Long-term results of the Tailored IMmunosuppression in virus-negative Inflammatory Cardiomyopathy (TIMIC) trial protocol have been evaluated.n = 43) vs. placebo (n = 42) for 6 months. Immunosuppressive treatment promoted an improvement in cardiac function in 88% of the cases compared with none of the patients in the placebo group, which were switched to a 6-month immunosuppressive therapy at the end of the 6-month study period. Long-term (up to 20 years) clinical outcomes of the whole cohort of 85 patients originally enrolled in the TIMIC trial (Group A) were compared with those of a 1:2 propensity score-matched control cohort of patients untreated with the TIMIC protocol (Group B) and followed for a comparable period of time. The primary outcome was a composite of cardiovascular death and heart transplantation. At long-term follow-up, the risk of cardiovascular death  and heart transplantation  was significantly higher in Group B patients. Group A showed a persistent improvement in the left ventricular ejection fraction compared with Group B . A higher number of Group B patients underwent implantable cardioverter defibrillator implantation. The incidence of recurrent myocarditis was similar between groups, and patients with evidence of a recurrent cardiac inflammatory process promptly responded to a TIMIC protocol application.Eighty-five patients with endomyocardial biopsy-proven virus-negative chronic inflammatory cardiomyopathy were enrolled in the randomized, double-blind, placebo-controlled TIMIC trial and received prednisone and azathioprine (Virus-negative inflammatory cardiomyopathy benefits from immunosuppressive therapy even after long-term follow-up. Recurrence appears to respond to a new TIMIC protocol application.  In the latter scenario, there was evidence of a virus-negative immune-mediated pathway that contributed to the formulation of the Tailored IMmunosuppression in virus-negative Inflammatory Cardiomyopathy (TIMIC) protocol, which was an immunosuppressive therapeutic strategy based on the combination of prednisone and azathioprine for 6 months.3 This approach has been demonstrated to successfully improve cardiac dimensions and function in 88% of treated patients enrolled in the randomized TIMIC trial. Of note, this 6-month immunosuppressive regimen led to a significant increase in the left ventricular ejection fraction (LVEF) even in patients with long-standing severe left ventricular dilation and dysfunction.3Acute HF due to active myocarditis can be a dramatic event that may require a prompt circulatory support with inotropes or mechanical devices in fulminant cases.4–11Further studies from several groups have confirmed the efficacy of immunosuppressive therapy in patients with biopsy-proven virus-negative inflammatory cardiomyopathy.12 In this perspective, it can be postulated that a new TIMIC protocol application may be potentially beneficial in the case of recurrent myocarditis.Nonetheless, little is known about the long-term implications of 6-month immunosuppression in cardiac structure/function, as well as the incidence of relapsing myocardial inflammation over time.The aim of the present report is to describe the long-term outcomes of patients originally enrolled in the TIMIC trial, the incidence of relapsing myocarditis, and its response to a new TIMIC protocol cycle.3The current study population consists of 85 patients  originally enrolled in the randomized, double-blind, placebo-controlled TIMIC trial.3 patients were enrolled between January 2001 and January 2007 and randomly assigned to one of the two treatment groups: oral administration of immunosuppressive therapy  including prednisone (1 mg/kg daily for 4 weeks followed by 0.33 mg/kg daily for 5 months) and azathioprine (2 mg/kg daily for 6 months) or placebo . All patients had complained about symptoms of HF of unknown cause for at least 3 months, despite optimal conventional therapy with angiotensin-converting enzyme inhibitors, beta-adrenergic blocking drugs, and diuretics. There were no significant differences in baseline characteristics between groups. All patients had undergone baseline biopsy; the diagnosis of myocarditis was achieved according to the Dallas criteria and confirmed by immunohistochemistry. Polymerase chain reaction (PCR) and reverse transcriptase–PCR analysis were performed on frozen sections to exclude the presence of cardiotropic viruses. The study protocol included cardiac catheterization, angiography, and biventricular endomyocardial biopsy at baseline and at 6 months. At 6 months from enrollment, all patients allocated to the placebo group showed persistent/worsening cardiac dysfunction and were prescribed the 6-month TIMIC protocol as a result of the superiority of this immunosuppressive strategy vs. placebo documented in the trial.In the original study,3 Control patients were selected via propensity score matching (PSM) among all patients admitted to our institution between June 2000 and December 2005 who had an endomyocardial-biopsy-proven diagnosis of virus-negative chronic inflammatory cardiomyopathy and were never prescribed immunosuppressive therapy.13 No clinical or histological differences regarding the burden of fibrosis and number of CD3-positive cells were detected between Group A and Group B. Group B did not receive any immunosuppressive therapy due to patient refusal to participate in the TIMIC study or clinical onset before TIMIC trial results. All patients were treated with optimal conventional HF therapy. Group A and Group B patients had a long-term follow-up of up to 20 years.In the current study, the entire group of 85 TIMIC trial patients who had undergone immunosuppressive therapy  was compared with a 1:2 propensity score-matched group of patients who had not received immunosuppressive therapy .The study complies with the Declaration of Helsinki, the locally appointed ethics committee approved the research protocol, and informed consent was obtained from all subjects.Long-term effectiveness was assessed in all patients on a yearly basis; routine follow-up visits included clinical evaluation  and non-invasive cardiac studies (ECG and 2D ecocardiography). The New York Heart Association (NYHA) class was used to assess functional capacity, which was determined by a questionnaire.14 In particular, the ejection fraction was calculated in the apical four- and two-chamber views from three separate cardiac cycles using the modified Simpson’s method. Cardiac magnetic resonance imaging (MRI) at baseline and short-term follow-up was not performed systematically and, therefore, not used for comparison in the present study. However, patients with recurrence of myocarditis during long-term follow-up were prescribed cardiac MRI, as previously described.15Echocardiographic studies were performed with Agilent Sonos 5500  (from 2001 to 2013) and with Model P7  (from 2014 to 2021). Patients were imaged, and data were analysed offline by senior echocardiographers. Echocardiographic parameters were determined according to the established criteria.16 and were processed for histology, immunohistochemistry, transmission electron microscopy, and molecular biology.An additional endomyocardial biopsy during the long-term follow-up was considered in case of severe worsening of cardiac function despite full conventional HF treatment. Five to seven samples were drawn from the septal apical region of the left ventricle as previously described2 and/or the presence of more than 2.0 CD3-positive lymphocytes per high power field, often adherent to the contour of cardiomyocytes and focally associated with cell necrosis, were considered diagnostic for myocarditis.In particular, the presence of 14 infiltrating leucocytes/mm17 Two frozen myocardial specimens from each patient were used for real-time PCR analysis to detect the presence of cardiotropic viruses, including adenovirus, Epstein–Barr virus, human herpesvirus 6, parvovirus B19, herpes simplex virus 1–2, cytomegalovirus, enterovirus, influenza A and B viruses, and hepatitis C virus.3In recurrent myocarditis, immunohistochemistry for TLR4 was used to detect the presence of autoimmune activation of cardiomyocytes, according to the evidence that myocardial TLR4 expression is a useful tool to discriminate responders vs. non-responders to immunosuppression.The primary outcome was a composite of cardiovascular death and heart transplantation.Secondary outcomes included each individual outcome of the primary composite outcome plus left ventricular systolic function changes [i.e. LVEF and left ventricular end-diastolic volume (LVEDV) at echocardiography] over time. Specifically, we classified patients as improved if they showed a >10% increase in the absolute LVEF, as in the TIMIC trial.In addition, we evaluated the rate of myocarditis relapse and the number of patients who underwent implantable cardioverter defibrillator (ICD) implantation.18 A logistic regression model was used to obtain propensity scores with the TIMIC protocol defined as the dependent variable, and age, gender, clinical characteristics, and echocardiographic parameters entered as covariates. Matching was performed using the nearest neighbour matching protocol (matching ratio of 1 to 2 without replacement) and a caliper width of 0.01. Assessment of balance in baseline characteristics was performed by estimating standardized differences between groups; standardized difference indicates the degree of systematic differences in covariates between groups. Operationally, a standardized difference >10% represents a meaningful imbalance in a given variable between groups.Propensity score matching was performed to reduce the risk of selection bias. Patients were divided into two cohorts: patients treated with the TIMIC protocol  and patients not treated with the TIMIC protocol (matched control group). Due to differences in key baseline characteristics, and echocardiographic and electrocardiographic parameters, we used PSM for the two cohorts and assembled a cohort for each comparison; all the measured covariates were well-balanced across comparator groups. The propensity score is defined as the subject’s probability of receiving a specific treatment or exposure  given a set of measured baseline covariates.t-test, the χ2 test, and the Fisher exact test were used for comparison. For all tests, a P-value of <0.05 was considered statistically significant.Normal distribution of variables was assessed with the Kolmogorov–Smirnov test. For continuous variables, descriptive statistics were provided , while the median (interquartile range) was used for non-normal data. Categorical data were presented as numbers (percentage). Student’s The Kaplan–Meier method was used to estimate cumulative event rates in the two groups. Differences in each group were compared using log-rank tests. The Cox regression hazard model was performed to obtain the hazard ratio (HR) for the primary and secondary endpoints.All statistical analyses were performed using STATA statistical analysis software (version 16).Tables 1 and 2.Clinical and echocardiographic data of patients enrolled in the two groups at baseline and long-term follow-up are summarized in P = 0.49), and most patients were in NYHA Class III or IV. Six months after immunosuppressive treatment, Group A patients showed a significant improvement in LVEF and a reduction in LVEDV compared with baseline; overall, 96.5% of patients were in NYHA Class I and II. This effect persisted over a long-term follow-up period   and was also documented in patients with severe left ventricular dilation and dysfunction at baseline. Conversely, no significant changes in LVEF occurred in Group B patients during a short- and long-term follow-up period. Overall, Group A had a significantly higher LVEF than Group B at long-term follow-up.At baseline, the mean LVEF for the two groups of patients  was comparable  vs. Group B: 14 (8.2%); P = 0.62].A higher number of patients in Group B underwent ICD implantation [Group A: 9 (10.6%) vs. Group B: 72 (42.7%); Figure 2.The cumulative incidence of recurrence, composite endpoint, heart transplantation, and death during follow-up is shown in Table 4. Four of them  had a history of autoimmune diseases (i.e. Hashimoto thyroiditis in three cases and autoimmune piastrinopenia in one case); the remaining patient  had a recurrence after 13 years following a flu-like syndrome. Cardiac MRI was suggestive of myocarditis, according to the Lake Louis criteria.15 In particular, tissue oedema was present in 60% of patients, while hyperaemia and late gadolinium enhancement, suggestive of fibrosis, were present in all patients and were mainly located in the mid-lateral basal segment of the left ventricle with either a mid-wall or sub-epicardial pattern of distribution. All five patients underwent a new endomyocardial biopsy after providing informed consent. No periprocedural complications were observed. Histology and immunohistochemistry showed a reactivation of the inflammatory process  and transmission electron microscopy revealed areas of myofibrillolysis  occupied by cytosolic components. In one patient (n. 5 in Table 4) with a left bundle branch block, inflammation of the conduction tissue was demonstrated at endomyocardial biopsy . None of them were positive for cardiotropic viruses. Patients were prescribed immunosuppressive therapy with the same 6-month TIMIC protocol.Five Group A patients (6%) experienced a worsening of cardiac function in the long term (9.8 ± 2.3 years). The characteristics of these patients are described in Table 4). Cardiac MRI showed a significant improvement in cardiac function with the disappearance of tissue oedema and hyperaemia and persistence in the areas of fibrosis. Control biopsy showed a resolution of the inflammatory process. Transmission electron microscopy showed an increase in the myofibrillar content compared with the first biopsy and the disappearance of areas of myofibrillolysis . Of note, the efficacy of immunosuppression on inflammation and cardiac function did not differ between first-time and relapsing myocarditis.Clinical assessment, resting ECG, and 2D echocardiography were performed at baseline, weekly during the first month, and every 4 weeks for the remaining 5 months. Control cardiac MRI, cardiac catheterization, angiography, and left ventricular endomyocardial biopsy were performed at 6-month follow-up  and intermediate-term follow-up (up to 2 years).10 A more recent analysis of prospective and retrospective studies showed lower mortality and improved cardiac function with immunosuppression, especially when patients were diagnosed with virus-negative biopsy-proven immune-mediated myocarditis.5The position statement of the European Society of Cardiology recommends the individualized use of immunosuppression in infection-negative lymphocytic myocarditis refractory to standard therapy, as well as in patients with proven autoimmune forms of myocarditis .19 The randomized, double-blind, placebo-controlled TIMIC trial was designed as a result of the findings of this retrospective study; its findings demonstrated a positive impact of immunosuppression on left ventricular function recovery in a high proportion (88%) of patients. Remarkably, a striking improvement occurred even in patients with extreme left ventricular dilatation and dysfunction; these findings suggested a long-lasting history of the disease and were associated with a concomitant disappearance of inflammatory infiltrates with the progression of the disease from an active towards a healed form at histological examination. Moreover, arrhythmia control, as well as conduction system (i.e. left bundle branch block) functional recovery, resulting in a restored biventricular synchrony,20 were also documented, while no deaths or cardiac transplantation occurred during the 6 months of the trial (short-term follow-up).Immunosuppression should be started only after ruling out any active infection on endomyocardial biopsy by PCR analysis. Indeed, a retrospective study performed on patients on immunosuppressive treatment prescribed without preliminary viral genome search showed that those with a myocardial viral infection were unresponsive to the treatment.In the present study, we reported the long-term data of patients originally recruited in the TIMIC trial. This is the first study on immunosuppression in inflammatory cardiomyopathy, describing the long-term efficacy of this treatment on cardiac dimension and function and on HF symptoms over a very long follow-up period (up to 20 years). Of note, similar functional improvements persisted over time also in patients with severe left ventricular dilation and dysfunction at the time of diagnosis.9In the present study, a 1:2 propensity-matched comparison was performed among TIMIC patients and those receiving conventional therapy. In the latter group, cardiac function did not significantly improve, and patients had a higher incidence of death, cardiac transplantation, and the need for ICD implantation. These data are in agreement with a previous study reporting 10-year follow-up outcomes in patients with virus-negative chronic myocarditis or inflammatory cardiomyopathy treated with immunosuppression; this study showed a correlation between long-term functional improvement and normalization of the inflammatory process at histology.There is another important finding of our study that deserves further consideration. Specifically, the effectiveness of the TIMIC treatment was also demonstrated in patients who were initially allocated to the placebo arm of the trial and were subsequently switched to immunosuppressive therapy at study completion as a result of the documented superiority of immunosuppressive therapy. This observation is suggestive of a long-lasting persisting focal myocardial inflammation that does not resolve spontaneously or with supportive therapy alone.Structured Graphical Abstract).The adoption of immunosuppression had important prognostic implications, since most treated patients did not experience new hospitalizations over time and progressively down-titrated the prescribed HF supportive treatment. This led to a significant cost reduction for the National Health System, especially since most patients were young with a long life expectancy. Mortality, need for heart transplantation, or ICD implantation occurred in a small number of patients who did not respond to immunosuppression (21 and that a close follow-up should be reserved for this cohort. Of note, all these patients showed cardiac functional recovery once immunosuppressive therapy was prescribed at the time of the index episode of myocarditis; similar beneficial effects occurred at the time of relapse once a new 6-month cycle of immunosuppression at the same dosage was started. Thus, immunosuppressive treatment can be safely repeated if a recurrence of virus-negative immune-mediated myocarditis occurs.Among TIMIC patients, 6% experienced a recurrence of myocardial inflammation at long-term follow-up. Cardiac function worsening was paralleled by the evidence of a reactivation of the inflammatory process in the absence of myocardial viral genomes documented via cardiac MRI and histology. Four of these five patients with relapsing myocardial inflammation had an associated autoimmune manifestation, such as Hashimoto thyroiditis and autoimmune thrombocytopenia. These findings suggest that some individuals can be more susceptible to an inflammatory myocardial immune-mediated process that an unknown trigger can reactivate, similar to what happens in patients with systemic autoimmune diseasesCardiac MRI was performed on a limited number of patients as this study was conducted at a time when this imaging technique was poorly available. Nevertheless, cardiac MRI was performed in all patients with recurrence of myocarditis before and after the application of the TIMIC protocol and showed the resolution of oedema and hyperaemia at follow-up, with persistence in the areas of fibrosis as suggested by late gadolinium enhancement.Virus-negative inflammatory cardiomyopathy may benefit from immunosuppressive therapy also after long-term follow-up. Recurrences of virus-negative myocardial inflammation appear to respond to a new TIMIC protocol application.


The emergence of a heavily mutated SARS-CoV-2 variant  and its rapid spread to over 75 countries raised a global public health alarm. Characterizing the mutational profile of Omicron is necessary to interpret its clinical phenotypes which are shared with or distinctive from those of other SARS-CoV-2 variants. We compared the mutations of the initially circulating Omicron variant (now known as BA.1) with prior variants of concern , variants of interest , and ~1500 SARS-CoV-2 lineages constituting ~5.8 million SARS-CoV-2 genomes. Omicron’s Spike protein harbors 26 amino acid mutations  that are distinct compared to other variants of concern. While the substitution and deletion mutations appeared in previous SARS-CoV-2 lineages, the insertion mutation (ins214EPE) was not previously observed in any other SARS-CoV-2 lineage. Here, we consider and discuss various mechanisms through which the nucleotide sequence encoding for ins214EPE could have been acquired, including local duplication, polymerase slippage, and template switching. Although we are not able to definitively determine the mechanism, we highlight the plausibility of template switching. Analysis of the homology of the inserted nucleotide sequence and flanking regions suggests that this template-switching event could have involved the genomes of SARS-CoV-2 variants , other human coronaviruses that infect the same host cells as SARS-CoV-2 , or a human transcript expressed in a host cell that was infected by the Omicron precursor. The Technical Advisory Group on SARS-CoV-2 Virus Evolution and classification of Omicron as a variant of concern by the WHO within 48 h facilitated timely epidemiological surveillance. After its initial discovery, this variant rapidly spread across the globe and was detected in over 75 countries across 6 continents by 16 December 2021 . Fo. Fo14]. First, substitutions can be introduced within the inserted sequence during template switching itself, or during subsequent rounds of viral replication, which would result in imperfect matching between the insertion and template sequences. This is particularly relevant for Omicron, which represents a long phylogenetic branch that arose after presumably several months of unobserved evolution ,47. We iCoronaviridae family, at relatively high frequencies . We. We14]. Nevertheless, we still assessed the homology between the 35 nucleotides upstream or downstream of the Omicron insertion and the 35 nucleotides upstream or downstream of all candidate templates (see Methods). The NHS distributions for these candidates were generally similar to the distributions observed previously for randomly selected SARS-CoV-2 35-mers . CandidaOmicron is more highly transmissible than prior variants ,63, is lWhile we cannot definitively determine the mechanism that gave rise to ins214EPE, we propose that template switching is a plausible explanation . AlthougThere may be additional mechanisms that contribute to the acquisition of insertions by SARS-CoV-2 beyond those considered here. Saltational viral evolution in immunocompromised patients has been suggested to underlie the emergence of highly mutated variants , and it It is not clear whether any one of these insertion-generating mechanisms would have more far-reaching consequences than the others. Template switching offers the intriguing possibility of new SARS-CoV-2 lineages borrowing protein domains or subdomains from previous variants, other viruses, or human proteins. However, it is worth noting that several of the possible templates that we identified for ins214EPE were derived from viral anti-genomes  or the reverse-complement sequences of human transcripts . In such cases, the polypeptide encoded in the Omicron genome would differ from that encoded by the positive-sense strand of the template. The genomic location and/or amino acid content of the inserted sequence may be more important than its origin, and we thus highlight the need to characterize the functional impact of ins214EPE on the clinical and epidemiological properties of the Omicron variant. Importantly, the data and hypotheses presented here are not sufficient to make inferences about properties such as transmissibility, immune evasion, or disease severity. Even if Omicron did acquire an insertion by utilizing a host transcript or the genome of a common-cold-causing coronavirus , we do not propose that this would explain the reduced severity of COVID-19 observed in patients infected with Omicron compared to prior VOCs ,82,83,84Multiple studies have demonstrated reduced effectiveness of COVID-19 vaccines against the Omicron variant compared to prior variants, including both primary vaccination series and booster doses ,87,88,89The rapid rise in COVID-19 cases attributed to the Omicron variant, including among fully vaccinated individuals, raised alarm globally. In this context, it is important to better understand both the origins and the consequences of new genomic alterations that distinguish Omicron from prior VOCs and VOIs. Here, we begin to address the former by providing several plausible hypotheses on the origins of a nine-nucleotide insertion in the N-terminal domain of the Spike protein of the initially identified Omicron BA.1 variant. We suggest that genomic surveillance strategies should include an emphasis on sequencing SARS-CoV-2 genomes from immunocompromised patients and individuals with viral co-infections (including co-infections with multiple SARS-CoV-2 variants), as such individuals may provide unique contexts for genomic recombination and the evolution of new variants.


Background: M7G modification is extremely vital for the development of many cancers, especially tumor immunity. M7G modification is a novel functional regulator of miRNA, and the researches on m7G-related miRNAs in kidney renal clear cell carcinoma (KIRC) are still insufficient. This research aims to establish a risk signature on the foundation of m7G-associated miRNAs, which can precisely forecast the prognosis of KIRC patients.Methods: Transcriptome data and clinical data used in this study come from The Cancer Genome Atlas database. Our team utilized univariable Cox, Lasso and multivariable Cox analyses to construct a m7G-associated miRNAs risk signature that can forecast the prognosis of KIRC patients. Kaplan-Meier method, time-dependent receiver operating characteristic (ROC) curve, and the independent analysis of risk signatures were employed to verify the predictability and accuracy of the risk signature. Subsequently, based on CIBERSORT, ESTIMATE and ssGSEA algorithms, we speculated the potential impact of the proposed risk signature on tumor immune microenvironment. Ultimately, by virtue of the risk signature and tumor immunity, the hub genes affecting the prognosis of KIRC patients were screened out.Results: Our team established and verified a prognostic signature comprising 7 m7G-associated miRNAs . The results of the Kaplan-Meier survival analysis revealed that the prognosis of KIRC sufferers in the high-risk group was often unsatisfactory. The accuracy of the prediction ability of the risk signature was verified by calculating the area under the ROC curve. Univariate-multivariate Cox analyses further showed that this risk signature could be utilized as an independent prognosis-related biomarker for KIRC sufferers. The results of the immune analysis revealed that remarkable diversities existed in immune status and tumor microenvironment between high-risk and low-risk groups. On the foundation of the proposed risk signature and other clinical factors, a nomogram was established to quantitatively forecast the survival of KIRC sufferers at 1, 3 and 5 years.Conclusion: Based on m7G-related miRNAs, a risk signature was successfully constructed, which could precisely forecast the prognosis of sufferers and guide personalized immunotherapy for KIRC patients. Renal cell cancer takes up 2%–3% of adult malignancies, second only to prostate carcinoma and bladder carcinoma in urinary system cancers, whereas it is the most deadly malignancy of the urinary system . Kidney METTL1 (methyltransferase like 1) and WDR4 (WD Repeat Domain 4)  . M7G modn cancer . METTL1 arcinoma . Abnormaarcinoma .MicroRNAs (miRNAs) are short single-stranded ncRNA molecules (19–25 nucleotides), which regulate gene expression after transcription and are indispensable in many biological processes like differentiation, apoptosis, drug resistance, proliferation, and metastasis . Some reIn this research, our team utilized The Cancer Genome Atlas (TCGA) public database to construct and verify a risk signature on the foundation of m7G-associated miRNAs, which could accurately forecast the prognoses of KIRC sufferers. It is proven that this risk signature can be utilized as an independent prognosis biomarker for KIRC patients, and it can also facilitate individualized immunotherapy for KIRC patients clinically. Finally, we used our risk signature and other clinical factors to establish a nomogram that could quantitatively forecast the overall survival (OS) rate of KIRC sufferers.The flowchart of the present research is displayed by n = 258, for the construction of the m7G-related miRNAs risk signature) and the testing cohort .By excluding some samples with incomplete data, a total of 516 KIRC samples with complete miRNA/RNA sequencing data and clinical data were used for subsequent analysis . The 516METTL1 and WDR4) that were confirmed to be associated with m7G modification on miRNA (https://www.targetscan.org) online database to predict the upstream miRNA of m7G-related genes and obtained m7G-related miRNAs. The “edgeR” package of R program was used to select differentially expressed m7G-associated miRNAs in KIRC tissue samples and normal kidney tissue samples (selection criteria: |log2 Fold Change (FC)| > 1, False Discovery Rate (FDR) < 0.05)  . The expp < 0.05). Lasso regressive analyses were further used to optimize the selection of prognostic m7G-related miRNAs  survival curve (Log-rank test) was employed to evaluate OS diversities between these 2 groups. The accurateness of the modeling method was evaluated by calculating the area under the ROC curve (AUC) values. Univariable-multivariable Cox proportional risk analysis was utilized to evaluate whether risk scores and clinical features were independent prognostic biomarkers for KIRC patients.Taking the median risk score of the training cohort as the threshold, KIRC patients in each cohort  were divided into the riskvia R-package “rms”. Nomogram can quantify the factors that affect the prognosis of patients with KIRC and predict the prognosis of patients with KIRC quantitatively. Subsequently, calibration curves were developed to illustrate the predictive power of the established nomogram. The calibration curve describes the calibration of each model according to the consistency between the predicted survival time of KIRC patients and the observed survival time of KIRC patients. The y-axis represents the actual survival time of KIRC patients. The x-axis represents the predicted survival time of KIRC patients. The dotted line indicates the perfect prediction of the risk model. The solid line of pink indicates the performance of nomogram, and the dotted line closer to diagonal indicates better prediction.On the foundation of risk scoring and other clinical independent prognostic factors, a nomogram risk identification model was established http://tide.dfci.harvard.edu) (high group and risklow group.We quantified the quantity of immunocytes in every specimen using the “Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT)” algorithm . The sinard.edu) . The tumard.edu) , includi50 values of therapeutic medicines were calculated by the R package “pRRophetic”. The values of IC50 represent 50% inhibited cells, that is, the cell survival rate is half of the control sample, which is the corresponding drug concentration. The lower the IC50 value, KIRC patients are more sensitive to this drug.We downloaded the somatic cell mutation data of KIRC tissue samples from the TCGA database (TCGA.KIRC.varscan.somatic.maf.gz). Tumor mutation burden (TMB) scoring was calculated based on somatic mutation data. The IChigh group and risklow group . As per the immunoscore in the TME scoring of each KIRC patient, KIRC patients were separated into 2 groups: the high-immunity group and the low-immunity group. The differentially expressed immune-related genes were obtained by the same method. Risk-immune-related genes were acquired via the intersection of risk differential genes and immune differential genes. The prognostic significance of these risk-immunity-associated genes was assessed by univariable Cox analyses. Spearman correlative analysis was employed to evaluate the association of prognostic risk-immunity-associated genes with immunocytes and immunofunction. Gene Ontology (GO), Kyto Encyclopedia of Genes and Genomes (KEGG) and Disease Ontology (DO) analyses were completed on risk-immunity-associated genes to explore the biological processes and potential signal pathways related to these genes (https://cn.string-db.org/cgi)  in the riskse genes . These porg/cgi) .p < 0.05, the above statistical methods had statistical significance. All analysis was conducted using R version 4.1.0 and the corresponding feature packages.Log-rank test was used for the K-M approach to create the survival curve. The Chi-square test was utilized to determine the diversities between different data sets or different classified data, and the Wilcoxon-rank test was utilized to determine the diversities between these 2 groups. Spearman method was used for correlation analysis, and cox proportional regressive analysis was employed to evaluate the influence of gene expression and clinical features on the prognoses of sufferers. When METTL1 and WDR4 in 18 tumor types and found that these two m7G-related genes were differentially expressed in many tumors, showing significant heterogeneity , the greater the expressing levels of METT1 and WDR4, the worse the prognoses of KIRC sufferers (https://www.targetscan.org), and altogether 792 m7G-related miRNAs were acquired  with positive coefficients can be deemed as the factors of unsatisfactory prognoses of sufferers, i.e., the increased expression of these miRNAs is associated with the low OS rates of sufferers, whereas 2 miRNAs (miR-1251-5p and miR-486-5p) with negative coefficients may be used as KIRC inhibitors, i.e., the increased expression of these 2 miRNAs is beneficial to the prognoses of KIRC sufferers, which has been verified in the KM survival curve , and multivariable Cox regressive results (p < 0.01) further evidenced that risk scoring could serve as independent prognosis biomarkers in KIRC patients regardless of clinical characteristics  and risk scoring for the quantitative prediction of 1-, 3-, and 5-year survival in KIRC patients . Subsequhigh group was higher, which suggested that there was a potential connection between risk scoring and the TME of KIRC sufferers. high group and risklow group. The scoring of CD8+ T cells, Mast cells, Macrophages and other immune cells was different between the riskhigh group and risklow group , etc., is greater in the riskhigh group  between the two risk groups . The TMEow group . There wow group . It can gh group . The rese escape . By complow sufferers displayed the mutation, whereas only 75.66% riskhigh sufferers displayed such mutation  in the riskhigh group and risklow group  in risklow patients is lower   (http://www.lirmed.com) shows that these risk miRNAs are mainly enriched in relevant functional pathways such as hematopoiesis, epidemiological-to-immunological transition, immune response, angiogenesis, etc. (As we have come to the conclusion that the risk scoring may be remarkably associated with the immune status and TME of KIRC patients. We will perform further research on the relationship among the expression of Seven risk miRNAs and immune status and TME.  < 0.05) . With th < 0.05) . The enris, etc. . The pothigh group and risklow group in a complete cohort . Based on the immune score of TME scoring, 4,358 immune-related DEGs were determined in the high-immunoscore group and low-immunoscore group . By crossing the two DEGs, a total of 1,548 DEGs related to risk score and immune score were obtained  that can improve the OS rates of patients with KIRC to a certain extent, the prognosis of patients with advanced KIRC is still not satisfactory. Some of the existing biomarkers of KIRC that have been verified have very limited predictive ability, which is not enough to meet the needs of clinical diagnosis, treatment and the prediction of patient survival. Hence, it is imperative to find a biomarker which can precisely forecast the prognoses of KIRC sufferers and provide guidance and assistance for individualized treatment to avoid under-treatment and over-treatment.METTL1 and WDR4 that are related to m7G modification on miRNA have been proved to be tightly associated with the onset of various diseases, and they are differentially expressed in various tumors including KIRC. In addition, they are also remarkably associated with the OS rates of KIRC sufferers. However, whether the m7G-related miRNAs signature can be utilized as a prognosis index for KIRC sufferers has not been elucidated.M7G is a modification method of miRNA, which is related to the initiation of miRNA biogenesis, cell migration, tumor immunity and other biological processes. Recent studies and literature reports have shown that the abnormal expression of miRNA can affect the progress of many kinds of tumors, and that it is tightly associated with the prognosis of patients. Currently, there are many signatures based on miRNA that can precisely forecast the OS rates of sufferers, for example, m6A-related miRNAs signature can be utilized as a marker to forecast the prognoses of esophageal carcinoma patients ; the sighigh sufferers is lower vs. risklow sufferers. Then, the ROC curve proved the accurateness of the signature in forecasting the prognoses of sufferers. Univariable-multivariable Cox analyses revealed that the risk score could be utilized as an independent prognostic index for KIRC patients. All these results were verified in the test cohort and full TCGA cohort. In addition, to facilitate the clinical application of signature risk score, our team constructed a nomogram to forecast the survival of KIRC sufferers in a quantitative manner. These results show that our prediction risk signature has great clinical application value in evaluating the prognosis of KIRC sufferers.Based on m7G-related miRNAs, our team established a prognostic risk signature comprising 7 m7G-associated miRNAs by univariable Cox, LASSO and multivariable Cox analyses. And a risk scoring computation equation was obtained to compute the risk scoring of every KIRC sufferers. In order to further assess the ability of the siganture in forecasting the prognoses of KIRC sufferers, it can be concluded by survival analyses that the OS of riskhigh patients have a high level of immunocyte infiltration, and the expressing levels of common immune checkpoint-associated genes in most riskhigh patients are higher vs. risklow patients. It indicates that the immune activity of riskhigh sufferers is higher. In addition, by comparison with riskhigh sufferers, the TIDE scoring of risklow sufferers is lower, which suggests that risklow sufferers have higher immune escape potential. This indicates that riskhigh sufferers can benefit from ICB therapy. These results reveal that riskhigh sufferers may benefit more from immune therapy. These immune analysis results can be helpful for guiding individualized immunotherapy for KIRC patients. In addition, we also analyzed the difference in TMB between the riskhigh and risklow groups, and the TMB of risklow sufferers was higher vs. riskhigh sufferers. Although this result was not statistically significant, it also explained the relationship between signature based on m7G-related miRNAs and TMB to some extent. We also tried to facilitate the clinical instruction of KIRC drug treatment based on our signature. By comparing the IC50 values of common drugs in different risk groups to speculate the potential drug sensitivity, it can be seen that AMPK activator (AICAR) is more suitable for riskhigh sufferers, while JAK1/2 inhibitor (Ruxolitinib) has lower IC50 values in risklow sufferers, which indicates that the therapeutic effect of Ruxolitinib is more beneficial to risklow sufferers. The prediction of the efficacy of these potential drugs can be helpful for the individualized drug treatment of KIRC.Our team also discussed the association among risk scoring and tumor microenvironment, common immune checkpoints. Because of the diversities in TME in diverse groups, these differences can promote the proliferative, migratory and invasive abilities of KIRC, which also explains the significant differences in prognoses amongst diverse groups. It can be seen that most riskmiR-342-3p, miR-223-3p, miR-1277-3p, miR-221-3p, and miR-6718-5p) in cancer samples are greater in contrast to healthy samples. These 5 risk miRNAs can be considered risk factors for KIRC patients. The expressing levels of miR-1251-5p and miR-486-5p are low in cancer samples, which can be regarded as protective factors for patients with KIRC. And the results of K-M survival curve verify our conclusion. There are also some literature reports about the roles of these 7 risk miRNAs in tumorigenesis and development. For example, over-expressed miR-1251-5p can inhibit the proliferative, migratory and immunoescape-related abilities of KIRC cells (miR-486-5p can repress the proliferative ability and promote the apoptosis of KIRC cells (miR-223-3p can facilitate the proliferative and metastatic abilities of renal clear cell carcinoma by downregulating SLC4A4 (miR-1251-5p and miR-486-5p can act as protective factors for KIRC; highly expressed miR-1251-5p and miR-486-5p can prolong the survival of KIRC patients; miR-223-3p is a risk factor for KIRC; and the high expression of miR-223-3p can cause poor prognoses in KIRC patients. Although the other 4 risk miRNAs are not reported in KIRC, they are reported in other tumor diseases. For example, miR-342-3p can stimulate the malignant potential of NSCLC by regulating the expression of LASP1 (miR-221-3p can promote angiogenesis in cervical cancer by regulating the expression of THBS2 (in vivo and in vitro assays to explore the causal link and function of risk miRNA, which are rarely reported in KIRC. With the increasing popularity of targeted therapy in recent years, nowadays, the targeted therapy of KIRC is also developing persistently, which brings us a hint that these seven risk miRNAs may foster the targeted therapy of KIRC.We further analyzed the influence of the expression of seven risk miRNAs that make up the prognosis signature on the patients with KIRC, and the results show that among these seven risk miRNAs, the expressing levels 5 miRNAs (RC cells , and oveRC cells , while mg SLC4A4 . These fof LASP1 , and miRof THBS2 . Most ofFinally, based on the predicted signature risk score and the immunoscore, we obtained the risk-immunity-associated genes and analyzed the influence of these genes on the prognoses of KIRC sufferers. Subsequently, our team established a PPI net and screened out 10 hub genes. These hub genes may affect the progress of KIRC through m7G modification on miRNA and immune-related ways. In the future, we can focus on the mechanism and function of these hub genes affecting the progress of KIRC at the m7G level and immune level, providing new assistance to the early diagnosis and treatment of KIRC.in vivo and in vitro assays in the next stage. Although there are some shortcomings, it is the first time that a signature based on m7G-miRNAs can precisely forecast the prognoses of KIRC sufferers, hence, the present research is quite promising in terms of clinical practice.The aforesaid results show that the risk signature of prognosis prediction based on m7G-related miRNAs has reliable predictability and sensitivity. Comparing our prediction model with the published KIRC prognosis prediction model, we come to the conclusion that our model is superior to other KIRC prognosis prediction models. Generally speaking, the signature based on m7G-related miRNAs can precisely forecast the prognoses of sufferers and can foster the diagnosis and personalized treatment of KIRC. However, our research still has great limitations. First of all, our signature is only verified internally, and no suitable external data set has been found in the published database for the purpose of further evaluating the reliability of our signature. Secondly, we need further functional experiments to verify the relationship between risk miRNAs and m7G modification. Finally, as our research content is retrospective, we need to further verify our conclusion via Our team smoothly established a prognosis-related risk signature on the foundation of m7G-associated miRNAs and verified its accuracy and reliability. A nomogram that could forecast the OS of KIRC sufferers in a quantitative manner was also established. The influence of risk score on the immune microenvironment and immunocyte infiltration of KIRC sufferers was also discussed. Our research results can accurately evaluate the prognosis of KIRC patients and facilitate individualized immunotherapy for KIRC patients. In addition, the identified 7 risk miRNAs are expected to be therapeutic targets for KIRC patients.


Physical activity (PA) confers numerous benefits to health and health care costs, yet most adults are not meeting recommended PA guidelines. Stress may be a factor that influences PA behavior. Research investigating the impact of stress on PA has yielded inconsistent findings. Most studies find that stress negatively impacts PA, but there is some evidence that habitual exercising buffers this association.This study aims to examine the relationship between stress and exercise habits among habitual exercisers with internet-connected home fitness equipment (Peloton Bike) during the COVID-19 lockdown.Participants were recruited through Facebook (N=146) and asked to complete an internet-based survey that assessed COVID-19–related stressors, perceived stress associated with those stressors, and general perceived stress. Self-reported exercise was assessed on the survey using the Godin Leisure-time Exercise Questionnaire (GLTEQ). Participants were also asked for consent to access their Peloton usage data through the Peloton platform. From their usage data, the frequency and duration of cycling classes was calculated for 4 weeks prior to and 12 weeks following the survey. Hierarchical regression equations tested the association between stress reported on the survey and subsequent exercise participation. Exercise participation was quantified both as the frequency and duration of Peloton cycling over the 12 weeks following the survey and as self-reported moderate to vigorous activity on a second survey completed by a subset of participants 12 weeks after the initial survey.R2=0.57; F2,143=95.27; P<.001) and duration  for the 12 subsequent weeks. Self-reported overall exercise likewise showed that this sample was very active, with an average of more than 8 times per week of moderate to vigorous exercise at the initial survey. Self-reported exercise on the initial survey was a strong predictor of self-reported exercise 12 weeks later . Perceived stress did not impact Peloton cycling duration or frequency  or self-reported exercise (P=.28).There were 146 participants in our Peloton analysis sample and 66 in the self-reported exercise analysis. Peloton user data showed that study participants cycled frequently (mean 5.9 times per week) in the month prior to the initial survey, and that presurvey Peloton use was a strong predictor of exercise frequency (The results suggest that stress did not negatively impact exercise participation among habitually active adults with access to internet-connected home fitness equipment. Habitual exercise may buffer the impact of stress on participation in regular moderate to vigorous activity. Future research should examine the role that the availability of home-based internet-connected exercise equipment may play in this buffering. It is well established that physical activity (PA) offers many health benefits including improved muscular strength ,2, cardiAmong the many factors that influence participation in PA, stress plays a complex role, with many studies indicating that stress negatively impacts PA participation, and a few suggesting that this association is absent or even inverted among habitual exercisers. Exercise has been defined as a subset of PA that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness . PerhapsAlmost three-fourths of 168 studies on the stress-PA association reviewed by Stults-Kolehmainen and Sinha . SimilarInvitations to participate in a study of Peloton Bike use and health were posted to 2 Facebook pages devoted to discussion of the Peloton Bike for 4 weeks during December 2020 to January 2021, during the time that many US residents were living under a stay-at-home order. For example, on December 3, 2020, the California Department of Public Health issued a stay-at-home order . ReflectA link in the invitation posted to Facebook directed potential participants to an internet-based survey. Within the survey, they provided consent to participate in the research and completed a survey on Peloton Bike use and health. Respondents were also asked to provide their Peloton username and permission for the study to access their archived usage data from the Peloton platform. Surveys were administered using the Research Electronic Data Capture (REDCap) tool ,29. REDCOver the course of this 4-week period, 225 surveys were completed. A follow-up survey request was sent via REDCap 12 weeks after each respondent completed the initial survey. The timing of the follow-up survey request was automated so that the request went out 12 weeks after the first survey was completed. To encourage responses, 2 additional reminder invitations were emailed at 3-day intervals after the first request. A total of 66 follow-up surveys were returned (response rate 45%).Peloton usage data were accessed via the “follow” function of the Peloton app. After acquiring respondents’ permission, we used Peloton’s application programming interface (API) to access the exercise data of our survey participants. Using each participant’s Peloton username, we downloaded data from the riders’ first ever cycling class through 12 weeks after the initial survey was completed, which included the date and duration of each cycling class. For each participant, we defined 2 fixed dates for our analysis: the start date (starting date of using the Peloton Bike continuously) and the initial survey date. We defined the start date as the first date after which the user had at least 4 workouts within a 4-week period. Using this definition, we were able to adjust the start date to account for participants who may have set up a Peloton account for a single trial and then entered a period of no activity until they obtained their own Peloton Bike. We divided the participants’ activities into pre- and postsurvey activities in reference to the date on which the participant completed the initial REDCap survey.For purposes of sample characterization, respondents were asked to self-report age, gender, race or ethnicity, the highest level of education completed, and whether they were a California resident.never to very often with reference to the past month. The scale showed strong internal reliability in the present sample (Cronbach α=.86).General perceived stress was assessed on both the initial and the follow-up surveys using the 10-item version of the Perceived Stress Scale (PSS) developed and validated by Cohen et al . A revienot at all stressful to extremely stressful. A total perceived COVID-19 stress score was obtained by computing the mean of all the COVID-19 perceived stress scores. This scale has not been previously validated. In this study, the correlation between total perceived COVID-19 stress and general perceived stress (assessed using the PSS) was significant .A modified version of a COVID-19 stress scale developed by Park et al  was usedOn the REDCap survey, participants were asked to report their participation in exercise for 3 life stages: teenage, twenties, and now. Using the Godin Leisure-time Exercise Questionnaire (GLTEQ)  format, Data retrieved from the Peloton API were used to estimate exercise behavior in the 4-week period prior to the initial survey and for the 12 weeks following the initial survey. For the 4-week period prior to the survey completion, a mean number of cycling days per week was computed as an indicator of frequency of exercise. Similarly, for the 12 weeks following survey completion, frequency was expressed as mean number of cycling days per week. The duration of cycling per week (both pre- and postsurvey) was calculated as the mean number of minutes per week.Hierarchical regression equations were used to test the association between perceived stress and exercise. Parallel analyses were conducted first using estimates of exercise participation (frequency and duration) derived from the Peloton data on cycling during the 12 weeks after the survey  and second using the self-reported data on moderate to vigorous exercise reported on the 12-week follow-up survey. Step 1 of each regression analysis controlled for age and gender. Step 2 controlled for exercise behavior at the time of the first survey . Perceived stress (assessed using the PSS) was entered on step 3 of each analysis.This study was determined to be exempt from human subject research ethics review. Study participants provided affirmative consent for the research even though there was a waiver of consent owing to data deidentification, public availability of the Peloton data, and usage of standard survey procedures. No compensation was provided to the study participants.t116=4.23; P<.001) or that during their twenties . Exercise behavior was not significantly different between participants in their teens and those in their twenties (P=.43). A comparison of respondent characteristics between the full survey sample of 225 respondents and the subsample included in the Peloton cycling analysis (N=146) revealed no significant differences in demographics, stress levels, or self-reported exercise participation. A comparison of the study participants who completed the 12-week follow-up survey with those who did not revealed that the mean education level was higher among those who completed the second survey . Among participants who did not complete the follow-up survey, 42% of them reported having a graduate degree, whereas among those who did complete the follow-up survey, 66% of them had a graduate degree. No other differences were found among the 146 participants in the Peloton data analysis and the 66 participants who completed the follow-up survey.Responses to the items assessing COVID-19 stressors indicated that these were very prevalent , with thr=0.67; P<.001), suggesting that stress levels were fairly stable over time.Responses to the Cohen PSS indicated that the mean PSS score among participants  was on the high side of the “moderate” range, typically given as 14-26. Stress levels across the 2 surveys separated across 12 weeks were highly correlated . In the week immediately following the survey, study participants completed a mean of 3.92 (SD 2.04) days of cycling and engaged in a mean of 156.89 (SD 108.77) minutes of cycling. During the last week of the 12-week period, participants completed a mean of 3.32 (SD 2.20) days of cycling and engaged in a mean of 122.98 (SD 97.67) minutes of cycling. During the final week of the 12-week monitoring period, 37% of participants met or exceeded 150 weekly minutes of cycling.R2=0.05; F1,144=8.45; P=.004) and Peloton cycling frequency . The model in step 2, in which Peloton usage during the 4 weeks prior to the survey was entered as a predictor variable, was a significant predictor of the frequency of postsurvey Peloton cycling  and for predicting the duration of postsurvey Peloton cycling . The change in R2 in step 2 suggested that presurvey exercise explained approximately 50% of the variance in postsurvey exercise. The regression models in step 3 of the 2 different equations examining the relationship of stress (assessed using the PSS) to postsurvey Peloton usage revealed that stress was not significantly associated with postsurvey cycling .As gender was not significantly associated with Peloton cycling (frequency or duration) in any of the equations, gender was excluded, and the analyses were rerun with only age as a covariate in step 1. Age significantly predicted Peloton cycling duration . There was no change in R2 values when stress was entered into the model, and stress was not significantly associated with overall exercise at 12 weeks (P=.28).In the regression analysis examining the impact of stress (assessed using the PSS) on overall self-reported exercise (assessed using the GLTEQ), neither age nor gender were associated with exercise at 12 weeks; hence, the analysis was performed without these 2 potential covariates. Overall moderate to vigorous exercise reported on the initial survey significantly predicted overall exercise reported on the 12-week follow-up survey  may limit the appeal to certain subgroups of individuals and may limit the generalizability of our research findings, as a model for conducting efficacy studies, internet-connected fitness equipment is an attractive option that merits further exploration.Several aspects of this study may limit the extent to which the findings can be generalized outside of this particular sample. The participants in the study were overwhelmingly female and mostly non-Hispanic White, although approximately 30% of them reported affiliation with non-White ethnic or racial groups. Moreover, recruitment for the study was conducted through Peloton Facebook groups. Caution should be exercised, therefore, in generalizing our findings to men, non-White ethnic or racial groups, and persons who do not engage with social media. Another consideration is that the Peloton Bike only collects data when the Peloton Bike is being used. Therefore, there are other forms of activity  that are not captured with this platform, which may have been differently affected by stress experienced during the COVID-19 lockdown. A possible explanation for the downward trend in Peloton Bike usage is that other forms of activity became available as COVID-19 lockdown restrictions were lifted. Nevertheless, even at the end of the 12-week monitoring period, the average duration of cycling was >2 hours per week, which is still sufficient to realize health benefits .It should also be noted that the Peloton Bike functions as a subscription service; hence, in addition to the cost of the equipment, there is a monthly cost associated with accessing the live, on-demand classes. As such, it could be argued that our findings might not be generalizable to individuals who cannot afford this expense. Whether less affluent individuals with access to internet-connected home-based fitness equipment would exhibit a similar resilience to reductions in PA during times of elevated stress is an empirical question that could be explored in future research. There are already cases of health insurance companies providing access to the Peloton app free of charge to their members  and withTo conclude, habitually active adults using internet-connected home fitness equipment maintained their exercise habits while experiencing high stress during the COVID-19 lockdown. This finding emerged using both the in-app cycling data from the Peloton Bike and self-reported moderate to vigorous leisure time activity. Given the strength of the evidence for the health benefits of exercise, identifying strategies for keeping individuals active during times of stress has tremendous public health implications. Future research should examine what role internet-connected home fitness equipment plays in supporting maintenance of exercise during periods of stress.


Operating Room Ramp-Up After COVID-19 Lockdown Ends-Extra Lists (ORRACLE-Xtra).During the quiescent periods of the COVID-19 pandemic in 2020, we implemented a weekend-scheduled pediatric surgery program to reduce COVID-19–related backlogs. Over 100 staff members from anesthesiologists to nurses, surgeons, and administrative and supporting personnel signed up to work extra weekends as part of a novel weekend elective pediatric surgery program to reduce COVID-19–related backlog: In this study, we sought to evaluate staff perceptions and their level of satisfaction and experiences with working extra scheduled weekend elective surgical cases at the end of the 3-month pilot phase of ORRACLE-Xtra and identify key factors for participation.Following the pilot of ORRACLE-Xtra, all perioperative staff who worked at least 1 weekend list were invited to complete an online survey that was developed and tested prior to distribution. The survey collected information on the impact of working weekends on well-being, overall satisfaction, and likelihood of and preferences for working future weekend lists. Logistic regression was used to estimate the association of well-being with satisfaction and willingness to work future weekend lists.P=.02) and willingness to participate in future weekend lists . Many  were willing to work weekend lists that included longer, more complex cases, which was associated with a sense of community .A total of 82 out of 118 eligible staff responded to the survey for a response rate of 69%. Staff worked a median of 2 weekend lists (IQR 1-9). Of 82 staff members, 65 (79%) were satisfied or very satisfied with working the extra weekend elective lists, with surgeons and surgical trainees reporting the highest levels of satisfaction. Most respondents  would continue working weekend lists. A sense of accomplishment was associated with satisfaction with working on the weekend (odds ratio [OR] 19.97, 95% CI 1.79-222.63; Staff participating in the first 3 months of the ORRACLE-Xtra program reported satisfaction with working weekends and a willingness to continue with the program, including doing longer, more complex cases. Institutions planning on implementing COVID-19 surgical backlog work may benefit from gathering key information from their staff. The COVID-19 pandemic has had a significant impact on health care delivery. Several jurisdictions canceled nonurgent surgeries repeatedly as each wave imposed pressure on the health care infrastructure . SurgicaOperating Room Ramp-Up After COVID-19 Lockdown Ends-Extra Lists (ORRACLE-Xtra). The ORRACLE-Xtra program scheduled weekend elective surgery lists of high-volume, low-acuity daycare procedures to reduce COVID-19–related backlog at our tertiary pediatric hospital [During the quiescent periods of the pandemic between January and April 2021, our institution implemented a novel program to mitigate the rapid increase in the surgical wait-list: hospital . Having Our aims for this cross-sectional survey study were to (1) determine staff perceptions of, experiences with, and level of satisfaction with working extra scheduled weekend elective surgical lists in the 3-month pilot phase of ORRACLE-Xtra; (2) assess the likelihood of staff continuing to support our weekend program; and (3) identify factors that will maximize engagement in the weekend elective surgery program in the longer term.The study setting was the perioperative department at The Hospital for Sick Children in Toronto, ON, an academic pediatric hospital that serves children aged 0 to 18 years. We surveyed all perioperative staff who participated in the pilot phase of ORRACLE-Xtra. Based on a total of 118 eligible staff, we needed a minimum of 95 respondents to achieve a margin of error of 5% with a 95% CI. We followed the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) guidelines for reporting surveys .Staff received an email invitation to complete the online survey at the end of the 3-month pilot phase, with a reminder sent one week later. The survey remained open during April 2021. All responses were anonymous, and consent was implied by participation in the survey.The ORRACLE-Xtra steering committee, which comprised representatives from staff groups and included nursing , administrative support, technical support, and physicians (anesthesiologists and surgeons), developed the questionnaire. The survey collected information on overall satisfaction with working weekend elective lists, impact of working weekends on aspects of well-being , and likelihood of and preferences for working future weekend lists .The survey included 12 questions. Questions 1 to 3 included information regarding each respondent’s role, department, surgical specialty lists they had worked on, and number of lists worked. Questions 5 to 12 ascertained the level of satisfaction with weekend lists, perceptions on well-being, and the respondents’ preferences for future weekend lists.We tested the questionnaire according to previously published guidelines and methodology -25. The P value ≤.05 was considered statistically significant. Statistical analyses were performed using SAS .Survey responses were collected and managed using REDCap (Vanderbilt University), a secure online electronic data capture tool ,27. DataThis study was approved by the Quality Improvement Committee at The Hospital for Sick Children (QIP-2021-01-08).Of 118 eligible staff, 82 (69%) responded to the survey. Of 82 staff members, 65 (79%) were satisfied or very satisfied with working the extra weekend elective lists . SurgeonMost respondents perceived working the weekend elective surgery lists to have a positive impact on their sense of accomplishment and community, as well as overall job satisfaction. There were no statistically significant differences in self-reported career development, well-being, and burnout for staff who were satisfied with their weekend surgery experience. Surgeons and nurses were more likely to experience a sense of accomplishment from working the weekend lists while also being more likely to report that the work contributed to their sense of burnout.Respondents were more willing to work extra weekends during nonsummer months, with a preference for the winter months .Of 82 staff members, 72 (88%) would be willing to continue working weekend lists and 56 (68%) would be willing to work weekends if cases were longer or more complex.P=.02)  A.P=.01). A sense of accomplishment was associated with a willingness to participate in future weekend elective lists   C.Our survey results demonstrate high overall satisfaction and positive feedback from staff working weekend elective surgical lists in the ORRACLE-Xtra program. A sense of accomplishment and community was associated with the intent to work weekend elective lists in the future, with a preference for nonsummer periods. Most staff would also be willing to work weekends that included longer and more complex cases.The burden of COVID-19 on health care workers has been unprecedented, with several studies reporting health workers experiencing inadequate preparedness, emotional challenges, insufficient equipment and information, and work burnout ,28-37. HFurther, with ongoing cycles of pandemic lockdowns, working the weekends was associated with satisfaction and a sense of accomplishment among respondents. This finding is unexpected, especially during a pandemic, but may be explained by the opportunity offered to engage in meaningful work and contribute to reducing the growing surgical wait-list. Surgeons were grateful to secure extra operating time when regular weekday opportunities were reduced. The cancelation of surgeries and reduced weekday workload around the study period may also have mitigated the sense of work burnout from working on weekends. An in-depth assessment of burnout was beyond the scope of this study and may yield different results. However, as staff could choose their availability for weekend lists, this sense of autonomy may have mitigated feelings of loss of control, creating a positive experience and environment -40. A feParticipants reported interest in working lists with longer and more complicated cases. This finding was surprising as the goal of the weekend list was low-acuity, high-volume cases to help minimize the number of required staff and stress levels among staff while managing cohorts of children who had their procedures deferred for more urgent cases during the waves of surgical slowdown. However, the sense of community associated with a willingness to work longer cases is consistent with reported efforts to improve workplace morale and reduce burnout by building cohesive teams -40.A key strength of our study is the high response rate and the availability of information for the planning of future weekend surgeries. Staff indicated their willingness to continue working weekend surgery, with preference for the nonsummer months of the year. This allowed institutional leaders to extend the ORRACLE-Xtra program for an additional 9 months, developing a weekend schedule cognizant of staff preferences and availability that addressed the surgical backlog while mitigating work-related burnout.Our study has several limitations. First, as a survey, the data are limited to the questions posed to the respondents. However, we also included open-ended questions to allow respondents to provide additional feedback. The qualitative data helped further explain some of the unexpected findings from our study. Second, we used a single question to gather information on the sense of burnout, which may underestimate the scope of burnout among staff. While the sense of accomplishment and community associated with working weekend surgery are encouraging, it would be important to check in with staff regularly if the program continues. Finally, our results are based on a 3-month pilot and the status, needs, and demands will change as the pandemic unravels. We would need to conduct a follow-up survey to assess whether working weekend lists would lead to fatigue in the longer term.Staff working the first 3 months of the ORRACLE-Xtra program reported satisfaction with working weekends. A sense of accomplishment and community was associated with satisfaction and willingness to continue working weekend surgery, including longer, more complex cases. Integrating considerations of staff well-being and preferences is important for the implementation and planning of future surgical backlog recovery work. Institutions planning on implementing COVID-19 surgical backlog work would benefit from gathering key information from their staff.


Reprocess reusable surgical instruments during steam sterilization; damage occurs to sharp scissor blades in close position, so steam cannot reach the blades. Surgical instruments' management requires standards to ensure patient safety and prevent harmful pathogens, especially in the COVID-19 pandemic. Although various devices can separate scissor blades, they do not prevent damage to cutting edges. To address the above problem, we developed a new scissor protector, the "Scissor-Tip-Separator," and evaluated its efficacy.The "Scissor-Tip-Separator" design follows the steam sterilization guideline that instrument tips must be separated. The locking handles and V groove mechanism keep the scissor blades separated while preventing damage to the cutting edges. For efficacy assessment, purposive sampling was performed to select 44 Thai perioperative nurses at Ramathibodi Hospital, Bangkok, Thailand, to evaluate the "Scissor-Tip-Separators" in 450 sterile instrument containers. All participants evaluated surgical scissors placed in the "Scissor-Tip-Separators" during instrument setup, following a problem record checklist. At the end of the fifth use, participants were asked to complete the "Scissor-Tip-Separator" Effectiveness Scale, which was used to test the structural design of the "Scissor-Tip-Separator" in terms of function, usability, and safety. The Adenosine Triphosphate surface test was also used to validate the "Scissor-Tip-Separator" cleanliness. Data were collected from August 2020 to November 2020, then analyzed via descriptive statistics.th use. Based on participants' opinions, the overall instrument effectiveness was high in terms of function, usability, and safety.The "Scissor-Tip-Separator" met the cleaning validation criteria, and in 44 uses, the physical property remained the same. The scissor shank was discovered loose from the handle before it had been unlocked (0.2–0.4%) at the 45The "Scissor-Tip-Separator" regulates scissor blade separation under sterilization guidelines; it prevents damage to cutting edges, thus ensuring patient safety. It protects against losses in a sterile field and can prevent hand injuries. The global coronavirus disease 2019 (COVID-19) pandemic has placed many patients at high mortality risk. The patients undergoing surgeries are attacked by COVID-19 transmission; thus, elective surgeries have been canceled or postponed to conserve beds and prevent the rapid spread of COVID-19 . HoweverSurgical scissors are characterized by a lap joint with ringed handles and sharp blades. The devices such as stringers or racks can maintain instruments in the open position and allow steam contact with all surfaces , 14, 15.From a literature search, we identified three main features of devices used to protect surgical scissors and regulate sharp blade separation for steam sterilization. First, tip protectors include one or two caps with different shapes  . These tA design and development research process was conducted to develop the "Scissor-Tip-Separator" and evaluate its effectiveness. This overall approach is commonly used to guide the development of medical devices . The detAfter analyses of problems with surgical scissors during sterilization, we found that the scissor blades were close and had damage to the cutting edges. The device used to hold the scissor blades separate for steam sterilization and prevent damage to cutting edges had limitations, including small size, unsafe grip, risk of injury during scissor blade insertion, and risk of loss in the surgical field , 17. FurWe designed the "Scissor-Tip-Separator" following the steam sterilization guidelines that steam must reach sharp instruments at the point of use while avoiding damage to cutting edges , 14, 23.We evaluated the initial version of the device with ten perioperative nurses from other surgical departments at Ramathibodi Hospital; these nurses were excluded from the principal analysis. After this pilot test, one participant reported that the scissor blades were spread too narrow because the length between V legs was insufficient. Therefore, the distance between V legs was adjusted from 20 to 24 mm. Additionally, two participants reported that the scissor shanks were unlocked from the locking handle because the upper space between the two locking arms was too wide. Therefore, we redesigned the locking handle structure by adjusting the upper cavity (between locking arms) from 6 to 5 mm, the locking arm thickness from 2 to 3 mm, and the outside of each locking arm from 12 to 13 mm for bending the angle of locking arm inside. One participant suggested that although the size was sufficient to fit all five scissors, it was too big for the 5-inch Metzenbaum scissors. Therefore, we developed another size of "Scissor-Tip-Separator." The original model is large and increases the medium with a length of 87 mm.We evaluated the Scissor-Tip-Separator's effectiveness in terms of patient safety. The evaluation process included validated cleanliness of the "Scissor-Tip-Separator" before steam sterilization, documentation of problems with the "Scissor-Tip-Separator," and an assessment of participants' opinions regarding using the "Scissor-Tip-Separator."Our study sample comprised perioperative nurses working in the surgical department of the Main Building, Ramathibodi Hospital, Bangkok, Thailand; these nurses were selected by purposive sampling. This hospital was chosen because all surgical instrument sets were steam sterilized in standard containers suitable for assessing "Scissor-Tip-Separator" effectiveness. This study included all participants with one year of experience as perioperative nurses who evaluated the "Scissor-Tip-Separator" in the Minor Set five times during surgical instrument setup. Participants who did not meet these criteria were excluded. In total, 46 prospective nurses were identified. Forty-four perioperative nurses met the inclusion criteria and were willing to participate in the study.The first author developed the "Scissor-Tip-Separator Problem Record." The record consisted of nine items that were used to assess whether the structural design of the "Scissor-Tip-Separator" was working. An example item was "The scissor shank is difficult to release from the locking handle"; participants were asked to record "yes" (if they met this problem) or "no" (if they did not meet this problem). The "Scissor-Tip-Separator Problem Record" was reviewed and validated by three experts: two head nurses from two perioperative units and one infectious disease nursing instructor.The first author developed the "Scissor-Tip-Separator Effectiveness Scale." The scale focused on nurses' opinions regarding using the "Scissor-Tip-Separator." The Effectiveness Scale contains 11 items within three primary subscales: "Scissor-Tip-Separator" functions, "Scissor-Tip-Separator" usability, and "Scissor-Tip-Separator" safety. Each item was answered on a five-point Likert scale, ranging from 1 (very ineffective) to 5 (very effective); higher scores indicated high effectiveness. A panel of three experts assessed the instrument's content validity; the S-CVI for the 11 items was 0.94, and CVI was 0.82. The internal consistency reliability  based on the opinions of the ten pilot perioperative nurses was 0.95. After assessment by all 44 perioperative nurses, the overall Cronbach's alpha coefficient for the instrument was 0.95. Cronbach's alpha was used to determine inter-item correlations among the three subscales , 28. TheThe Adenosine Triphosphate (ATP) Surface Test was chosen to validate the cleanliness of the reusable surgical instruments. Although several methods are used to verify cleaning efficacy, they are not currently regulated by the FDA . The stuEach Minor Set comprised three types and five pieces of surgical scissors: one Mayo, two Metzenbaum, and two Suture scissors. Therefore, we used five "Scissor-Tip-Separators": two medium sizes for the two sizes of Metzenbaum scissors and three large sizes for Mayo and Suture scissors. The sterilization staff began preparation by inserting scissor blades through the rectangular box at the back into the front; the staff placed scissor blades into the V-groove, with the sharp tips in the safeguard. The staff then pressed the scissor shanks into the locking handles at the back Fig. .Subsequently, the sterilization staff placed five Class IV steam chemical indicators (integrating indicators) in the "Scissor-Tip-Separator" to evaluate whether steam could reach the entire scissor blade surface , then wrThe instrument sets used to evaluate the "Scissor-Tip-Separator" were designated "Minor Sets." This study used 10 Minor Sets labeled with numbers 1 to 10. We trained the sterilization staff to prepare "Scissor-Tip-Separators" and pack them in paper packages for steam sterilization of the Minor Set. The following process was used to prepare "Scissor-Tip-Separators" in the Minor Set for steam sterilization.Each day, one research team member checked the operation schedule that used a Minor Set and met the participants who were the scrub nurses or circulating nurses in the minor surgeries. The researcher explained the activity's objective and asked the participants for cooperation. The process began with a demonstration of the "Scissor-Tip-Separator" release. Next, participants were asked to examine and verify the scissor package when they opened the Minor Set, following the checklist in the problem record. Then, the five indicators were checked and evaluated for color, from the rejection zone to the acceptance zone. If the black color did not reach the acceptance zone, "yes" was marked in the "Problem Found" item. At the end of the surgical procedure, the "Scissor-Tip-Separators" were sent to clean in the washing machine at the CSSD and subjected to validate the cleanliness of the reused medical device with the ATP Test; they were then placed in a sterile package for steam sterilization. The cleaning test began with the staff of CSSD randomly selecting one of 30 large "Scissor-Tip-Separators," and one of 20 medium "Scissor-Tip-Separators" from 10 Minor Sets. Two sizes of "Scissor-Tip-Separators were subjected to the ATP Test once daily for 45 days and recorded the ATP levels for two sizes each day. In the operating room, the scrub and circulating nurses checked the "Scissor-Tip-Separators" in each Minor Set, following the problem record checklist for a total of 450 sets . At the end of the surgical procedure, the names of the perioperative nurses who checked the "Scissor-Tip-Separators" were recorded. Participants who checked the "Scissor-Tip-Separator" in Minor Set five times  were asked to complete an effectiveness evaluation scale within 15–20 min. These data were collected from August 2020 to November 2020.Descriptive statistics, including frequencies and percentages, were used to analyze the ATP level and identify problems using the "Scissor-Tip-Separator." The "Scissor-Tip-Separator Effectiveness Scale" findings were analyzed in two parts. First, the overall items and the subscales regarded as an interval scale were analyzed as a group via means and standard deviations , 28. SecFrom August 2020 to November 2020, all 44 participants used the "Scissor-Tip-Separator" in Minor Sets 450 times . The participants checked 2250 chemical indicators, all turning back to the accepted area. Evaluate the "Scissor-Tip-Separator" cleanliness 45 times, ATP level for large size range 4–29 RLUs mean 16.44 SD 5.29 and for medium size range 3–58 RLUs mean 17.40 SD 9.67.th use, the locking handle of the large "Scissor-Tip-Separator" (sets 4 and 10) and medium "Scissor-Tip-Separator" (set 9) were slightly changed, as shown in Table The problem record showed that two samples of 450 surgeries presented the scissor shanks were released from the locking handle of the large "Scissor-Tip-Separator" before unlocking (0.4%) and one of 450 times lost from the medium size (0.2%). The physical properties of the "Scissor-Tip-Separator" did not change during 44 uses. For the 45n = 36, 81.8%) gave all items a score of 5 (median = 5 points).The mean score of all items evaluated was 4.85 ± 0.30 Table . Mean scThis study was conducted to develop the "Scissor-Tip-Separator" to standardize the separation of scissor blades and prevent damage to cutting edges. Our results showed that the "Scissor-Tip-Separator" could effectively maintain scissor blade separation and avoid damage to cutting edges, and it passed the validation of the cleaning process.ATP is one of many methods used to verify cleaning conditions , 34. TheThe problem record showed that all 2250 chemical indicators inserted between the scissors and the "Scissor-Tip-Separators" turned black from the rejection zone to the acceptance zone; no water droplets were present in the space of the V groove or the safeguard. The essential step is to ensure the proper sterilization of the scissors to the point of use; steam must be able to penetrate chemical indicators from the rejection to the acceptance zones by changing the color from white to black . Thus, tHistorically, in an annual year, our surgery department records that there are damaged scissors that require repair of 36 pieces and outright replacement of ten pieces [unpublished record]. However, since using the "Scissor-Tip-Separator" to protect scissors for four months, the problem record showed no reports of scissor blade deformation or damage upon removal of the "Scissor-Tip-Separator." Confirm with, 38 participants (86.4%) reported a score of 5 points for the "Scissor-Tip-Separator" to protect scissor blades (at the point of use) from chipping, bending, and deformation. This result can be attributed to the 10 mm width of the V groove, which is enough to hold the scissor blades in place. According to ANSI/AAMI ST79, sharp items should be protected from damage; tip protectors should loosely fit . Even thThe total cost of the "Scissor-Tip-Separators" that were used on 10 Minor sets was 15,000 baht or 420 USD  compared to use the repair and replacement scissors which cost 44,760 baht or 1252 USD . Thus, using the "Scissor-Tip-Separator" protect scissors can reduce our institute's cost of 832 USD.In the usability assessment of the "Scissor-Tip-Separators," there were no reports of the scissor tips slipping out of the safeguards. Consistent with this result, participants reported that the "Scissor-Tip-Separators" had high usability. These findings are presumably because the rectangular box in the middle is 20 × 38 mm, which is the proper size for maintaining the pivot joint in place, keeping the scissor blades in the V groove, and holding the scissor tips in the safeguard. The V groove locks the scissor blades into the safeguard functions as a locking system. According to the steam sterilization protocol of sharp instruments, keep them orderly, do not touch their points, and prevent damage with perforated tip protectors , 14. ThuConcerning the locking design, no difficulty was reported by scrub nurses in releasing the scissor shanks from the locking handles. Consistent with this result, 84.1% of participants reported that "the scissor shanks were easily pressed and released from the locking handles, while the locking handles were secure and prevented the scissor shanks from slipping out." Thus, the locking handles function as a secondary locking system for ensuring that scissor blades remain separate. The "Scissor-Tip-Separator" has a U shape; when releasing or placing surgical scissors, the "Scissor-Tip-Separator" can be firmly gripped to prevent slippage. Poor structural design, such as difficulty in use, may increase patient safety risks, as mentioned in the assessment of medical device usability . The duaThe safety assessment revealed no instances in which the scissor tips penetrated out of the safeguards or exited from the back of the "Scissor-Tip-Separators." Consistent with these findings, participants' safety ratings showed high effectiveness. The V shape, which is 37 mm in length, firmly locks the scissor blades (28–34 mm distance from the bottom to the middle part of the V legs) in place and protects scissor tips from penetrating out of the safeguard, thereby preventing user injury. In addition, the safeguard, which is 18 mm in length and 2 mm in thickness, firmly protects against scissor blade damage by other instruments' compression . Thus, tth round of sterilization. These findings were consistent with participant ratings, indicating that the materials used to produce the "Scissor-Tip-Separator" did not melt or adhere to scissors after steam sterilization. The "Scissor-Tip-Separator" can be resterilized under high steam pressure without changing its form or deteriorating. The explanation is that the "Scissor-Tip-Separator" made of medical-grade silicone is resistant to high temperatures (> 200 °C); it does not lose physical characteristics or exhibit substantial degradation [For evaluating the physical properties, the "Scissor-Tip-Separators" did not exhibit breakage or adhesion to the scissors; they were consistent; however, the locking handles were slightly dilated in the 45radation . TherefoThere may be several limitations in this study. First, we packed surgical scissors placed in the "Scissor-Tip-Separator separated from other instruments. To decrease bias, we packed the scissors together, similar to those in Minor Set. Second, our study used purposive sampling, which involved a small sample size in assessing participants' opinions. However, we used specific inclusion criteria and total population sampling to minimize bias related to sample selection . Third, Our results showed that the locking handles and safeguard of the "Scissor-Tip-Separator" could ensure the scissor blades remained separated, allow steam to reach the entire surface of surgical scissors, and prevent damage to cutting edges. In addition, perioperative nurses can firmly release surgical scissors from the "Scissor-Tip-Separators," promoting themselves and patient safety. In this study, we used a problem record to describe "Scissor-Tip-Separator" functions and participants' opinions; this enabled the identification of possible design errors and assessment of "Scissor-Tip-Separator" effectiveness. The crucial finding revealed that the size of the scissor protector should be large enough to grip to prevent loss in the surgical area and protect against personal injury. Furthermore, the CSSD involves preparing and managing surgical instruments and should apply tip separators to surgical scissors in an appropriate size. Accordingly, we designed the "Scissor-Tip-Separators" with different sizes to match different types and sizes of surgical scissors.