TAVI, and in the long term, most likely as a result of LV hypertrophy regression and favorable LV remodeling, which is usually a process lasting weeks to months after aortic valve replacement [p = 0.0008). This effect was due to the fact that hyperemic systolic flow increased significantly post-TAVI [With this pathophysiology as a background, the study by Vendrik et al. mentioned above assessed FFR and iFR in the cohort of 13 patients with intermediate- to high-grade coronary stenoses . FFR vallacement . The limlacement . They alost-TAVI . Pesarinost-TAVI . Overallost-TAVI . Similarost-TAVI . In 12 oost-TAVI . In a reost-TAVI . LimitatIn summary, the majority of studies investigating FFR changes in AS patients after TAVI show a decline in FFR values immediately after TAVI that is further aggravated months after TAVI. From a clinical standpoint, these findings indicate that FFR measurements of intermediate coronary artery stenoses should be performed preferentially after TAVI, ideally after a certain period of time when regression of LV hypertrophy has occurred, especially in lesions with borderline significance.p = 0.66), there were wide individual variations in the values that led to a crossing of the threshold of 0.89 in 15% of lesions and hence a change in the treatment decision, especially in patients with more severe aortic valve gradients and higher transaortic pressure drops after TAVI [p = 0.011) [p < 0.001), and, conversely, for iFR to detect lesions with an FFR ≤ 0.80 this was 0.995  [In several studies, invasive functional assessment of moderate or severe epicardial stenoses was performed, and the changes pre- vs. post-TAVI in non-hyperemic indices were compared with the gold-standard FFR ,49,53. Iter TAVI . Similarter TAVI . While F= 0.011) . In a st< 0.001) . However< 0.001) .In summary, studies indicate that iFR values are less affected by TAVI than FFR measurements due to the mostly unaltered flow during the diastolic wave-free period before and after TAVI. The validity of the iFR cut-off of 0.89, however, remains controversial, as compared with both the gold-standard FFR and non-invasive ischemia testing, more false-positive lesions were detected that could potentially result in unnecessary coronary interventions. Even the usefulness of the standard cut-off value of FFR in the setting of AS has to be discussed, as several studies indicate that hyperemic flow is attenuated, leading to higher and, thus, potentially false-negative FFR values. Of note, all studies have in common that the sample sizes were small, and the extent of concomitant CAD differed across the studies.Our current knowledge of the role of invasive functional testing with either hyperemic or non-hyperemic pressure indices in AS patients with concomitant CAD before and after TAVI is based on retrospective, observational analyses of small numbers of patients. Therefore, the conclusions drawn from these studies are mainly hypothesis-generating. In order to adequately address issues such as the validity of the conventional cut-off values of FFR and iFR in AS patients, the effect of these cut-off values on outcome in AS patients undergoing TAVI, and the best timepoint for invasive functional evaluation of CAD in AS patients, larger-scaled studies carried out in a prospective, randomized fashion are urgently needed.Currently, there are several ongoing trials addressing the aforementioned topics that will hopefully provide answers to these unresolved questions in the future. One such trial is the FAITAVI study (NCT03360591), a prospective, randomized, open-label, multicenter trial with planned enrollment of 320 AS patients undergoing TAVI that will compare an angiography-guided vs. a physiology-guided PCI strategy (both FFR and iFR) with regard to 12-month primary outcome . Additionally, in a post-hoc analysis, different iFR cut-off values are planned to be compared with the standard cut-off of 0.80 in FFR measurements in terms of the same endpoints. The NOTION-3 (NCT0305862) trial is designed to compare TAVI only vs. TAVI + FFR-guided PCI with regard to the primary endpoints all-cause mortality, myocardial infarction, or urgent revascularization within a 12-month follow-up with a planned recruitment of 454 participants. The TAVI-PCI trial (NCT04310046) will investigate differences between a complete revascularization strategy via PCI before and after TAVI in stenoses >90% or with a pathological iFR measurement in terms of the primary outcome measures all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, rehospitalization , and life-threatening/disabling or major bleeding (according to VARC-2). Of note, in the “PCI after TAVI” arm, iFR measurements are made both before and after TAVI and before PCI.


This vaccine induced broad- spectrum neutralizing antibodies and fully protected mice and non-human primates against challenge with live Delta and Omicron virus.He et al. recently reported in Nature CommunicationsEmergence of SARS-CoV-2 variants of concern, especially Omicron, has resulted in an important number of breakthrough infections that may allow viral transmission and generation of new variants. Although initially described as less pathogenic, Omicron has demonstrated an infectious capacity higher than other previous variants. Moreover, sera from vaccinated and convalescent individuals show a poorer recognition capacity against Omicron, due to mutations located at relevant neutralization-associated epitopes. Therefore, development of vaccination strategies affording protection against Omicron is of paramount importance.With this aim, He et al. recently reported data obtained using a recombinant vaccine based on a trimeric RBD denominated RBD-HR/trimer. The RBD-HR/trimer protein is a typically structure-guided design of a vaccine antigen. It is only composed of the SARS-CoV-2 RBD and HR sequences, and successfully trimerizes RBD without introducing any non-SARS-CoV-2 viral sequences, reserving the native conformation, and readily interacting with the ACE2 receptor. This is important since exogenous sequences in the design could complicate the potential clinical use. Multimeric subunit vaccines have demonstrated superior immunogenicity, therefore, they designed an immunogen with the RBD fused to the heptad-repeat sequences 1 and 2 (HR1 and HR2), that would allow assembling the proteins in a bouquet-like trimeric structure. Moreover, besides providing these structural features without introducing foreign elements, HRs are well conserved between SARS-CoV-2 variants and have been described as targets for neutralizing antibodies. With this structure, He et al. designed a vaccine with RDB sequence obtained from the Delta variant. Previous results had indicated a lower immunogenicity of Omicron-derived vaccines, prompting here the use of Delta as a more immunogenic variant that shares some mutations with Omicron.Immunization of mice with RBD-HR/trimer vaccine induced antibodies that neutralized pseudovirus and authentic SARS-CoV-2 virus belonging to different variants, including Omicron, at equivalent neutralization levels. Interestingly a three-dose immunization regimen with RBD-HR/trimer or two doses of mRNA plus RBD-HR/trimer induced a superior neutralizing activity than three doses of an mRNA vaccine, suggesting that RBD-HR/trimer could be a suitable booster for individuals previously vaccinated with mRNA vaccines. As for the broad neutralizing capacity of antibodies induced by RBD-HR/trimer, especially recognition of Omicron, authors demonstrate that it is facilitated by inclusion of L452R and T478K mutations, presumably by increasing antigenicity of the vaccine. This potent humoral immunogenicity was accompanied by the induction of strong CD8 and CD4 T cell responses, including memory cells and T follicular helper cells, known to facilitate antibody induction. Finally, in vivo protection assays showed that mice vaccinated with RBD-HR/trimer had undetectable viral load at different organs, associated with normal histological features and lack of inflammation. Similarly, vaccination of non-human primates induced potent neutralizing antibodies against different viruses and protected these animals from infection with a live Delta variant virus.3 demonstrating a superior immunogenicity. All these conformations seek to resemble the natural structure found in the SARS-CoV-2 virion, allowing induction of antibodies with higher affinity for the targeted epitopes. A better epitope exposure and a higher Ag receptor cross-linking and signaling have been proposed as mechanisms accounting for this enhanced immunogenicity. However, in addition to this common feature, antigen size (full S or RBD-based immunogens) may dictate differences between these constructs narrowing the epitope repertoire. Considering neutralizing and non-neutralizing antibodies and, although it is difficult to compare their efficacy due to lack of side-by-side studies and to differences in schedules, dose, adjuvants, etc., smaller immunogens are designed to focus on neutralizing epitopes.This study contributes with structural and sequence features necessary to design more immunogenic vaccines against Omicron. Considering structural properties, several multimerization approaches  have been used,On the other side, selection of the most suitable sequence to induce potent Omicron-specific neutralizing responses has been a point of interest, in terms of vaccine immunogenicity and cross-neutralization capacity. There is some controversy in immunogenicity studies, with some authors reporting lower immunogenicity of Omicron-based vaccines, whereas others describe a similar potency. Regarding cross-recognition of Omicron variants by vaccine-induced antibodies, it is dependent on the similarity between the vaccine and the virus targeted. Most Omicron variants are less recognized by antibodies induced by vaccines based on prototype or beta or delta sequences, with a gradual loss of recognition of more recent Omicron variants. Antibodies induced by the vaccine proposed by He et al., based on Delta sequence, nicely recognize and neutralize the original prototype isolate, not differing significantly with recognition and neutralization of beta, delta and Omicron viruses. Similarly, recognition of B.1.1.529 Omicron variant by sera from vaccinated individuals showed a somehow detectable but not dramatic decrease. However, other studies show that, newer Omicron variants XBB or BQ.1, more distant from Delta variant, are barely recognized by sera from vaccinated individuals and mice, suggesting that the closer is the sequence of the immunogen, the better the recognition of the new variant. Thus, although the RBD-HR/trimer vaccine based on Delta variant shows a good neutralization capacity against earlier Omicron strains, the abovementioned results suggest that responses against newer variants might be more affected. However, the RBD sequence of the variant in the RBD-HR/trimer design could be easily changed into the equivalent amino acid sequences of other SARS-CoV-2 variants , leading to a new variant specific vaccine. The self-assembled trimeric-RBD architecture could be developed into a vaccine platform with the capacity of rapidly responding to the currently circulating SARS-CoV-2 variants in the future.4 suggesting an important immune imprinting generated by initial antigen exposure. Boosting can be highly biased towards previously encountered shared epitopes, dampening responses to novel epitopes on the newer viral strain. This imprinting might be detrimental when a response to a non-protective epitope dominates. Vaccines with a reduced size, focusing the response on relevant RBD epitopes, as opposed to larger immunogens containing more shared epitopes between variants, might limit the negative effects of imprinting (Fig. 5 would allow activating new B cell clones specific for the variant sequence not imprinted by original antigenic priming, leading to a higher cross-reactivity against new variants. The strategy proposed be He et al. could be suitable for this approach, by including the adequate sequence according to the predominant variants.Besides results against Omicron obtained after primary immunization, another scenario is the use of new vaccines, including bivalent vaccines, as booster. Clinical studies have shown that the boosting capacity of bivalent vaccines containing prototype sequence plus either BA.1 or BA.4-BA.5 sequence is similar or slightly better than that provided by a monovalent prototype vaccine,


Rationale: Pancreatic cancer, comprising mostly pancreatic ductal adenocarcinoma (PDAC), is a highly malignant disease, typically known as a hypoxic tumor microenvironment. The application of PDT in pancreatic cancer in clinic is still hampered by several shortcomings, including the (i) deep location of pancreatic cancer, (ii) tissue damage induced by optical fibers, (iii) hypoxic microenvironment, (iv) short excitation wavelengths of traditional photosensitizers, and (v) poor delivery efficiency of photosensitizers.Methods: We designed an organic nanoparticle as photosensitizer for near-infrared II (NIR-II) fluorescent (FL) imaging that exerts a type I PDT effect on deep orthotopic pancreatic tumors under excitation by a NIR (808 nm) laser.Results: This novel photosensitizer exhibits enhanced accumulation in orthotopic pancreatic cancer in mice and could be used to effectively detect pancreatic cancer and guide subsequent laser irradiation for accurate PDT of deep pancreatic cancer. In addition, we built an endoscopic platform monitored by NIR-II FL imaging to achieve minimally invasive endoscopically guided interventional photodynamic therapy (EG-iPDT) with efficient inhibition of orthotopic pancreatic cancer, which prolonged overall survival up to 78 days compared to PBS + EG-iPDT group (*p < 0.05) in a mouse model.Conclusions: Minimally invasive EG-iPDT has promise as an intraoperative treatment for early-stage or unresectable or metastatic pancreatic cancer. In 2020, there were more than 490,000 new cases of pancreatic cancer and 460,000 deaths related to the disease worldwide Recently, photodynamic therapy (PDT) has attracted increasing attention as a promising clinical method for treating cancer, such as cholangiocarcinoma and oral cancer due to its low systemic toxicity and minimal invasiveness •OH by the type I PDT process. The BTz-IC NPs exhibited a long-excitation wavelength, satisfactory NIR-II FL intensity, efficient •OH production capability and stable photostability in vitro. This type I PDT system was able to overcome the hypoxic property of the pancreatic cancer TME and enhance the photodynamic effect.Given the three key problems of conventional photosensitizers being excited by short wavelengths, the special challenge presented by the hypoxic TME in pancreatic cancer, and the invasive injury caused by traditional PDT, we adopted a strategy of combining a minimally invasive endoscopically guided method with a multifunctional photosensitizer for NIR-II FL based type I PDT for orthotopic pancreatic cancer. First, we designed a large conjugated system (A-D-A'-D-A) by introducing two electron-absorbing groups at both ends of the D-A'-D core. Due to the introduction of two electron-absorbing groups, the absorption wavelength was significantly redshifted, and the FL emission was redshifted to the NIR-II region by expansion of the conjugated system. Next, we prepared a theranostic agent via the nanoprecipitation method as photosensitizers that could be excited at long wavelengths (~800 nm) and generate in vivo. After EG-iPDT, the orthotopic pancreatic tumors were significantly suppressed, and the overall survival was extended up to 78 days. Thus, the combination of interventional technology and PDT enabled the precise and efficient treatment of deep pancreatic tumors.Endoscopy, as a minimally invasive surgical adjunct can reduce trauma while enabling clearer and more intuitive detection of tumors, including deeper microscopic tumors that are difficult to detect with the naked eye. The advantages of endoscopy applied in hepato-pancreato-biliary surgery included faster recovery, a shorter hospital stay, decreased postoperative pain and a reduced risk of infectious complications 1H NMR) confirmed the successful synthesis of the BTz-IC , named BTz-IC. To create water-soluble NIR-II NPs, the surfactant DSPE-mPEG was coated onto BTz-IC by nanocoprecipitation Scheme A. Transme BTz-IC . The obte BTz-IC . UV-vis 1O2 content and evaluate the reactive oxygen species (ROS) generation of the BTz-IC NPs under 808 nm laser irradiation. When TEMP, DMPO and the BTz-IC NPs were present, the typical resonance peak of the TEMP/1O2 adduct  and DMPO/•OH adduct  under 808 nm laser irradiation indicated the type I (•OH) and type II (1O2) photodynamic effects of the BTz-IC NPs  was employed as an indicator of total ROS production. We discovered a significant decrease in the DPBF peak at 415 nm under 808 nm laser irradiation, demonstrating the robust efficacy of the BTz-IC NPs in generating ROS upon irradiation  in PBS were irradiated with an 808 nm laser (0.5 W/cm2) for 8 min, the temperature increased to 40.8, 53.6, 60.2 and 72.8°C, respectively . The results showed that the stability of the BTz-IC NPs in solution was preserved, with the irradiated agent retaining its original activity  and then immediately subjected to 808 nm laser excitation using a 1,040 nm filter. Subcutaneous Pan02 tumor-bearing mice were administered PBS and the BTz-IC NPs to verify the passive targeting ability of the NPs. The location of each subcutaneous tumor was determined by bioluminescence (BL) imaging . As shown in Figure To estimate the An excellent antitumor effect was observed in the BTz-IC NPs + laser group compared with the other groups. As shown in Figure in vivo using the BTz-IC NPs in an orthotopic tumor mouse model. The location of the orthotopic pancreatic tumor was determined by BL imaging . The FL intensity of the orthotopic tumor and in the NIR-II window was 3.55-fold higher than that of normal pancreatic tissue, demonstrating the superior imaging ability in the NIR-II window.Forty-eight hours after the intravenous injection of the BTz-IC NPs, r Figure F  and intravenously injected with the BTz-IC NPs  or PBS. The mice were anesthetized with isoflurane and placed on an operating table, and the extremities were secured with tape. The skin of the abdomen was incised to create an opening ~4 mm in diameter (see schematic diagram), and an endoscopic lens was placed.We divided the EG-iPDT procedure for the pancreatic tumor into four steps.Step One: Abdominal exploration was performed to check for metastases in the abdominal cavity. Endoscopy clearly showed the liver, pancreas, and spleen of the mouse Figure ni, as weStep Two: Tumor localization was performed by endoscopically searching for suspicious lesions Figure nvi, clar2, 5 min) was turned on for treatment -stained tumor sections were obtained, and increased apoptosis was observed in the tumors treated with the BTz-IC NPs + laser compared with those treated with PBS + laser Figure G. TerminPancreatic cancer is an invasive disease with high malignancy and a poor prognosis due to the difficulty of early detection and treatment. After more than a century of development, PDT has been clinically applied to treat various tumors and nontumor diseases, such as cancer of the skin, retina, bladder, esophagus, gastrointestinal tract, bile duct, oral cavity, head, and neck. Furthermore, PDT has attracted increasing attention as a promising complement for, or alternative to, classical surgery and interventional treatments involving drugs. This is because the photodynamic activity that exerts a tumoricidal effect occurs only upon light irradiation.Despite the benefits of precise and effective treatment, the application of PDT is limited to surface lesions due to the insufficient penetration of light into biological tissues, preventing clinical treatment for deep abdominal tumors, particularly pancreatic tumors. However, the effect of PDT on deep abdominal tumors is weakened by the limited penetration depth of NIR light. In the relevant literature, optical fibers are mainly inserted into pancreatic tumors via US-guided percutaneous puncture, EUS, or computed tomography (CT), which may lead to bleeding or difficulty in evaluating ablation boundaries, potentially leading to failure. In addition, the limited tissue penetration depth of PDT severely hinders its applications in the treatment of deep tumors due to the difficulty of delivering sufficient irradiation energy into deep malignant tissues. There are two ways to address this challenge. The first is to increase the local power density of the NIR laser, but this will inevitably cause burns to the skin and muscles. Additionally, although long-wavelength lasers have a greater penetration depth, they are not sufficient to reach abdominal organs. The second is to use an interventional photodynamic approach in which NIR optical fibers are delivered to the tumor region for local ablation. However, there have been few reports on interventional PDT. In this work, we improved the endoscopic resolution compared to that in a previous study, enabling clearer visualization of microscopic tumors and application of the method in the treatment of orthotopic pancreatic cancer. For the treatment of deep and early-stage tumors, open surgery can be invasive, but good results can be achieved with EG-iPDT. Interventional PDT is less invasive, and complete ablation followed by fast recovery may be achieved by EG-iPDT.However, early-stage tumors, such as those of early-stage stomach cancer and bowel cancer, can be effectively treated by endoscopic therapy, most commonly by ablative resection followed by endoscopy in vitro and in vivo phototherapeutic performance, we discovered that the BTz-IC NPs also have excellent NIR-II FL imaging capabilities. Early-stage pancreatic tumors could be effectively detected by NIR-II FL imaging and would be suitable for type I PDT. Furthermore, we demonstrated that under 808 nm laser irradiation, not only is 1O2 generated by type II PDT through type II energy transfer, but •OH is also generated by type I PDT electron transfer. Importantly, type I PDT, which is less dependent on O2, can improve the efficacy of PDT for pancreatic cancer and is expected to become an alternative treatment strategy.The hypoxic TME is an intrinsic characteristic of pancreatic cancer that can reduce the efficacy of novel PDT strategies. Mounting clinical evidence has shown that the hypoxic TME in pancreatic cancer can influence both genomic stability and proteomic changes in cancer cells, thereby affecting intracellular and extracellular matrix (ECM) metabolism In the future, it is expected to develop a multifunctional endoscope with NIR-II FL imaging function for real-time guided ablation by PDT. Combining NIR-II FL imaging and endoscopy into one lens is the current trend in the development of cancer treatments. In this respect, we have conducted a simple exploration, but many technical adjustments still need to be investigated. These initial explorations have motivated us to pursue the potential clinical translation of this strategy for the treatment of early-stage pancreatic cancer that cannot feasibly be treated by radical surgery. Our findings have important implications for patient care and hold promise for clinical translation and application.In vivo results confirmed that the BTz-IC NPs were able to define the boundary of subcutaneous and orthotopic tumors and overcome pancreatic tumor-associated hypoxia via the generation of •OH through type I PDT. Furthermore, we developed EG-iPDT, a minimally invasive method for ablation with a biocompatible contrast agent, to completely ablate orthotopic pancreatic tumors in a mouse model. Neither recurrence nor obvious side effects were observed during the experiments. Overall, this work proposes a potential strategy for improving the efficacy of PDT for orthotopic pancreatic cancer.In summary, we successfully developed a unique and effective endoscopically guided antitumor strategy that combines NIR-II FL with PDT for the treatment of orthotopic pancreatic cancer in mice. The developed noncytotoxic BTz-IC NPs exhibited a satisfactory NIR-II FL intensity, excellent passive targeting, and efficient ROS production. Supplementary materials and methods, figures and table.Click here for additional data file.


IgA vasculitis, also known as Henoch-Schonlein Purpura (HSP), is an inflammatory disorder of small blood vessels that can present with palpable purpura, arthralgias, abdominal pain, and kidney disease. It is most commonly found in pediatric patients after an inciting infection but has been seen across all ages and associated with certain drugs and vaccines. COVID-19 has been associated with various cutaneous manifestations, but HSP is a rarely reported one.We present a case of a 21-year-old female presenting with a petechial rash found to be seronegative IgA vasculitis presenting concurrently with dyspnea secondary to COVID-19. She was initially seen by an outside practitioner, tested negative for COVID, and was prescribed a course of oral prednisone. Shortly thereafter, she visited the ED for worsening shortness of breath and tested positive for COVID-19, for which she received Paxlovid. Biopsy after a visit to a dermatologist confirmed intramural IgA deposition on immunofluorescence, and she was tapered off prednisone and started on azathioprine. Several dermatoses have been associated with COVID-19, with the most common presentations including pseudo-chilblains, maculopapular, urticarial, vesicular, and vaso-occlusive [A 21-year-old female with no history of inflammatory arthritis or skin psoriasis presented to the clinic with a morbilliform, petechial rash without pain or pruritus on her legs, feet, back, and forearms slightly improved with ibuprofen Figures , 1B. SheBiopsy taken at a later visit showed mild perivascular neutrophilic infiltrate in the superficial dermis with extravasated erythrocytes Figures , 3. ImmuThis was an interesting case of IgA vasculitis temporally correlated with COVID-19 in the absence of other associated infections. As more patients are diagnosed with COVID-19, we anticipate an increase in cases involving HSP associated with COVID-19. While HSP is often self-limited, a small proportion of patients experience long-term effects such as joint pain and stiffness, renal damage, and gastrointestinal bleeding. In severe cases, it can lead to chronic renal disease and even renal failure .To evaluate a patient with IgA vasculitis and COVID-19, renal tests such as urinalysis, serum creatinine, glomerular filtration rate (GFR), and biopsy may be used to assess kidney function and damage . MonitorThe mainstay of treatment in uncomplicated cases is non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain . CorticoOne proposed mechanism of COVID-19-induced HSP is direct damage to blood vessels by the virus followed by the formation of immune complexes and an inflammatory response. Another proposed mechanism is the viral induction of a systemic inflammatory response that triggers HSP development. Cases of IgA vasculitis following vaccination for COVID-19 have also been described, indicating a possible involvement of the spike protein used in some vaccines . The exaHSP following COVID-19 is an uncommon occurrence, with most cases of HSP appearing in children  . A systeIgA vasculitis, also known as HSP, should be considered in patients who develop a pathognomonic rash after a COVID-19 infection. Early recognition and appropriate management of IgA vasculitis are crucial to prevent long-term complications and improve patient outcomes. A thorough work-up, including a complete metabolic panel and involvement of nephrology, is necessary to evaluate for renal involvement. Future studies with larger sample sizes are recommended to expand on the relationship between COVID-19 and vasculitis.


A Mediterranean-style diet (MED) can promote people lengthen the span of life and avoid atherosclerotic cardiovascular disease (ASCVD) in primary prevention. Metabolic syndrome (MetS) can significantly reduce life expectancy and increase the risk of ASCVD. However, few studies have focused on the role of the Mediterranean diet in patients with MetS. Participants in the National Health and Nutrition Examination Survey (NHANES) with MetS (N = 8301) from 2007 to 2018 were examined. A 9-point evaluation scorewas used to measure the degree of adherence to the MED diet. In order to compare the various levels of adherence to the MED diet and the effects of the specific MED diet components on all-cause and cardiovascular mortality, Cox regression models were utilized. Among the 8301 participants with MetS, about 13.0% (1080 of 8301) died after a median follow-up of 6.3 years. In this study, participants with MetS with adherence to high-quality and moderate-quality Mediterranean diet were significantly associated with lower all-cause mortality as well as cardiovascular mortality during the follow-up period. Futhermore, in joint analysis of the Mediterranean diet and sedentary behavior or depression, we found that high-quality or moderate-quality Mediterranean diet could attenuate, even reverse the adverse effects of sedentary behavior and depression on all-cause and cardiovascular mortality in participants with MetS. Among the components of the MED diet, greater intakes of vegetables, legumes, nuts and high MUFA/SFA ratio were significantly associated with lower all-cause mortality and greater vegetables intake was significantly associated with lower cardiovascular mortality, while more red/processed meat intake was significantly associated with higher cardiovascular mortality in participants with MetS. MetS is defined as the presence of central obesity combined with at least two of the following four conditions: hypertension, diabetes mellitus, hyperlipidemia, and hypo-high-density lipoprotein cholesterolemia. The incidence of Mets has sharply increased as people’s living standards have improved, modern urban lifestyles have emerged, and various influences like diet, exercise, genetics, and race have become more important . Prior rSince Trichopoulou et al. demonstrated in a Greek population that the Mediterranean diet prolongs life expectancy , there hThe development of MetS is closely related to obesity. IR and its associated metabolic issues might occur as a result of the uneven production of pro- and anti-inflammatory adipocytokines, which may be treated with weight-loss regimens. Obesity is the primary characteristic of those who have MetS, and its pathological process includes visceral fat infiltration and IR. Numerous research has been done to demonstrate that weight loss and calorie restriction are efficient ways to combat MetS and lessen IR. However current research indicates that not only eating less can help lower IR, eating healthfully, such as combining with a Mediterranean diet, can have an even greater impact on reducing insulin sensitivity. Low-carbohydrate and Mediterranean diets might be superior choices to low-fat diets. The better results on lipids (with the low-carbohydrate diet) and glycemic control (with the Mediterranean diet) imply that dietary interventions may be individually tailored based on preferences and metabolic factors . AccordiThe beneficial effects of the Mediterranean diet on life expectancy and as a primary prevention of ASCVD have been well recognized. However, few studies have investigated the association between the Mediterranean diet and all-cause mortality and cardiovascular mortality in people with MetS. Moreover, the joint effect of Mediterranean diet and unhealthy lifestyle habits or mental diseases, such as sedentary behavior and depression, on all-cause mortality and cardiovascular mortality in people with MetS has not been studied. Lastly, the effect of specific components of the Mediterranean diet on mortality has not been analyzed in more depth. Our aim in this study was to assess the effect of the Mediterranean diet on all-cause and cardiovascular mortality in participants diagnosed with MetS from NHANES cohort, then to analyze in depth the joint effect between the Mediterranean diet and other adverse factors in daily life and to explore the impact of specific components of the Mediterranean diet on all-cause mortality and cardiovascular mortality in participants with MetS.https://www.cdc.gov/nchs/nhanes/index.htm.A prospective cohort study was designed using the population data from The National Health and Nutrition Examination Survey (NHANES) 2007–2018 database to explore the role of Mediterranean diet on all-cause mortality and cardiovascular mortality in people with MetS, study in depth the joint effect of Mediterranean diet, sedentary behavior and depression on all-cause mortality and cardiovascular mortality in people with MetS and figure out the impact of each Mediterranean dietary component on all-cause mortality and cardiovascular mortality in people with MetS. The related data were collected from NHANES 2007–2018, and the mortality follow-up data was from the date of survey participation through December 31, 2019. The National Health and Nutrition Examination Survey (NHANES) is a collection of cross-sectional studies that are nationally representative and aimed at tracking the health of the American population. Its goal was to evaluate both the nutritional and physical health of adults and children. For in-home interviews and visits at a mobile examination center, participants are chosen from the non-institutionalized, general population of the United States using a complicated, stratified, and multi-stage probability cluster sampling approach. All survey participants supplied informed written agreement, which was approved ethically by the Ethics Review Board of the National Center for Health Statistics. Detailed questionnaires regarding dietary components, previous medical history of participants and the survival information for these populations is available are available. It is accessible to obtain this data collection for free online at 2 can be obtained from the database. The patient rested in a sitting position for five minutes before having their blood pressure taken three times, with the mean of the three readings being used for analysis. Trained healthcare professionals used a calibrated Omron IntelliSense Blood Pressure Monitor (Model: HEM-907XL) to measure the patient’s systolic and diastolic pressures. Participants’ blood was drawn to measure their blood glucose levels after an overnight fast using a Cobas C Chemistry Analyzer . A Cobas Chemistry Analyzer was used to measure the blood’s levels of TG and HDL-C. . The NHANES survey was used to gather data on prescription medicine usage. In order to further enhance the universality of this design and make the conclusions more reliable, we additionally decided to adopt another diagnostic standard for MetS to form the new MetS participants for research. The new diagnostic criteria is that three of the above five conditions are met, which can be diagnosed as MetS.All participants are selected from the NHANES 2007–2018. We characterized MetS according to International Diabetes Federation as central obesity  plus any two of the following four factors: Reduced HDL-C (40 mg/dL (1.03 mmol/L) in men and 50 mg/dL (1.29 mmol/L) in women) or specific treatment for this lipid abnormality; Raised fasting TGs ≥ 150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormality; Raised blood pressure (systolic > 130 or diastolic > 85 mm Hg) or treatment of previously diagnosed hypertension and raised fasting plasma glucose (FPG) > 100 mg/dL (5.6 mmol/L) or previously diagnosed . The resThe dietary data of this study is derived from The United States Department of Agriculture’s Food Patterns Equivalents Database, which was applied to NHANES database. The relationship between a high-quality Mediterranean diet and obesity in the population has been previously well summarized by a relevant scale. In a group of people at high cardiovascular risk, a quick 14-item test was able to capture a substantial monotonic inverse correlation between adherence to a high-quality dietary pattern (Mediterranean diet) and obesity indices . HoweverParticipants in NHANES used the Global Physical Activity Questionnaire to self-report their PA data (GPAQ). It is an approved tool for PA surveillance . ParticiDuring the face-to-face MEC interview, the PHQ-9 was given to evaluate depressive symptoms over the previous two weeks . The folThe National Center for Health Statistics (NCHS) has linked data collected from several NCHS population surveys with death certificate records from the National Death Index (NDI). The definition of all-cause mortality included all kinds of deaths. The sub-classifications of causes of death into cardiovascular, cancer, respiratory disease, diabetes mellitus, or miscellaneous other causes related mortality were also derived from National Death Index data . To complement the restricted-use files and increase data access, NCHS developed public-use versions of the LMF for the 1999–2018 National Health and Nutrition Examination Survey (NHANES). Information regarding vital status was not perturbed. The public-use LMF provide mortality follow-up data from the date of survey participation through December 31, 2019.Demographic variables included age, sex, race, education, marital status and poverty to income ratio. Race/ethnicity were categorized as Hispanic-Mexican American, Hispanic-Other Hispanic, Non-Hispanic Black, Non-Hispanic White and other (including multiple races). Education was categorized as less than 9th grade, 9-11th grade (includes 12th grade with no diploma), high school Grad/GED or equivalent, some college or AA degree and college graduate or above. Marital status was categorized as married, widowed, divorced, separated, never married and living with partner. PIR was presented a ratio of family income to poverty. Smoking status was defined as former or current smokers if they smoked at least 100 cigarettes in one’s lifetime. Cardiovascular disease is defined as having been diagnosed with any of the following four diseases: congestive heart failure, coronary artery disease, angina pectoris, or heart attack. Treatment for hypertension was defined as having taken prescription for hypertension. Treatment for diabetes was defined as having taken insulin. Treatment for cholesterol was defined as having taken prescription for cholesterol.P < 0.05.We adopted the NHANES official recommended statistics due to the complexity of the surveys used in the NHANES study. In order to accurately reflect the population of the United States, all analyses needed to be properly weighted. The weighted estimates were calculated in accordance with the analytical guidelines from the National Health and Nutrition Examination Survey for the years 2007 through 2018, which is accessible online. All data were analyzed using Empower Statistics version 4.1, GraphPad Prism 8.0  and Free Statistics version 1.7 . In Table For our study, six cycles of continuous NHANES 2007–2018 data were employed, with 10,487 participants diagnosed Mets included. Individuals aged < 20 years and without complete data of diet, physical activity, PHQ9 and mortality were excluded, resulting in 8301 subjects included in our analysis. Figure Participants in the National Health and Nutrition Examination Survey (NHANES) with Mets N = 8301) from 2007 to 2018 were examined. Up to the end of 2019, their unique vital status was connected to the National Death Index. After a median follow-up of 6.3 years, 1080 out of the 8301(about 13.0%) individuals with MetS died. They were categorized into below median (aMED scores 0–3), median (aMED scores 4), and above median (aMED scores 5–9) groups based on their aMED scores. Table  from 200To explore independent predictors strongly associated with all-cause mortality and cardiovascular mortality of MetS participants, the cox regression analysis was performed. The cox regression analysis showed that alternative Mediterranean diet score (Median and Above Median), physical activity, work activity, recreation activity, treatment for hypertension and treatment for diabetes were significantly associated with a lower HR for all-cause mortality while depression, sedentary behavior, smoking, cardiovascular disease were significantly associated with a higher HR for all-cause mortality after adjustment for age, sex, race, education, marital status and poverty to income ratio. The cox regression analysis also showed that alternative Mediterranean diet score (Median and Above Median), recreation activity and treatment for diabetes were significantly associated with a lower HR for cardiovascular mortality whereas sedentary behavior and cardiovascular disease were significantly associated with a higher HR for cardiovascular mortality after adjustment for age, sex, race, education, marital status and poverty to income ratio. These results are presented in Table Appendix 1). Surprisingly, the similar conclusions were also drawn. The only difference is that in MetS participants without sedentary behavior, LaMED is an independent risk factor for all-cause mortality , which also demonstrated high-quality Mediterranean diet could reduce all-cause mortality in MetS participants without sedentary behavior.To investigate the joint effect of the Mediterranean diet and sedentary behavior on all-cause mortality and cardiovascular mortality in participants with MetS, we divided all paticipants with MetS into the following six groups: HaMED-non S (MetS participants with above median aMED without sedentary behavior), MaMED-non S (MetS participants with median aMED without sedentary behavior), LaMED-non S (MetS participants with below median aMED without sedentary behavior), HaMED-S (MetS participants with above median aMED with sedentary behavior), MaMED-S (MetS participants with median aMED with sedentary behavior) and LaMED-S (MetS participants with below median aMED with sedentary behavior). Cox regression analysis of the all-cause mortality risk for MaMED-non S, LaMED-non S, HaMED-S, MaMED-S, LaMED-S groups using HaMED-non S group as the control group showed that, after the adjustment for age, sex, race, education, marital status, poverty to income ratio, cardiovascular disease, smoking, treatment for hypertension, treatment for diabetes and treatment for cholesterol, there was no significant difference in HR between HaMED-non S, MaMED-non S and LaMED-non S groups. HaMED-S and MaMED-S groups showed a similar increased HR in all-cause mortality ,  compared to HaMED-non S group. While LaMED-S group showed the biggest risk in all-cause mortality , which suggested high-quality Mediterranean diet might attenuate the risk of all-cause mortality resulting from sedentary behavior. In terms of cox regression analysis of the cardiovascular mortality risk, there was no significant difference in HR between HaMED-non S, MaMED-non S group, LaMED-non S, HaMED-S groups. As for MaMED-S, LaMED-S groups, HR of two groups was progressively increasing and statistically significant. LaMED-S group also shows the biggest risk in cardiovascular mortality . In MetS participants with sedentary behavior, participants with HaMED shows no difference in HR compared to HaMED-non S group while participants with MaMED or LaMED showed increased HR in cardiovascular mortality, which suggested high-quality Mediterranean diet could completely offset the adverse effects of sedentary behavior to cardiovascular mortality , MaMED-non D (MetS participants with median aMED without depression), LaMED-non D (MetS participants with below median aMED without depression), HaMED-D (MetS participants with above median aMED with depression), MaMED-D (MetS participants with median aMED with depression) and LaMED-D (MetS participants with below median aMED with depression). Cox regression analysis of the all-cause mortality risk for MaMED-non D, LaMED-non D, HaMED-D, MaMED-D, LaMED-D groups using HaMED-non D group as the control group showed that, after the adjustment for age, sex, race, education, marital status, poverty to income ratio, cardiovascular disease, smoking, treatment for hypertension, treatment for diabetes and treatment for cholesterol, there was no significant difference in HR between HaMED-non D group and MaMED-non D group. However, LaMED-non D group showed a increased HR in all-cause mortality  compared to HaMED-non D group, which means in participants with MetS without depression, lower-quality Mediterranean diet significantly increases all-cause mortality. Similar results can still be observed in participants with MetS with depression. LaMED-D group had the highest all-cause mortality . Interestingly, even when MetS participants combined with depression, but with a higher quality Mediterranean diet, all-cause mortality was not significantly increased and was even lower than those without depression but with a lower quality Mediterranean diet. A similar trend can be observed in cardiovascular mortality. Compared to HaMED-non D group, MaMED-non D, HaMED-D and MaMED-D groups did not show significant difference in HR in cardiovascular mortality. Combined low-quality Mediterranean diet shows higher cardiovascular mortality, regardless of depression, in participants with MetS. LaMED-non D group shows the notable risk in cardiovascular mortality  while LaMED-D group shows the biggest risk in cardiovascular mortality  . One difference is that under this version of the criteria, greater vegetable intake does not significantly reduce cardiovascular mortality in participants with MetS.To examine in depth the association between Mediterranean diet components and all-cause mortality and cardiovascular mortality in MetS participants, cox regression analysis was utilized. Among the components of the MED diet, greater vegetables, legumes, nuts intake and high MUFA/SFA ratio were significantly associated with lower all-cause mortality after adjustment for age, sex, race, education, marital status, poverty to income ratio, cardiovascular disease, smoking, treatment for hypertension, treatment for diabetes and treatment for cholesterol in participants with MetS Table . GreaterModel was adjusted for age, sex, race, education, marital status, poverty to income ratio, cardiovascular disease, smoking, treatment for hypertension, treatment for diabetes and treatment for cholesterol.In our study, we discovered that the Mediterranean diet was a strong protective factor for mortality outcomes in people with MetS, whereas depression and sedentary behavior were significant risk factors. The health advantages of a Mediterranean diet are abundantly established. First, patients with diabetes may have altered lipid metabolism and IR due to unsaturated fatty acids in the Mediterranean diet. According to a randomized controlled trial, patients with T2D who follow a diet typical of Mediterranean nations may have a decrease in all-cause and CVD-related mortality . Olive oSince MetS and depression are both risk factors for cardiovascular disease, their connection has received a lot of attention recently. An elevated risk of developing MetS among middle-aged adult university graduates from a Spanish cohort was linked to depression in a prospective cohort study . A recenStudying the risk and protective factors linked to MetS is crucial because of the rising prevalence of MetS and the socioeconomic cost it imposes on society. Already, the MetS is an independent risk factor for cardiovascular disease and death. However, poor lifestyle choices, such as inactivity, and sedentary behavior are frequently linked to MetS patients. The MetS in conjunction with these other risk factors can hasten the incidence of adverse events. It is generally known that exercise reduces IR in population with MetS . Both obSedentary behavior, while still a reliable indicator of the quality of exercise, was clearly a risk factor in our study. At the same time being sedentary tends to mean lower levels of exercise. A national study showed that sedentary behaviors in the US population either increased from 2001 to 2016 or remained generally stable and high . BesidesOur study suffers from the following shortcomings: First, in order to make the findings more robust, we did cox regression analysis by adjusting for a series of covariates. However, the information on these covariates was collected by the NHANES questionnaire, and a number of these variables may have been missing, which further led to a reduction in included population of this study. Secondly, dietary data was collected by questionnaire. Although NHANES interviewers were trained to perform better documentation of diet and we used the average of dietary data from two different weeks to minimize bias in statistical process, there may be some discrepancies between participants’ dietary habits and the questionnaire. Last, there is a minor flaw in the patient mortality follow-up data. Deaths due to pre-existing serious illnesses of participants may potentially contribute to contamination of mortality data.In this study, we found that participants with MetS with adherence to high-quality or moderate-quality Mediterranean diet were significantly associated with lower all-cause mortality as well as cardiovascular mortality during the follow-up period in the NHANES study. High-quality or moderate-quality Mediterranean diet could attenuate, even reverse the adverse effects of sedentary behavior and depression on all-cause and cardiovascular mortality in participants with MetS. Among the components of the MED diet, greater intakes of vegetables, legumes, nuts and high MUFA/SFA ratio were significantly associated with lower all-cause mortality and greater vegetables intake was significantly associated with lower cardiovascular mortality, while more red/processed meat intake was significantly associated with higher cardiovascular mortality in participants with MetS.


Accurately identifying potential piRNA-disease associations is of great importance in uncovering the pathogenesis of diseases. Recently, several machine-learning-based methods have been proposed for piRNA-disease association detection. However, they are suffering from the high sparsity of piRNA-disease association network and the Boolean representation of piRNA-disease associations ignoring the confidence coefficients. In this study, we propose a supplementarily weighted strategy to solve these disadvantages. Combined with Graph Convolutional Networks (GCNs), a novel predictor called iPiDA-SWGCN is proposed for piRNA-disease association prediction. There are three main contributions of iPiDA-SWGCN: (i) Potential piRNA-disease associations are preliminarily supplemented in the sparse piRNA-disease network by integrating various basic predictors to enrich network structure information. (ii) The original Boolean piRNA-disease associations are assigned with different relevance confidence to learn node representations from neighbour nodes in varying degrees. (iii) The experimental results show that iPiDA-SWGCN achieves the best performance compared with the other state-of-the-art methods, and can predict new piRNA-disease associations. PIWI-interacting RNAs (piRNAs) are a kind of small non-coding RNAs with approximately 23–36 nucleotides in length, showing critical impact on various biological processes. It is crucial to develop computational methods for identifying piRNA-disease associations. Although several computational methods have contributed to the piRNA-disease association detection, there are still two main limitations for the further improvement of piRNA-disease association prediction: (i) The high sparsity of piRNA-disease associations prevent the predictors to accurately infer potential associations. (ii) Most existing methods focus on the Boolean connectivity of piRNA-disease associations, ignoring the correlation information with different confidence. To solve aforementioned limitations, we propose a supplementarily weighted strategy in this study. Combined with Graph Convolutional Networks (GCNs), a novel predictor named iPiDA-SWGCN is proposed for piRNA-disease association prediction. The supplementarily weighted strategy for piRNA-disease association complement cannot only enrich network structure information, but also provide the association confidence information for GCN to learn node representations. As a result, the evaluation results show that iPiDA-SWGCN can effectively detect missing piRNA-disease associations, and outperforms the other state-of-the-art methods. PIWI-interacting RNAs (piRNAs) belong to a category of small non-coding RNAs composed of approximately 23–36 nucleotides ,2, showiEmerging evidence indicate that piRNAs participate in many disease genesis and prognosis –9. For eSeveral computational methods have been proposed to predict the associations between non-coding RNA s and diseases. These methods usually rely on network link , recommeAlthough the aforementioned methods have contributed to the piRNA-disease association detection, there are two main limitations for the further improvement of piRNA-disease association prediction: (i) The high sparsity of piRNA-disease associations. For example, there are only about 5% piRNA-disease associations with experimental validation in piRDisease v1.0  and MNDRTo solve the above limitations, we propose a supplementarily weighted strategy to enrich the topology structure information of piRNA-disease network so as to provide more information for piRNA-disease association detection. As shown in With the development of representation learning, Graph Convolutional Network (GCN)  is propohttp://www.rnadisease.org/) [A recently constructed database MNDR v3.0 (se.org/)  records all is split into a benchmark dataset all with the equivalent number of piRNA-disease associations, representing the positive and negative subset of In this study, machine learning predictors are trained with two phases: (i) Training several basic classifiers to compute the weights of unknown piRNA-disease associations. (ii) Training GCN to capture piRNA and disease features. In the first phase, the dataset DIn the second training phase, we divide the dataset following the previous studies ,31:DalTo prevent overestimating the performance of the proposed method, the piRNA-disease associations in the independent dataset for model evaluation are removed from the training phases:In this study, we propose a novel method named iPiDA-SWGCN for piRNA-disease association detection. The overall process of iPiDA-SWGCN is shown in piR−disease, EpiR−piR, Edisease−disease, VpiR, Vdisease}. In detail, three types of edges and two types of nodes are included in the piRNA-disease network. The three kinds of edges are piRNA-disease associations, piRNA-piRNA edges and disease-disease edges, represented as EpiR−disease, EpiR−piR and Edisease−disease, respectively. EpiR−disease are the original piRNA-disease associations derived from the database MNDR v3.0. The other two kinds of edges are obtained based on the similarity between homogeneous biological entities. VpiR and Vdisease represent the nodes of piRNAs and diseases. The specific calculation of above edge and node representations will be introduced in the following sections.In this section, we construct a heterogeneous piRNA-disease network denoted as G = {EAPD represents the associations for each pair of piRNA-disease, denoted as:m and n are the number of piRNAs and diseases, respectively. The element ai,j is 1, if the association between i-th piRNA and the j-th disease is confirmed with experimental verification, otherwise ai,j = 0.The adjacency matrix http://bigdata.ibp.ac.cn/piRBase/) [pi, pj) denotes the sequence alignment score between pi and pi calculated by Smith-Waterman alignment algorithm.For each pair of piRNAs, the sequence similarity is calculated, where the sequence information is downloaded from piRBase v3.0 (iRBase/) . PiRNA-piRBase/) , which iiRBase/) ,35. We ciRBase/) :Pseqpidi and disease dj, the disease semantic similarity Dsem is calculated by [i is composed of all subterms in the DAG of disease di, t ∈ Ti to the i-th disease according to [θ is the semantic contribution factor which is set as 0.5 following [Disease semantic similarity has been extensively used in ncRNA-disease association detection –39. Direlated by :Dsemdirding to . θ is thollowing .Pseq or Dsem can serve as the feature vector for a piRNA or disease. However, they ignore the connectivity information, especially for non-neighboring and higher-order connected nodes. Therefore, in order to introduce the global topology information of similarity networks, we further apply random walk with restart (RWR) [Pseq and Dsem to extract piRNA and disease features. The feature generation for node i based on RWR can be formulated as [i, whose elements indicate the probabilities of walking from node i to all the other homogeneous nodes after k steps. S is the probability transition matrix obtained from similarity matrix (Pseq or Dsem) with row-wise normalization, yi is a one-hot vector representing the initial probability vector of node i, and α is the restart probabilities. Finally, we obtain i.The row vector of similarity matrix rt (RWR)  on Pseq lated as :Fik+1=Many unknown pairs lead to the high sparsity of piRNA-disease association network. GCN performing on such a network may lead to performance degradation because of limited neighbor information aggregation. To overcome this problem, we propose the Supplementarily Weighted Graph Convolutional Network (SWGCN). Firstly, the supplementarily weighted adjacency matrix is computed to achieve an informative piRNA-disease association network with high quality, and then GCN is adopted to capture hidden structure information for feature learning.In this section, we define the supplementarily weighted adjacency matrix in SWGCN for piRNA-disease association completion as follows:Definition 1. Supplementarily weighted adjacency matrix. Given a network G = {V, E}, we train several basic machine-learning-based predictors to compute the average relevance scores for unknown associations among nodes. Specifically, wi,j represents the average score of edge ei,j between node ni and node nj, and the adjacency matrix of the completed network can be denoted as APD = 0, then pi and disease dj, the element k-th SVM classifier. 15 predictors are employed to score the unknown associations, and the average scores are set as the weights for unknown associations. Finally, the weighted edges are added into the original heterogeneous network to generate the supplementarily weighted piRNA-disease network.To improve the quality of SWGCN, 15 different basic predictors based on Random Forest , SupportHl learned by GCN in the l-th layer can be formulated as [Aall ∈ R(m+n)×(m+n) indicates the association adjacency matrix for the whole network, and Aall added with self-loop. W represents the trainable parameters of GCN model, σ(·) denotes the nonlinear activation function. Hl ∈ R(m+n)×c is initialized by concatenating the piRNA and disease representations, where c denotes the common dimension of piRNA and disease features obtained by the dense layer. It is denoted that the batch norm layer is added before each dense layer and convolution layer to alleviate the problem of vanishing or exploding gradients and speed up the convergence. The batch norm layer can standardize the mean and variance of the input to each layer based on the statistics computed over a batch of training examples to make the distribution of each layer’s input relatively stable, and further reduce the risk of overfitting.GCN has been widely used for capturing graph structural information, and aggregating neighbour information so as to extract the node features ,50. Aftelated as :Hl=σD˜a as an example, on the original piRNA-disease network, the first layer of GCN updates the feature representation of node a by aggregating the features of its first-order neighbor node b1 and b2  [After obtaining the feature representation learned by GCN, the full connection networks with three layers are constructed to separately reduce the dimensions of representations for piRNAs and diseases. The probability of piRNA ion (BN)  followinU and the label matrix APD. Nevertheless, the high sparsity of piRNA-disease association matrix may cause prediction bias to the unknown associations. To alleviate this problem, we adopt β-enhanced loss function [APD and predicted score matrix U with hyper-parameter α. The loss function is formulated as:W denotes the trainable parameters. μ is a decay factor controlling the regularization term of W to prevent overfitting.We utilize the mean square error as the loss function which minimizes the Frobenius norm of the difference between prediction score matrix function  that enlTwo metrics are employed to comprehensively evaluate the predictor performance, including AUPR   and AUC In this study, three basic machine learning methods  are used to compute weights for the unknown piRNA-disease pairs. To analyze their contribution to weighting associations in the proposed model, we compare the predictors based on different basic methods and their combinations. Previous studies represent the piRNA-disease associations as Boolean values, where the element in the adjacency matrix is 1 if the association in the network is known, otherwise it is 0. In this study, we compute weights for unknown associations in the network instead of 0. To illuminate the effectiveness and necessity of assigning weights instead of Boolean values for unknown edges, we perform experiments on five networks with different edge types. The experimental results are listed in To illuminate the effectiveness of iPiDA-SWGCN for identifying piRNA-disease associations, we conducted a performance comparison of our method with five state-of-the-art approaches, including iPiDi-PUL , iPiDA-sIn order to visually illustrate the effectiveness of the supplementarily weighted network used in iPiDA-SWGCN, the prediction results of GCN performing on different networks are compared. We take two piRNA-disease associations for further analysis, including <piR-hsa-22710, Parkinson’s disease> and <piR-hsa-28405, renal cell carcinoma>. Parkinson’s Disease (PD) is a widely prevalent neurodegenerative disorder. The gross pathological findings reveal significant damage to dopaminergic neurons in the midbrain’s substantia nigra (SN), leading to dopamine deficiency in the nerve terminals located in the basal ganglia . PiR-hasThe results are shown in To illuminate the practicability of iPiDA-SWGCN, we applied iPiDA-SWGCN to detect potential piRNAs associated with three important diseases . The top five detected piRNAs and their corresponding literature evidence are listed in In this work, we propose a novel predictor named iPiDA-SWGCN for piRNA-disease association prediction by combining the supplementarily weighted strategy and GCN. The iPiDA-SWGCN mainly has following advantages: (i) Potential piRNA-disease associations are supplemented in the piRNA-disease network by integrating various basic predictors to provide an informative network, based on which GCN can capture deep proximity structure, and fully utilize network information for feature learning. (ii) Different confidences are assigned to the piRNA-disease associations instead of Boolean values. Therefore, GCN aggregates node information and accurately learns node representations from neighbor nodes in varying degrees. (iii) Although iPiDA-SWGCN is proposed for predicting piRNA-disease associations, it can be extended to other link prediction tasks.It is anticipated that the strategy of supplementarily weighted adjacency matrix will be applied to other related fields to solve the problems of limited positive samples, such as lncRNA–disease association detection and drug repositioning. In particular, there are plenty of unknown associations in link prediction field resulting in high sparsity problem. The supplementarily weighted strategy can be implemented to preliminarily enrich the association network so as to provide more useful information and improve the prediction performance.Besides, the value of piRNA-disease associations without independent experimental validation is worth mentioning. PiRNAs are potential biomarkers that may provide new avenues of investigation into the pathogenesis of diseases. However, it should be noted that these associations predicted by iPiDA-SWGCN are only correlations and require experimental validation to confirm their significance. This is especially relevant for piRNA studies due to their high abundance and poorly understood roles in diseases.Future studies should aim to validate these associations through a combination of biological experiments and bioinformatics analysis to ensure their reliability and accuracy, promoting to gain a better understanding of the complex mechanisms underlying diseases and develop more effective strategies for prevention and treatment.S1 TextFig A. Parameter analysis of iPiDA-SWGCN. Table A. The performance comparison of basic predictors on (DOCX)Click here for additional data file.


Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration.The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities.We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes.Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level.Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment. Approximately 39% of global deaths from suicide occurs in the WHO region of South-East Asia . For eacA risk factor globally recognized as associated with suicidal behaviour is the harmful use of alcohol . The conSri Lanka, a middle-income country, had one of the highest suicide rates worldwide in the 1990s . This raThe harmful use of alcohol has numerous socio-economic impacts in Sri Lanka, such as domestic violence ,14 and iet al in 2014 [Sri Lanka is one of a few middle-income countries where diverse self-harm and suicide literature exists, including a review of the available literature conducted by Pearson  in 2014 . Yet, a 2Since a scoping review of literature is relevant to identify knowledge gaps, scope a body of literature and to make recommendations for future research , this wa2.1Peer-reviewed articles, editorials, commentaries, academic book chapters, and theses included in the study were: (i) fully accessible; (ii) published in English (iii) between August 1, 2008 and December 31, 2022 and (iv) addressed alcohol use in the context of suicide or self-harm in Sri Lanka. Research focusing on Sri Lankans living outside of Sri Lanka and studies whose authors were from Sri Lanka, but the content not specific to the context of Sri Lanka were excluded. Studies discussing terrorism-related suicide bombs and abstracts or corrections to papers were excluded. Information from newspaper articles were not included, given difficulty of ensuring their credibility.2.2(i)An initial search for relevant databases and identification of key words.(ii)Searches with key words that entailed a combination of terms related to Sri Lanka, pesticides (a common means of self-harm in Sri Lanka), self-harm, and suicide were used for each database  for literature on suicide and self-harm in Sri Lanka. Hand searches were conducted through Google and Google Scholar.(iii)Searches for additional studies in the reference lists of the identified reports were conducted.(iv)Included literature were screened for whether they included a focus on alcohol's role in self-harm and/or suicide.The search for literature included the following steps :(i)An inTwo reviewers  reviewed the selected studies according to the inclusion criteria.2.3Included articles were uploaded to NVivo12  , where d33.1Searches generated 834 references. After removing 329 duplicates, 505 articles were screened. A total of 389 articles were excluded. This yielded 116 references eligible to be included in the study. Overview of articles included in the study is provided in 3.2Of the 116 articles, 8 had both alcohol and self-harm or suicide in the title. In 55 articles, the authors mentioned alcohol when explaining the background or rationale of the study. The three main themes emerging from the analysis included (i) gendered, inter-relational explanations of alcohol's role in self-harm and suicide, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide.3.33.3.1et al. [Across articles, alcohol drinking was explained to be unusual amongst women . A studyet al. .3.3.2Women were commonly mentioned to be affected by someone else's alcohol use, typically a husband or a father's, which subsequently resulted in self-harm or suicide . Interpeet al. found that the risk of attempted suicide nearly doubled in women living in households with someone who misused alcohol [et al. of 22,000 individuals between the age of 12–18 found that factors associated with higher rates of self-harm included being female, no longer being involved in education, and living in a household with an individual with problematic alcohol consumption [et al. explained how women resorted to self-harm to "teach him a lesson" and thereby hoped to change their husbands' alcohol behaviour. Due to gendered hierarchy, it was difficult for the women to be heard in other ways [Knipe  alcohol . Furthersumption . A sociasumption . In a stsumption . In a qusumption , noting sumption . Widger,sumption . In theiher ways ,41. Mareher ways .A qualitative study examining students' perspectives on suicidal behaviour showed how problems between parents and youth were often due to parental, most likely fathers', alcohol abuse. The harmful use of alcohol put families under strain, especially because parents would fight in front of children, making it difficult for them to get on with their studies . Several3.3.3et. al noted how women's migration to improve their families' economy and sometimes leave a difficult marriage was connected to alcohol and self-harm [Several articles highlighted how women's perceived inappropriate behaviour was linked to others' self-harm ,51. Bothelf-harm ,51. Widgelf-harm .3.4et al. found that patients who co-ingested alcohol and organophosphorus insecticide required intubation more often and had a higher risk of death than those who did not co-ingest alcohol. The authors speculated whether this was due to larger quantities of pesticide ingestions by alcohol intoxicated individuals compared to individuals who had not consumed alcohol [In total, 27 clinically focused articles were concerned with treatment of individuals who co-ingested alcohol and pesticides . Here, i alcohol . These s3.4.1A total of 8 articles stated how interventions targeting problematic alcohol use was needed in order to prevent self-harm, though without expounding on what they would entail . Other a3.5et al. called for larger, clinical studies to comprehensively assess the interaction of acute and chronic alcohol use on outcome in poisoning [The included articles emphasized several future research areas focusing on alcohol's role in self-harm. This included recommendations for more systematic research using epidemiological tools; devising methods to get more accurate estimations of alcohol consumption, including illicit alcohol; as well as the development of a culturally appropriate national survey providing policy makers with an accurate picture of alcohol consumption . Testingoisoning . The neeoisoning ; contextoisoning ; and illoisoning .4In this scoping review of 116 articles, we found alcohol discourses depicted in the Sri Lankan suicide literature both quantitatively, for example, through analysis of police and hospital data, as well as qualitatively via, for example, ethnographic investigations.Inter-relational explanations of alcohol's role in self-harm were a common theme, which reflects the importance of relationships in Sri Lanka. In contrast to many high income settings, the self is embedded in a web of relations in Sri Lanka, and the individual is thus less important , which aThe importance of relationships might also explain why suggestions for alcohol, self-harm and suicide prevention interventions are primarily targeted at the community. It should however be noted that the few individually targeted interventions suggested in the included literature might also reflect the limited treatment, mental health and alcohol support available in the country, especially in rural areas.Several issues were not mentioned in the literature included for this study. The connection between depression and alcohol use, as evidenced consistently in international literature , was scaThis review highlighted how self-harm and suicide is contextual and complex, without a one-sided cause.Considering how both alcoholconsumption and self-harm happens within and have consequences for web of relations, family- and community-based interventions seem most relevant in the Sri Lankan context. Future research should explore and test context-appropriate interventions targeting this, preferably through participatory methods, thereby including the voices of a hard-to-reach population group, such as harmful alcohol consumers. Cases of self-harm provide a window of opportunity for health personnel to identify and intervene in families affected by harmful alcohol consumption. At the individual level, introduction of and increased access to treatment of alcohol use disorder appear appropriate. Qualitative studies based on verbal autopsy would be useful to further explore the link between alcohol, self-harm and suicide.4.1We only included literature in English, though other conclusions could have been captured in Sinhala and Tamil literature. We conducted a scoping review, acknowledging that a systematic review with quality ratings of the included literature would have equipped us to make more robust conclusions.5Alcohol consumption is an important part of many cases of self-harm and suicide. The findings from this scoping review of the association between alcohol use, self-harm and suicide in Sri Lanka included three main themes: i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. Suggestions for alcohol, self-harm and suicide interventions were primarily targeted at the community, which might reflect the limited treatment, mental health and alcohol support available in Sri Lanka. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm into prevention and treatment efforts.All authors listed have significantly contributed to the development and the writing of this article.Data will be made available on request.There are no conflicts of interest.