COVID-19 is impacting people worldwide and is currently a leading cause of death in many countries. Underlying factors, including Social Determinants of Health (SDoH), could contribute to these statistics. Our prior work has explored associations between SDoH and several adverse health outcomes . Our findings reinforce the emerging consensus that SDoH factors should be considered when implementing intelligent public health surveillance solutions to inform public health policies and interventions.This study sought to redefine the Healthy People 2030’s SDoH taxonomy to accommodate the COVID-19 pandemic. Furthermore, we aim to provide a blueprint and implement a prototype for the Urban Population Health Observatory (UPHO), a web-based platform that integrates classified group-level SDoH indicators to individual- and aggregate-level population health data.The process of building the UPHO involves collecting and integrating data from several sources, classifying the collected data into drivers and outcomes, incorporating data science techniques for calculating measurable indicators from the raw variables, and studying the extent to which interventions are identified or developed to mitigate drivers that lead to the undesired outcomes.We generated and classified the indicators of social determinants of health, which are linked to COVID-19. To display the functionalities of the UPHO platform, we presented a prototype design to demonstrate its features. We provided a use case scenario for 4 different users.UPHO serves as an apparatus for implementing effective interventions and can be adopted as a global platform for chronic and infectious diseases. The UPHO surveillance platform provides a novel approach and novel insights into immediate and long-term health policy responses to the COVID-19 pandemic and other future public health crises. The UPHO assists public health organizations and policymakers in their efforts in reducing health disparities, achieving health equity, and improving urban population health. COVID-19 is a highly transmissible disease caused by SARS-CoV-2. COVID-19 has been one of the leading causes of death in many countries since December 2019 when it was first reported in Wuhan, China. As of May 5, 2021, there have been over 156 million confirmed cases of COVID-19 and more than 3.2 million deaths worldwide ,5.Although COVID-19 adversely affects people’s lives in many respects, it disproportionally impacts certain groups and populations -11. ReseOur prior studies have explored associations between SDoH and several health outcomes -19. ConsIn this study, we describe the design and development of the Urban Public Health Observatory (UPHO), a web-based knowledge-based surveillance platform that integrates multidimensional heterogenous data including SDoH indicators and population health data and provides near–real-time analysis and dashboarding of ongoing COVID-19–related comorbidities and mortalities. In particular, we aimed to (1) redefine the Healthy People 2030’s SDoH taxonomy to classify SDoH indicators into 6 domains to characterize barriers that are specific to the COVID-19 pandemic and (2) design and develop a prototype for the UPHO surveillance platform.According to the literature -11,22-33We intend for the UPHO system to impact the health care infrastructure and services at multiple levels; for example, availability of timely, accurate, and complete public health surveillance systems; patient’s engagement in self-care or management; competency in patient-centered diagnosis for COVID-19 and other diseases; and effective policy- and decision-making through the analysis of causal relationships among disease prevention, treatment options, and patient outcomes. The process of building UPHO involves (1) collecting and integrating data from several sources, (2) classifying the collected data into drivers and outcomes, (3) incorporating data science techniques for calculating measurable indicators from the raw variables, and (4) determining the extent to which interventions are identified or developed to mitigate drivers that lead to the undesired outcomes. The UPHO architecture is composed of three different layers : data, aAs shown in The COVID-19 registry systematically collects individual-level COVID-19 indicator variables, including administered test results collected from several testing sites and self-reported outcomes collected from surveys. We performed data transfer between the different sites, including results from both surveys and diagnostic tests stored in the CSV format.To obtain SDoH variables, we utilized data from the United States Census Bureau’s 2018 American Community Survey , US DepaIndividual-level anonymized data are collected through Internet of Things devices, including wearable devices or mobile global positioning system devices , need for mechanical ventilation, escalation to the intensive care unit, and death.A core component of UPHO is the analytics layer, which is used for intelligent query-answering to formally propose hypothesis-driven research questions. In the following sections, we explain the different steps that we performed within the analytics layer.In step 3, we examined the spatial distribution to depict patterns. We conducted geospatial cluster analyses of COVID-19 transmission patterns, which includes neighborhood-level clusters and hotspots to identify high-risk groups. Hotspots are detected by implementing a spatiotemporal pattern mining, which expands the hotspot analysis to 3 dimensions by incorporating time.In this step, we imported data from the geographic information systems’ database management system into the analytics engine to perform geostatistical modeling and make causal inferences and to assess various epidemiological hypotheses. We have explained each operation below.We examined the association among COVID-19 outcomes, SDoH, and policy adherence metrics at various levels of granularity, using global and local geostatistical modeling methods such as ordinary least squares regression and geographically weighted regression (GWR). Among implemented global and local models, we shall also depict which model better explains the association between COVID-19 outcomes and indicators. Global models such as the ordinary least squares regression model (Equation 1) assumes that the processes being modeled are stationary:βk represents the parameters, Xk represents the observed values of the SDoH and policy adherence metrics variables k , and ε represents the random error term.where Y is the COVID-19 outcome variable, However, local models such as GWR (Equation 2) generate location-specific results that account for spatial nonstationarity: ui, vi) represents the coordinates, β0  represents the intercept, and βk  and Xik are the parameters and observed values of the independent variable k , where i  represents the spatial location. β values are estimated using spatial weights. εi is the error term for location i.where the term  and varying spatial coefficient estimate distribution maps .F3: intervention impact. The user can use this tab to explore the causal impact of the intervention and temporal trends.F4: hotspot analysis results. The user can use this tab to explore interactive maps of high-risk groups.F5: geospatial disease distribution. The user can use this tab to select the geographic granularity of interest  and the upstream social determinant risk factors . This will allow the user to explore spatial variability maps.In this section, we have provided use case scenarios for each of the 4 different users to demonstrate the features available in the dashboard through the first scenario.Scenario 1: A public health official wants to launch a task force of physicians and nurses to run mobile testing or vaccination sites that will cater to areas that are socially disadvantaged and have low testing rates to reverse the trend of an infectious disease. Furthermore, she may wish to use neighborhood-level information  about temporal trends of COVID-19 to inform the reopening of facilities  during or after the pandemic.Scenario 2: A primary care physician focuses on how SDoH from his patient’s neighborhood, such as distance to the nearest health facility, count of housing units, average household size, multigenerational family residence, increased prevalence of frontline workers, and reliance on public transportation, can influence his clinical diagnosis and management plans for patients presenting with COVID-19 symptoms at his clinic.Scenario 3: A patient uses SDoH characteristics obtained from her neighborhood population health data  to develop self-care and management plans for type 2 diabetes, which renders her at an increased risk of severe COVID-19.Scenario 4: A caregiver with 2 children uses information from her parents-in-law’s neighborhood population health data  to decide whether to take her children to visit these in-laws for the Thanksgiving holiday.We used scenario 1 to explore the capabilities of the UPHO surveillance platform and the dashboard features. In this scenario, the health official would be interested in only features F1, F3, and F5, to explore the causal pathways of testing, the geospatial distribution of administered COVID-19 tests and SDoH, and the temporal trend of daily COVID-19 cases in a geographical urban area. We used the UPHO user-centered platform to show how these 3 goals are achieved through the distinctive features of the dashboard.First, the public health official signs in to the UPHO platform, which will determine her role and establish the appropriate access permissions. On logging in, the health official selects a specific chronic or infectious disease, in this case COVID-19, and the outcome of interest . If she selects COVID-19 testing as the outcome of interest, she can explore the causal structure as an analytical aim and the corresponding social determinants of COVID-19 of interest F1; . ThroughIn Thereafter, the public health official can explore the administered COVID-19 tests and the SDoH spatial distribution F5, . To thatMany factors including SDoH increase the burden of COVID-19 on particular groups of the population. In the current study, we proposed the development of UPHO, a web-based urban population health observatory that can help mitigate the disparities of the disease burden of COVID-19 and to facilitate timely responses and better public health planning for equitable distribution of health care resources and services . In this study, we redefined the Healthy People 2030’s SDoH taxonomy into 6 thematic domains, and these SDoH indicators were integrated with other group-level and individual-level data sources within the UPHO platform. UPHO provides an innovative surveillance tool that systematically incorporates group-level SDoH indicators and population health data to facilitate informed decision-making necessary for preparedness, detection, rapid response, and management after disease outbreaks. The platform provides a reproducible, durable, and scalable model for data-driven, socially informed policymaking for recovery and future-readiness for COVID-19 and other large-scale pandemic events. UPHO enables precision observation and assessment, early detection, and health promotion  by disseFurthermore, depending on the UPHO user’s role  and interests, access can be gained to certain features within the dashboard. For instance, public health officials can visualize graphical representations of analytical results on the dashboard . Similarly, physicians may also utilize graphs and charts to summarize and provide context to data from patients’ electronic health records, thereby allowing for better clinical decision-making and improved health care efficiency. The dashboard is not limited for use only by scientific investigators, epidemiologists, and health care professionals. Measures of SDoH from the dashboard can be accessible to both the general public and to government officials to identify neighborhood-level risk factors to inform decisions and policymaking. Accordingly, examples of the current and future applications of the UPHO platform include a policymaker who needs to make reliable, accurate, and informed decisions on school reopening and effective policy implementation during a disease outbreak or a clinician who uses information from a patient’s postal codes for diagnostic reasoning, monitoring, and disease management. In addition to the epidemiological surveillance of infectious diseases such as COVID-19, the UPHO may also have utility in monitoring and learning about chronic diseases; for example, cancers in the urban population. The platform implements an intelligent digital health solution that offers the appropriate security and access control mechanisms that are necessary to achieve protections on the privacy of health data.Although this knowledge-based surveillance platform facilitates intelligent query-answering, there is some potential for improvement that could be considered for future studies. Relationships between upstream risk factors and health outcomes are important, but the addition of contextual knowledge would provide better insights. Consequently, future studies are required to incorporate a semantics layer into the UPHO platform, through which we will define domain ontologies and import some existing ontologies  to encoSocial and environmental determinants have a disproportionate impact on minority and disadvantaged populations for COVID-19 infections and related illnesses. Although racial health inequalities have persisted throughout the health care system for years, the COVID-19 pandemic has exacerbated these disparities and made them more visible. Therefore, incorporating SDoH when implementing policies and interventions could facilitate COVID-19 response and management efforts. The UPHO surveillance platform provides a novel approach and novel insights to inform immediate or long-term health policy responses to the COVID-19 pandemic and other future public health crises. In summary, local COVID-19 registries systematically collect individual-level indicators from several regional testing and vaccination sites and align those indicators with population-level indicators, thereby providing decision support, measures for quality care, individual and population-level health reporting systems, and communication tools. The application of the UPHO could help reduce health disparities, thus achieving health equity and improving urban population health.


We encountered the novel coronavirus infection as a pandemic in 2020. The infection started in Wuhan, China, and spread rapidly all over the world. CT scan has been used as an important diagnostic method in the detection of suspicious patients. One of the uncommon complications of coronavirus disease 2019 (COVID-19) is pneumothorax.2 saturation was in normal range an there was no dry cough anymore.A 47-year-old smoker male with COVID-19 diagnosis, good general condition and no respiratory complaint, complicated by pneumothorax. He refused hospitalization. After educating him about the red flags and quarantine protocols, he continued treatment at home .Cap amoxicillin/clavulanic acid 625mg was prescribed for one week. A follow-up CT represented only small involvement of lungs. Pneumothorax was resolved spontaneously without any medical intervention and hospitalization. OAccording to our clinical experience, pneumothorax is resolved spontaneously in a COVID-19 case. Considering general status and hemodynamic stability, it is suggested to reduce invasive interventions in COVID-19 cases with pneumothorax. The role of imaging in controlling the epidemic of coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2, has been dominant at the forefront of investigation for patients suspected to have COVID-19. Computed tomography (CT) of the chest has been performed on large scales to detect the typical features of the lung involvement in COVID-19 . Complic2saturation was 97%. There was no history of suspicious contact to a person with COVID-19. His blood sample results showed leukocytosis  with 75 % neutrophil and 20% lymphocyte. C-reactive protein (CRP) was negative but erythrocyte sedimentation rate (ESR) was 25 mm/hour . On March 13, 2020, a 47-year-old occasional-smoker man with unremarkable past medical history was admitted to our emergency department in the northeast Iran, with myalgia, dry cough, low-grade fever (37.9 °C), shivering and diaphoresis for the past 5 days. His vital signs were stable. He had no complaint of dyspnea and his OA non-contrast chest CT was done and showed a wedge-shaped consolidation with air bronchogram in the left upper lobe. Another small pleural based consolidation was also seen in the superior segment of the left lower lobe . Accordith of March, 2020 he fainted at home suddenly and experienced severe pain in left hemithorax. He was referred to the emergency department to rule out the cardiac angina. His electrocardiogram (ECG) and troponin level was normal. We performed the second CT at this time to distinguish any complication or progression of coronavirus infection that was encountered with left pneumothorax. Patchy consolidation with air bronchogram was seen in the left upper and lower lobe and right lower lobe. Patchy ground-glass opacity with superimposed septal thickening (crazy paving pattern) was seen in the right upper lobe too  loculated pneumothorax and pleural thickening in the medial basal part of the left hemithorax. A subpleural band-like opacity was also seen in the anterior portion of left lower lobe and right upper lobe, and patchy ground-glass opacity was more predominant in the left side (2 saturation of 98% and the dry cough has been resolved.One week later his general condition got better, and only complained from minimal pain in left hemithorax. We performed an x-ray and saw a little pneumothorax. He was in a good shape with normal Oeft side . His genAs the pandemic of COVID-19 progressed around the world, physicians encountered different complications and atypical presentations of the disease. One of the rare complications is pneumothorax that has been reported in the course of treatment with different consequences -6. The pOur patient’s imaging showed same findings with previous reports of COVID-19 cases with spontaneous pneumothorax. as we observed in our case, consolidation and ground-glass opacities were also reported in previous clinical studies . The neeAlthough the explanation of the mechanism for this phenomenon is blurred but its self-limitation in our case could be accounted as a hint for further investigations about how spontaneous pneumothorax can be resolved in COVID-19 without hospital care. In conclusion our clinical experience showed pneumothorax can be resolved spontaneously in a COVID-19 case without hospitalization. Considering this case, it is then suggested in such cases with stable status to reduce invasive interventions.


Systemic sclerosis  is a rare autoimmune connective tissue disease. We completed an initial feasibility trial of an online self-administered version of the Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program using the cohort multiple randomized controlled trial (RCT) design. Due to low intervention offer uptake, we will conduct a new feasibility trial with progression to full-scale trial, using a two-arm parallel, partially nested RCT design. The SPIN-SELF Program has also been revised to include facilitator-led videoconference group sessions in addition to online material. We will test the group-based intervention delivery format, then evaluate the effect of the SPIN-SELF Program on disease management self-efficacy (primary) and patient activation, social appearance anxiety, and functional health outcomes (secondary).http://www.spinsclero.com/en/cohort) and via social media and partner patient organizations. Eligible participants must have SSc and low to moderate disease management self-efficacy (Self-Efficacy for Managing Chronic Disease (SEMCD) Scale score ≤ 7.0). Participants will be randomized  to the group-based SPIN-SELF Program or usual care for 3 months. The primary outcome in the full-scale trial will be disease management self-efficacy based on SEMCD Scale scores at 3 months post-randomization. Secondary outcomes include SEMCD scores 6 months post-randomization plus patient activation, social appearance anxiety, and functional health outcomes at 3 and 6 months post-randomization. We will include 40 participants to assess feasibility. At the end of the feasibility portion, stoppage criteria will be used to determine if the trial procedures or SPIN-SELF Program need important modifications, thereby requiring a re-set for the full-scale trial. Otherwise, the full-scale RCT will proceed, and outcome data from the feasibility portion will be utilized in the full-scale trial. In the full-scale RCT, 524 participants will be recruited.This study is a feasibility trial with progression to full-scale RCT, pending meeting pre-defined criteria, of the SPIN-SELF Program. Participants will be recruited from the ongoing SPIN Cohort (The SPIN-SELF Program may improve disease management self-efficacy, patient activation, social appearance anxiety, and functional health outcomes in people with SSc. SPIN works with partner patient organizations around the world to disseminate its programs free-of-charge.ClinicalTrials.govNCT04246528. Registered on 27 January 2020The online version contains supplementary material available at 10.1186/s13063-021-05827-z. Rare diseases, which together affect an estimated 6–8% of people worldwide, are defined as conditions with a prevalence rate fewer than 1 in 2000 . Common Chronic disease self-management involves active participation in one’s health care to better manage symptoms and improve coping. Self-management programs have been shown to be effective and are widely disseminated in many chronic diseases –13. Therhttp://www.spinsclero.com/en/cohort) with over 1600 active participants from 47 centers in 7 countries to collect longitudinal data on patient-reported outcomes and as a framework for embedding RCTs of educational, rehabilitation, psychological, and self-management interventions [The Scleroderma Patient-centered Intervention Network (SPIN) , 18 is aventions , 18. Theventions –13 and iventions , and inpN = 466; 61%) [We conducted an initial feasibility trial of a self-administered online version of the SPIN-SELF Program , 20 usin66; 61%) .Thus, we have made two major revisions for the present feasibility trial with progression to full-scale trial to address the low acceptance of offer to try the intervention from the initial feasibility trial. First, instead of the cmRCT design, we will obtain consent for the trial and randomize post-consent to the SPIN-SELF Program or usual care. Second, we will incorporate 8 videoconference-based groups led by peer facilitators to support delivery of the online program material, similar to what we did in our recent successful trial of an intervention to address mental health symptoms in the early stage of COVID-19 , 27.To test our revised trial design and program delivery method, we will conduct a new feasibility trial with direct progression to full-scale trial , 29 if cThe SPIN-SELF feasibility trial with progression to full-scale trial will be a pragmatic, two-arm, parallel, partially nested RCT (PN-RCT)  with 1:1ClinicalTrials.gov, NCT04246528), and the protocol follows Standard Protocol Items Recommendations for Interventional Trials (SPIRIT) 2013 Statement reporting recommendations [The trial has been registered  trial procedures that may help us to optimize trial management for the full-scale trial but would not lead to stoppage and re-start for the full-scale trial and (2) stoppage criteria that will determine if we can proceed directly from the feasibility trial to the full-scale trial or if substantial revisions require starting the full-scale trial anew. See Table  trial prMany of the trial management procedures to be used in the SPIN-SELF trial have been successfully tested in previous SPIN trials with common design and intervention delivery features, including the SPIN Scleroderma Support Group Leader Education Program (SPIN-SSLED) Trial , 36, SPITo be eligible for the SPIN Cohort, participants must meet 2013 American College of Rheumatology / European League Against Rheumatism SSc classification criteria ; be ≥18 We plan to enroll 40 English-speaking participants in the feasibility portion of the trial and a total of 524 English- and French-speaking participants in the full-scale trial (including feasibility participants if progression occurs). Eligible participants must (1) meet 2013 American College of Rheumatology / European League Against Rheumatism SSc classification criteria , verifieThe SPIN-SELF Program will include access to online program material for the duration of the trial and participation in 8 group videoconference sessions to be delivered over 12 weeks (weekly for 4 weeks then every other week) to support online material. The SPIN-SELF Program curriculum was designed based on key principles of behavior change that have been integrated in successful self-management programs for other chronic diseases –42, inpuEach videoconference-based intervention group will be led by a person with SSc who previously received training as a support group leader via our SPIN-SSLED Program , 36. GroEach of the 8 intervention sessions will last between 60 and 75 min and include 3 segments: (1) review of modules, including questions and sharing of experiences 20–25 min); (2) education on goal setting, goal achievement, and discussion of goal progress (40–45 min); and (3) presentation of new assignments (5 min). Session 1 will cover an introduction to the SPIN-SELF Program and online modules and tools. Sessions 2–4 will focus on common challenges identified as salient to most people living with SSc  to facilitate group learning. Sessions 5 and 6 will provide participants the opportunity to select among other modules most relevant to them . Session 7 will cover the Effective Communication with Health Care Providers Module. Session 8 involves summarizing progress and planning for the future. Sessions 1 to 4 will be weekly, after which sessions 5 to 8 will be scheduled bi-weekly . See Table 0–25 min;Group sessions will be delivered using the GoToMeeting® videoconferencing platform, which we have used successfully in previous trials , 35, 36.All group sessions will be video-recorded, and 25% of the sessions will be randomly selected for intervention fidelity evaluation. Consistent with best-practice recommendations for assessing treatment fidelity , this wiParticipants randomized to the usual care control group will receive care as usual but will not have access to the SPIN-SELF Program during the trial period. They will be able to access the online version of the program following completion of all trial assessments, but they will not be able to access the group-based part of the program.There will be no restriction on any concomitant interventions for participants in the intervention or usual care control groups.During the feasibility and full-scale portions of the trial, we will assess participants’ experience with the program and will collect outcomes that will be used to evaluate intervention effects in the full-scale portion of the trial. Participant satisfaction with the intervention will be assessed 3 months post-randomization among intervention participants using an adapted version of the 8-item Client Satisfaction Questionnaire (CSQ-8) . During The primary outcome analysis in the full-scale trial will compare SEMCD Scale scores  between The 8-item CSQ-8, which measures client satisfaction with health care services, has been adapted to assess participant satisfaction with the SPIN-SELF Program. Items are scored on a 4-point scale from 1 (low satisfaction) to 4 (high satisfaction). Total scores range from 8 to 32, with higher scores indicating higher satisfaction. The CSQ-8 is available in English and French .The adapted PEMAT is a 23-item questionnaire that allows participants to provide comments on their experiences with the format and procedures of the trial, the program content, group sessions, and other input. Responses are assessed qualitatively. The PEMAT is available in English and French.Usage among participants in the intervention group will be examined via automated intervention usage log data. These data will provide information on online program logins and usage of specific modules.The SEMCD is a 6-item measure that evaluates confidence in ability to manage fatigue, pain, emotional distress, and other symptoms; to do things other than take medications to reduce illness impact; and to carry out tasks and activities that may reduce the need to see a doctor. Items are rated on a 1  to 10  scale. The total score is the mean of all items, and ranges from 1 to 10. SEMCD scores have been validated in SSc through the SPIN Cohort in English and French .Patient activation, which reflects the extent to which patients effectively engage with and manage their own health , 54, wilThe SAAS consists of 16 items that measure patients’ self-reported anxiety related to situations where one’s appearance will be evaluated, with response options ranging from 1  to 5 (“Extremely”). To calculate total scores, the first item (“I feel comfortable with the way I appear to others”) is reverse-coded, all items are summed, and total scores range from 16 to 80, with higher scores indicating greater anxiety. SAAS scores have been validated as a measure of social appearance anxiety for people with SSc through the SPIN Cohort in English and French , 60.The PROMIS-29v2 measures 8 domains of health status with 4 items for each of 7 domains  plus a single item for pain intensity. Domain items are scored on a 5-point scale (range 1–5), with different response options for different domains. The single pain intensity item is measured on an 11-point rating scale. Higher scores represent more of the domain being measured; that is, better physical function and ability to participate in social roles and activities, but higher levels of anxiety, depression, fatigue, sleep disturbance, pain interference, and pain intensity. Total raw scores are obtained by summing item scores for each domain, which are converted into T-scores standardized in the general US population . The PROMIS-29v2 scores have been validated in SSc in English and French , 62.N = 7,442) of lay-led self-management programs reported a standardized mean difference (SMD) effect size of 0.3  for improved self-efficacy in 10 studies [α = 0.05, a mean of 8 participants per group, and intra-class correlation coefficient of 0.08 (based on SPIN-CHAT results) [N = 471 provides ≥ 80% power. In our recent SPIN-CHAT [A Cochrane Review ( studies . With a results) , N = 471PIN-CHAT  and SPINPIN-CHAT , 36, whiPIN-CHAT  participQualtrics platform to introduce the SPIN-SELF Program and explain the enrollment procedure and what participation involves. The email will contain a secure Qualtrics survey link by which participants will have the opportunity to consent, decline, or request to be contacted by a study team member for more information. Those who consent will also provide days and times when they could take part in group sessions.Eligible SPIN Cohort participants identified via routine cohort assessments will receive an email from a SPIN Team member sent using an automated email feature in the Qualtrics survey link with information on the trial and a consent form for the completion of eligibility questionnaires online, items to assess eligibility, similar consent options for trial participation as SPIN Cohort enrollees for those who are eligible, and days and times available for those who are eligible.Additionally, recruitment announcements will be posted on SPIN’s Facebook page and Twitter account and distributed via SPIN’s patient organization partners in countries with large English-speaking populations  and French-speaking populations . Recruitment announcements for non-SPIN Cohort participants will direct potential participants to a different Consent forms for the feasibility portion of the trial will explain (1) that the purpose of the feasibility trial is to test the procedures and intervention delivery prior to proceeding to the full-scale trial; (2) that if based on the feasibility trial we determine that no substantive changes are needed to procedures we will proceed directly to the full-scale trial with data from the feasibility study included in the full-scale RCT; and (3) that if substantive changes are required, the feasibility trial data will be analyzed separately from the full-scale trial.Qualtrics; (5) depending on availabilities, it is possible that some enrolled participants will not be able to be randomized; and (6) enrolled participants who do not receive the intervention as part of the trial, either because they are selected for the control group or because they are not randomly assigned to either the intervention group or control, will be offered access to the online-only SPIN-SELF Program version after the full-scale trial but will not be placed into videoconference groups. A member of the SPIN research team will call all consented participants to confirm availability, time zone, and answer any questions they might have prior to including them in the pool of participants eligible for randomization. Potential participants who decline enrolment in the SPIN-SELF trial will not be reassessed for eligibility if they are again eligible at a future SPIN Cohort assessment.Consent forms for both the feasibility and full-scale portions will explain that (1) new intervention groups will be started on an approximately monthly basis; (2) each month, enrolled participants with availabilities compatible with scheduled groups will be randomly selected and assigned to an intervention group or care as usual control with 1:1 allocation ratio; (3) participants randomized to the SPIN-SELF intervention group, plus those allocated to care as usual, will complete outcome measures online at 3 and 6 months post-randomization through Recruitment will be paused once our enrollment target for the feasibility trial has been reached. We will restart at the beginning of the full-scale trial.For the feasibility and full-scale portions of the trial, consented participants will be entered into pools of participants available to participate in the same weekly group based on availability and, for the full-scale trial, language. For the full-scale trial, separate English- and French-language groups will be formed (feasibility only includes English-speaking participants). De-identified codes for participants in each pool will be provided to an external randomization service. Starting with the largest pool, the service will randomly select the largest possible even number of participants (12 to 20 participants to obtain intervention groups of 6 to10 participants) then randomly allocate half to intervention and half to control via single block randomization using R version 3.6.3. For the feasibility trial, depending on scheduling availability and pool sizes, we will form 2–3 pools. For the full-scale trial, we will form as many pools as possible each month until the enrollment target is met.All participants who are randomized will receive an email to communicate their assignment to the SPIN-SELF Program or usual care. The intervention group email will include the date and time of their first group session and information on how to access SPIN-SELF Program and login to the videoconferencing system. Participants who have not been randomly assigned to either the intervention group or the waitlist will receive an email to inform them that they could not be assigned but will be re-contacted to confirm eligibility and interest and attempted to be randomized when new sessions begin again in a month.In most pragmatic trials of education and psychological interventions, including the SPIN-SELF Trial, participants are typically not able to be blinded to intervention status. This may be understood as part of the response to being offered an intervention, as may occur in clinical practice . AnotherQualtrics survey tool. To ensure accuracy and link to SPIN Cohort data, for SPIN Cohort enrollees an email authentication check will ensure that emails entered match eligible SPIN Cohort participant emails. Data security measures in place at Qualtrics are described in the Qualtrics security statement [Informed consent for SPIN Cohort and external enrollees will be obtained via the tatement .Qualtrics. Baseline measures will be completed through regular SPIN Cohort assessments for SPIN participants and through Qualtrics for externally recruited participants. The SPIN Cohort uses a secure electronic data management platform designed and managed by the Information Management Services of the Centre for Clinical Epidemiology, Jewish General Hospital, Montreal. All information obtained from participants during the trial will be treated confidentially within the limits of the law. To protect the privacy of participants, a unique participant identification number has been automatically assigned to each participant .For both the feasibility and full-scale trials, all participants will complete the outcome measures at 3 and 6 months post-randomization through Separate from the SPIN Cohort portal, an encrypted database has been created for SPIN interventions, including the SPIN-SELF Program, which includes the usage log information of participants in the intervention group. Participant identification numbers are also available in the usage log to link participants’ intervention and regular cohort data.During the trial, access to the cohort portal and the encrypted database will be limited to study investigators. Once the trial ends and results are reported, de-identified data will be made available upon reasonable request. No biological specimens will be collected.Consistent with the feasibility trial design and small sample size, no hypothesis tests are planned for the feasibility portion of the trial , 67. InsIn the full-scale trial, we will use intent-to-treat analyses to estimate score differences between intervention and care as usual participants with a linear mixed-effects model fit using the lmer function in lme4 . Score dTo minimize the possibility of bias from missing outcome data, we will use multiple imputation by chained equations using the mice  package To estimate average intervention effects among compliers , we will use an instrumental variable approach to inflate intent-to-treat effects from main models by the inverse probability of compliance among intervention arm participants , 73; 95%Participant satisfaction scores for the intervention group will be reported descriptively.α = 0.05. We will not adjust for multiple analyses since we identified a single primary outcome a priori.All outcome analyses will be conducted in R . All analyses will be 2-sided with The trial will be coordinated by the SPIN Team in Montreal, Canada. The trial will be overseen by the SPIN Steering Committee along with the trial investigators. The Steering Committee will be updated periodically on the progress of the trials. The SPIN Director, together with trial investigators, will be responsible for routine monitoring of data quality and RCT protocol execution. These groups are independent from trials sponsors.We do not anticipate any serious risks or safety concerns associated with participating in the SPIN-SELF Trial. Nonetheless, any reported adverse event will be recorded, and when necessary, the event will be discussed with clinical members within the team and a referral to SPIN’s health care professionals from the recruiting site will be made. Any serious adverse events that occur will also be reported to the Research Ethics Committee.Although it is hypothesized that the SPIN-SELF Program will improve disease management self-efficacy and functional health outcomes, it cannot be guaranteed that participants will receive any benefits from this study. However, knowledge gained from this study may lead to the implementation and dissemination of the SPIN-SELF Program, which may benefit those living with SSc in the future. There will be no financial compensation for participants in the trial.Qualtrics prior to participating in the trial. Any modifications to the protocol which may impact the conduct of the study, including changes of study objectives, study design, patient population, sample sizes, study procedures, or significant administrative aspects will undergo a formal amendment to the protocol. Any such amendment will be submitted to the Research Ethics Committee for approval and documented in the trial’s registration.The SPIN Cohort was approved by the Research Ethics Committee of the Jewish General Hospital, Montreal (#12-123), and by ethics committees of each recruiting site. The SPIN-SELF Feasibility Trial with Progression to Full-scale Trial has been approved by the Research Ethics Committee of the of Centre intégré universitaire de santé et de services sociaux du Centre-Ouest-de-l'Île-de-Montréal (#2021-2777). All participants will provide electronic consent via The SPIN-SELF Program may improve disease management self-efficacy and health-related quality of life of people with SSc. If effective, the online program will be made available via the SPIN-SHARE online platform  and adveThis is the first version of the protocol, finalized on June 10, 2021. Recruitment and enrollment via the SPIN Cohort and social media announcements are planned to begin in August 2021 and will continue until our enrollment target is reached.Additional File 1. Items from the World Health Organization Trial Registration Data SetAdditional File 2. Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: Recommended items to address in a clinical trial protocol and related documentsAdditional File 3. Participant consent form (English version)


Coronavirus Disease 19 (COVID-19) is a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has grown to a worldwide pandemic with substantial mortality. The symptoms of COVID-19 range from mild flu-like symptoms, including cough and fever, to life threatening complications. There are still quite a number of patients with COVID-19 showed enteric symptoms including nausea, vomiting, and diarrhea. The gastrointestinal tract may be one of the target organs of SARS-CoV-2. Angiotensin converting enzyme 2 (ACE2) is the main receptor of SARS-CoV-2 virus, which is significantly expressed in intestinal cells. ACE2 links amino acid malnutrition to microbial ecology and intestinal inflammation. Intestinal flora imbalance and endotoxemia may accelerate the progression of COVID-19. Many herbs have demonstrated properties relevant to the treatment of COVID-19, by supporting organs and systems of the body affected by the virus. Herbs can restore the structure of the intestinal flora, which may further modulate the immune function after SARS-CoV-2 infection. Regulation of intestinal flora by herbal medicine may be helpful for the treatment and recovery of the disease. Understanding the role of herbs that regulate intestinal flora in fighting respiratory virus infections and maintaining intestinal flora balance can provide new ideas for preventing and treating COVID-19. Coronaviruses are mainly divided into four genera, alpha (α), beta (β), gamma (γ), and delta (δ), which can infect humans and a variety of animals. The seven human coronaviruses (HCoV) that have been discovered are HCoV-229E, HCoV-NL63, HCoV-OC43, HCoV-HKU1, Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV-2. Coronaviruses can cause respiratory as well as gastrointestinal infections in humans and animals . In addiAngiotensin-converting enzyme 2 (ACE2) is the primary receptor of the SARS-Cov-2 virus. ACE2 is significantly expressed in alveolar type II cells and intestinal cells . CurrentCOVID-19 is mainly manifested by fever, fatigue, and dry cough, but some patients have abdominal pain, nausea, vomiting, diarrhea, and other symptoms. According to relevant reports on COVID-19 symptoms, the number, range, and severity of COVID-19-related symptoms may vary from person to person. Overall, our symptom analysis of independently published studies  involvinAmong the 1,299 hospitalized patients with SARS included in the statistics, 514 (39%) developed gastrointestinal symptoms, included diarrhea (7–20%) , there aLactobacillus or Bifidobacterium in the intestines are significantly reduced , genotype tissue expression and mammalian genome function annotations, the top three tissues with the highest expression levels belong to intestinal tissues , which further binds to the cell surface receptor MAS to establish a second axis through ACE2/ANG-(1-7)/MAS, whose end point is the metabolite ANG-(1-7). The downstream ERK, P38, and JNK signaling pathways are regulated by Mas, which plays a protective role in inhibiting the inflammatory response . BesidesRestore the intestinal flora and reduce the intestinal barrier disruption may be of great value in preventing and treating SARS-CoV-2 infection. The intestinal flora can affect the occurrence of respiratory diseases through the production of metabolites . A varieClostridium difficile) and more likely to cause infections. The intestinal flora contains probiotics, which can prevent the colonization of pathogens. Antibiotic treatment destroys the structure of the intestinal flora and reduces resistance to pathogenic bacteria . However, the colonization resistance of the intestine would be destroyed as soon as antibiotics treatment for pathogenic bacterial infections, caused profound and lasting changes in the intestinal flora. Antibiotics can cause changes in the intestinal flora, which can also lead to an increase in opportunistic pathogens  efficiently binds the S1 domain of the SARS-CoV S protein. ACE2 is a functional receptor for SARS-CoV. SARS-CoV-2 uses the SARS-CoV receptor ACE2 for entry and the serine protease TMPRSS2 for S protein priming. Several retrospective studies conducted on COVID-19 patients infected with SARS-CoV-2 pointed out that the combination of herbal medicine and Western medicine can significantly improve the clinical symptoms of COVID-19 patients and shorten the treatment time for patients in severe or critical condition . As showAs mentioned above, restoring intestinal flora may help prevent and treat SARS-CoV-2 infections. In clinical practice, herbal medicines are usually extracted by water or ethanol and are mainly taken orally. An intestine is an important place for oral drugs to be metabolized in the body . After tClostridium, Escherichia coli, and Lactobacillus. Lactic acid can regulate intestinal peristalsis and inhibit the reproduction of harmful bacteria.There are five main categories of herbal ingredients that can affect the intestinal flora, including glycoside, flavonoids, alkaloids, phenylpropanoids, and organic acids. The intestinal flora secretes glycoside hydrolases, lyases and esterases to cut sugar chains to obtain energy. An important type of product produced by polyglycolysis is short-chain fatty acids, including acetic acid, propionic acid and butyric acid. Short-chain fatty acids have a wide range of physiological function . Most flHere, we sort out some representative herbs that interact with the intestinal flora according to the types of active ingredients, as well as the possible mechanisms of the interaction of these herbs and effective ingredients with the intestinal flora. The interaction between the effective ingredients of traditional Chinese medicine and the intestinal flora are summarized in Stable intestinal tight junction function is an important prerequisite for the stability of the intestinal mucosal barrier. It is closely related to tight junction protein including Occludin, ZO-1, and Claudin, and plays a key role in maintaining intestinal permeability. Tight junction protein is a critical protein that connects the gaps between cells and regulates the intestinal mucosa's permeability. Tight junctions have two main functions: 1) Maintain the polarity of cells, prevent the top and bottom sides of integral membrane proteins from spreading from the side; 2) Prevent ions and molecules from passing through Intercellular space. Under normal circumstances, the tightly connected structure is complete and the function is normal, but the structure and function will be destroyed under pathological conditions. Herbs relieve the destruction of intestinal epithelial cell tight junctions by proinflammatory cytokines , up-regulating tight expression junction proteins, and enhance the effect of mechanical barriers . There aThe active ingredients in the herbal medicine increase the expression level of tight junction protein, improve the ultrastructure of intestinal epithelial cells, up-regulate the ultrastructure of intestinal epithelial cells ZO-1 and Occludin expression, and then repair the colonic epithelial barrier and reduce Intestinal permeability . Herbs cIn addition to protecting the integrity of the intestinal mucosa, herbal medicine also has a regulatory effect on the intestinal mucosa's immune function with a wide range of immunomodulatory effects. In recent years, extensive research on herbs’ intestinal mucosal immunity has helped to reveal its mechanism of action . Many heThe secretion balance of pro-inflammatory cytokines and anti-inflammatory cytokines is the guarantee for the body to produce a correct immune response. The immunomodulatory effect of herbal medicine on the body is one of the important mechanisms to prevent and treat intestinal mucosal damage. Herbs can affect the expression of IL-2, IL-4, IFN-γ, and SIg A in the intestinal mucosa, can increase the proliferation of mucosal cells and maintain the integrity of the intestinal mucosa . Herbal MODS refers to the occurrence of two or more system or organ dysfunctions or failures at the same time or sequentially after 24 h of acute damage to the body. It is a clinical syndrome in which multiple organ function changes in patients with acute injury cannot maintain a stable internal environment. MODS is dangerous and has a high mortality rate. Among the patients in severe or critical condition after infected by SARS-CoV-2, about two out of three patients will develop severely life-threatening ARDS , manifesThe pathogenesis of MODS is currently unclear. However, the intestine is an important source of bacteria and endotoxins in patients in severe or critical condition, the intestine is one of the important sites for inflammatory cell activation and release of inflammatory mediators . For theAs the most extensive and crucial functional organ of the GI tract, the intestinal flora is bound to participate in specific complications' occurrence and development. In particular, some abnormal changes in the small intestine found on autopsy suggest the correlation between the SARS-CoV-2 infection and the intestinal flora. Of course, this correlation needs more research to confirm.Sepsis is one of the main causes of death of patients in severe or critical condition, and its pathophysiological mechanism is more complicated. SARS-CoV-2 invades the body, produces pro-inflammatory and anti-inflammatory reactions, and releases a large number of inflammatory mediators to cause sepsis . The intMost of the nutrient supply of intestinal epithelial cells comes from direct absorption from the intestinal lumen. The intestinal flora mainly depends on the intestinal nutrients to survive and participate in the metabolism of nutrients . Some poThe gastrointestinal tract is considered the largest immunological organ in the body having a central role in regulating immune homeostasis . The intatypical Haemophilus influenzae can simultaneously increase the number of specific Th17 cells in mesenteric lymph nodes and airways  [40–42] also mentioned the use of intestinal microecological regulators to maintain the intestinal flora Balance and prevent secondary bacterial infections. Many patients with mild COVID-19 chose to self-isolate at home to enhance their immunity and achieve self-healing. The immune function of patients is essential in defeating and clearing the virus. The gut microbiota in particular plays important roles in host metabolism, immunity and anti-inflammation. Herbs can restore the structure of the intestinal flora, which may further modulate the immune function after SARS-CoV-2 infection. Regulation of intestinal flora by herbal medicine may be helpful for the treatment and recovery of the disease . Underst


There is growing evidence that depression is frequently comorbid with tuberculosis (TB) and is often associated with a decreased quality of life and poor treatment outcomes. The Patient Health Questionnaire (PHQ-9) is widely used to screen for depression in clinical settings in low-and middle-income countries. This study examined the construct validity and reliability of an interviewer-administered PHQ-9 in a sample of new TB patients in the Free State province of South Africa.A pilot study was conducted in 2019 amongst 208 new adult TB patients attending primary healthcare facilities in the Lejweleputswa District in the Free State. Trained fieldworkers administered a structured questionnaire comprising of questions on patient’s socio-demographic characteristics and the nine-item PHQ-9 to the patients. Confirmatory factor analysis and Cronbach’s alpha were respectively used to investigate the construct validity and internal consistency of the PHQ-9.The model was a good fit, with a Tucker–Lewis index of 0.976, a comparative fit index of 0.982 and a root mean square error of approximation of 0.062 (90% CI: 0.032–0.089). All indicators showed significant positive factor loadings, with standardised coefficients ranging from 0.467 to 0.799. The PHQ-9 was characterised by a single factor latent structure – depression – underlying all items. The Cronbach’s alpha of the scale was 0.84.The results support a unidimensional structure of the PHQ-9, with satisfactory internal consistency implying that the scale is valid and reliable. The TB programme can confidently consider the PHQ-9 for the routine assessment of depression amongst TB patients in the Free State province and similar settings. Whilst most NTP directors were receptive to the notion of integrated TB and mental healthcare, the main perceived barriers to service integration were limited capacity, non-recognition of mental health as a problem, insufficient resources and TB-related social stigma.22 has been widely used to screen for depression in clinical settings in low- and middle-income countries.23 The tool is useful for criterion-based diagnosis of depressive disorders and the assessment of the severity of depression.22 The PHQ-9 has been validated for use in various healthcare settings across Africa.26 In South Africa, the criterion validity of the PHQ-9 has been demonstrated amongst patients attending PHC in the North West and Gauteng provinces.27 The tool has also been translated and administered to patients proficient in at least 5 out of the 11 official languages in South Africa27 but it has never been translated to Sesotho for use in the Free State province.The Patient Health Questionnaire (PHQ-9) developed by Kroenke and colleagues28 have established a unidimensional structure of the PHQ-9, that is, depression. However, other studies in clinical settings in the developed countries have established that the PHQ-9 can display a bidimensional factor structure, that is, somatic and cognitive-affective factors.30 For this reason, the current study aimed to investigate the construct validity of an interviewer-administered PHQ-9 using confirmatory factor analysis (CFA) in a sample of TB patients. The hypothesis was that the unidimensional structure of the PHQ-9 as presented in other African settings would be replicated amongst TB patients in the Free State province of South Africa.There are mixed findings regarding the structure of the PHQ-9. Using exploratory factor analysis (EFA), previous studies in clinical settings in AfricaA pilot study was conducted amongst new TB patients across 11 PHC facilities in the Lejweleputswa District in the Free State. Data were gathered between November and December 2019. The clinics were purposefully selected based on high volumes of drug-susceptible TB patients.The study population comprised new adult patients susceptible to TB treatment. Patients were purposefully selected for the study. The patients were included in the study if they were 18 years and older, initiated treatment between 01 May 2019 and 31 October 2019 and were proficient in either Sesotho or English. Patients younger than 18 years, those who were too ill to be interviewed, those undergoing TB re-treatment and those with MDR-TB were excluded.Eligible patients were recruited through their attending nurses. The nurses informed them about the study and referred them to trained fieldworkers located in private spaces within the facility premises. Those who were willing to participate in the study provided written informed consent for the interviews and access to their clinical information.22 The questionnaire and consent forms were forward-translated into Sesotho and back-translated to English by two independent translators. The translators then reconciled the final translated draft by comparing the original questionnaire to the back-translated questionnaire. The process yielded minor discrepancies that were discussed with the research team before consensus was reached on the final translated questionnaire. A team of experienced bilingual fieldworkers administered the questionnaires to the patients through face-to-face interviews. On average, the questionnaire took about 10 minutes to complete.A structured questionnaire was used for data gathering. It comprised questions about patient socio-demographics and the nine-item PHQ-9.22 Accordingly, patients in this study were asked to indicate how often they experienced the following: (1) little interest or pleasure in doing things (anhedonia), (2) depressed mood or hopelessness, (3) trouble falling asleep (insomnia) or sleeping too much (hypersomnia), (4) fatigue or loss of energy, (5) appetite disturbances, (6) feelings of guilt or worthlessness, (7) diminished ability to think or concentrate (cognitive dysfunction), (8) moving/speaking slowly [retardation] or being fidgety/restlessness [psychomotor agitation] and (9) suicidal ideation. Response options were on a 4-point Likert scale as follows: 0 = not at all, 1 = several days, 2 = more than half the days and 3 = nearly every day. In line with three validation studies in Africa,27 the response set was adapted to improve respondent comprehension, such that ‘several days’ was illustrated as 1–7 days; ‘half the days’ was illustrated as 8–11 days; and ‘nearly every day’ was illustrated as 12–14 days. Socio-demographic and clinical measures included sex , age (continuous variable), marital status (married or unmarried), education qualification  and HIV status (negative or positive or not recorded).The PHQ-9 questionnaire is widely used to measure depression. It comprises items assessing the frequency of depressed mood over 2 weeks preceding assessment.31 Socio-demographic and clinical characteristics of participants were described using frequency counts and percentages. Mean and standard deviations (SD), median and inter-quartile range (IQR) were used to describe continuous variables. Confirmatory factor analysis was used to establish the construct validity of the PHQ-9 in the South African sample of 208 drug-susceptible TB patients. The models were fitted using lavaan version 0.5–2332 in R version 3.6.0.33 Confirmatory factor analysis requirements of multicollinearity, residual values, multivariate outliers and normality were examined. The data set satisfied the CFA assumptions of multicollinearity, residual values and multivariate outliers. However, the assumption of normality was violated for several variables. As variables were measured on a Likert scale and were thus ordinal rather than continuous, this is not surprising. In order to account for the violation of this assumption, the variables were specified as ‘ordered’  when fitting the CFA model. As the items were ordinal, a weighted least squares estimator with robust estimation of means and variances (WLSMV) was chosen. The comparative fit index (CFI) and the Tucker–Lewis Index (TLI) were used to determine whether the model fitted the data better compared to a more restricted baseline model. The root mean square error of approximation (RMSEA) was used to measure how closely the model represented data patterns. The model’s performance was tested by examining the differences between the expected and actual correlation matrix. The internal consistency of the PHQ-9 was evaluated by calculating Cronbach’s alpha.Descriptive data analysis was performed using SPSS version 25.Participation in the research was voluntary. Trained bilingual fieldworkers explained the purpose of the study to eligible patients before the commencement of data collection. They were also informed about the voluntary nature of participation and assured about the anonymity of their information. Those who agreed to participate in the study provided verbal and written informed consent. Arrangements were in place to refer patients for further clinical assistance if they expressed distress during interviews. This study was approved by a Health Sciences Research Ethics Committee in the Free State province (UFS-HSD2019/1574/2611).n = 137; 65.9%). Patients’ median age was 38.5 (IQR: 30.3–54.0) years. The sample comprised largely of unmarried patients  and patients who had attained secondary school education . Almost 6 out of every 10 patients were co-infected with HIV .The sample characteristics are displayed in The model fit was good, with a TLI of 0.976, a CFI of 0.982 and an RMSEA of 0.062 (90% CI: 0.032–0.089). As expected, the indicators all showed significant positive factor loadings, with standardised coefficients ranging from 0.467 to 0.799 . Taken t34 in this study, it was prudent to confirm the construct validity of the PHQ-9 using CFA. African studies have established variable cut-off points for probable depression, ranging from 5 to 11.26 Besides, the PHQ-9 is freely available, easy to understand and simple to score, making it even more advantageous to use in resource-constrained health settings, where administering comprehensive screening instruments may present challenges.8The clarion call for the integration of mental health into PHC services worldwide reinforces the need to utilise psychometrically suitable assessment instruments. The PHQ-9 is widely used for assessing depression in PHC settings worldwide. This was the first time the tool was translated to Sesotho and used in the Free State province. As previous studies in clinical settings in Africa have employed EFA to establish the structure of the PHQ-9 for the assessment of depression,25 would be replicated amongst TB patients attending PHC facilities in the Free State province, thereby providing evidence for the construct validity of the PHQ-9. The clinical implication of the unidimensional structure of the PHQ-9 is that the potential overlap between TB symptoms and somatic symptoms of depression may not significantly compromise the construct validity of the tool.12 Furthermore, clinicians can confidently count all symptoms towards the probable diagnosis of depression without necessarily having to scrutinise the aetiology of each symptom.35 Future studies in this Free State population should supplement the quantitative assessment with qualitative investigations on whether there are aspects that might require the adaptation of the PHQ-9 for culturally relevant use.The results confirmed the hypothesis that the unidimensional structure of the PHQ-9 established in other clinical settings in Africa36 In this study, the translation of the questionnaire yielded minor discrepancies between the original and back-translated versions. These were duly discussed with the research team before consensus was reached on the final draft. Besides, reliability analysis showed that the internal consistency of the tool was satisfactory and was similar to other studies in Africa25 where the PHQ-9 was translated into local dialects. However, because of time and logistic limitations, it was not possible to administer the PHQ-9 twice to the TB patients to establish test–retest or inter-rater reliability.In this study, the PHQ-9 was forward-translated to Sesotho – the predominant local language amongst patients seeking PHC services in the Free State province – and back-translated to English by experienced translators. Previous research in Kenya finding a discrepancy between original and translated versions of the PHQ-9 highlighted challenges with the translation of the PHQ-9 because of differences between spoken or common and written or formal dialect and recommended stakeholder consensus on the translated tool.37 A recent study whilst finding gaps in the assessment of common mental health disorders in adult patients attending PHC in KwaZulu-Natal province38 surmised that nurses might not have routinely identified these patients because of lack of clear pathways for treatment and follow-up. However, there is also a possibility that human resource constraints, such as inundation of professional health workers, negatively impacts the timely identification of patients with common mental health disorders such as depression.39 In light of extant professional health worker shortages in the Free State province,40 the TB programme could potentially explore the effect of supervised non-mental health specialists such as community health workers using this tool to screen and refer patients for clinical evaluation of depression. Ultimately, this would contribute to better TB treatment outcomes through early identification and treatment of depression in patients who might otherwise have been missed by the programme. A limitation of this study is that the sample was purposefully selected and results may not be generalised to other TB populations. Nonetheless, this study is the first to ascertain the construct validity of the PHQ-9 in a sample of susceptible TB patients in the Free State and South Africa.The PHQ-9 in this study was interviewer-administered as opposed to being self-administered. Previous research has established consistent performance between self-administration and interviewer administration of the PHQ-9.Results support the unidimensional structure of the PHQ-9, thereby confirming its construct validity. Besides, the tool has satisfactory internal consistency and is, therefore, reliable for use in the TB patient population. These findings provide TB programme coordinators with confidence in the psychometric properties of the PHQ-9 when considering its use in the routine mental health assessment of TB patients in the Free State province and similar settings.


Background: The study of circulating miRNAs in CSF has gained tremendous attention during the last years, as these molecules might be promising candidates to be used as biomarkers and provide new insights into the disease pathology of neurological disorders. Objective: The main aim of this study was to describe an OpenArray panel of CSF-enriched miRNAs to offer a suitable tool to identify and characterize new molecular signatures in different neurological diseases. Methods: Two hundred and fifteen human miRNAs were selected to be included in the panel, and their expression and abundance in CSF samples were analyzed. In addition, their stability was studied in order to propose suitable endogenous controls for CSF miRNA studies. Results: miR-143-3p and miR-23a-3p were detected in all CSF samples, while another 80 miRNAs were detected in at least 70% of samples. miR-770-5p was the most abundant miRNA in CSF, presenting the lowest mean Cq value. In addition, miR-26b-5p, miR-335-5p and miR-92b-3p were the most stable miRNAs and could be suitable endogenous normalizers for CSF miRNA studies. Conclusions: These OpenArray plates might be a suitable and efficient tool to identify and characterize new molecular signatures in different neurological diseases and would improve the yield of miRNA detection in CSF. Neurological disorders are diseases that might affect the peripheral and central nervous system (CNS), affecting hundreds of millions of individuals of all age groups and races worldwide ,2. NeuroCerebrospinal fluid (CSF) is an ultrafiltrate of plasma that is found around and within the organs of the CNS and maintains an appropriate chemical environment for the neural tissue . In diffmicroRNAs (miRNAs) are small non-coding RNAs that are evolutionarily conserved whose mature and biologically active form is 18–25 nucleotides long . miRNAs CSF circulating miRNA studies in neurological conditions have gained tremendous attention during the last years, as they might be promising candidates to be used as biomarkers and provide new insights into the disease pathology and therapeutic targets of neurological disorders. CSF miRNAs might discriminate between Alzheimer’s disease (AD) individuals and controls  or distimiRNA profiling studies show great promise for the biomarker field in neurological disorders, but further research is needed to validate theresults ofdifferent laboratories . TherefoThe whole cohort of patients was composed ofspinal anesthesia subjects (SAS), corresponding to neurologically healthy patients with hip/knee impairment undergoing surgical intervention; subjects affected by other neurological diseases (ONDs) ratherthan MS, whose pathologies were of vascular origin, migraines, dementia or dizziness; and MS subjects, including the phenotypes relapsing–remitting MS (RRMS) and primary progressive MS (PPMS). Most individuals were recruited at the Girona Neuroimmunology and Multipe Sclerosis Unit of Dr. Josep Trueta University Hospital . All participants signed a written informed consent form. The Ethics Committee and the Committee for Clinical Investigation from Dr. Josep Trueta University Hospital approved the protocol employed.g and 19 °C for 15 min in order to obtain cell-free CSF.CSF samples were obtained at the moment of diagnosis by means of a lumbar puncture made by a neurologist. In the case of SAS, an anesthesiologist performed this technique during surgery. After collecting CSF, it was centrifuged at 400× g, 10 min, 19 °C) was recovered. This phase was mixed with 100% ethanol and placed into a filter cartridge provided in the kit. After the RNA washing procedures, total RNA was eluted with 40 µL of nuclease-free water and stored at −80 °C for its lateruse.Circulating RNA from CSF was purified from 300 or 500 μL of starting material using the mirVana PARIS Isolation kit (Applied Biosystems) according to the manufacturer’s protocol. Briefly, the initial volume of sample (300 μL in most cases) was mixed with the same volume of 2× Denaturing solution containing 375 μL of 2-mercaptoethanol. At this point, two exogenous miRNAs (cel-miR-39 and cel-miR-54) were added at 5 pM to verify the quality of the extraction process. The same volume of acid-phenol:chloroform was then added, and the upper aqueous phase obtained after centrifugation  was used to obtain miRNA cDNA in this study. This kit has been specially designed to work with materials whose miRNA contents are limited. It employs universal reverse transcription (RT) chemistry to obtain the cDNA template used for mature miRNA detection and quantification with TaqMan Advanced miRNA Assays. Two microliters of RNA eluate were used for the preparation of miRNA cDNA and, after the addition of a poly(A) tail and an adaptor following the manufacturer’s instructions, an RT reaction and miRNA amplification reaction were performed.To analyze the miRNA expression ofCSF samples, cDNA templates were subjected to PCR amplification to detect specific miRNAs using TaqMan Advanced miRNA assay technology. These assays were pre-loaded during the manufacturing process in TaqMan OpenArray Human Advanced microRNA plates—the high-throughput screening platforms chosen to carry out the profiling step in this study. Two different formats were used: fixed-content plates (fc-OA) and custom-configured plates (cc-OA). The first werepre-loaded with 754 human Advanced miRNA assays and allowed the analysis of three samples per plate. cc-OA plates were designed to analyze specifically 215 CSF-enriched miRNAs for this study .cDNA templates were diluted to 1:20 in 0.1X TE buffer to be run in triplicate in TaqMan OpenArray Plates. These diluted cDNA samples were combined with the same volume of TaqMan OpenArray Real-Time PCR Master Mix in tubes. Five microliters of the combined master mix and cDNA sample were added to the determined wells in an OpenArray 384-well Sample Plate. The automated OpenArray AccuFill System was used to load the samples into the TaqMan OpenArray Plate through holes. Then, they were cycled and imaged with the QuantStudio 12 K Flex Real-Time PCR System, resulting in Cq values for each sample and miRNA.To study the potential sources of the 20 most abundant miRNAs in CSF, the human miRNA tissue atlas, CNS microRNA profiles described by Hoye et al. and FANTOM5 human miRNA atlas were used to identify miRNA expression across tissue, CNS cells and primary cells, respectively ,23,24. VThree different algorithms were used to identify stable miRNAs in CSF samples: Normfinder , geNorm Three samples of CSF were used to extract RNA from an initial volume of 500 μL and 300 μL in order to establish the average miRNA detection in CSF samples using two fc-OA panels containing 754 TaqMan Advanced miRNA assays.As observed in Previously associated with MS in tissue, serum/plasma or CSF;Particularly brain-enriched;Detectable in CSF based on existing literature and/or our previous experience;Potential endogenous normalizer;Negative control.Due to the low detection presented by CSF samples in fc-OA, cc-OA plates were customized for studying CSF miRNA profiles. The selected 224 format allowed us to analyze 12 samples simultaneously, covering a total of 215 miRNAs plus one mandatory control (miR-16). miRNAs needed to meet at least one of the following criteria to be included in the panel:The list of 215 miRNA assays included in these cc-OA panels is shown in To analyze the performance of the detection of miRNAs with these cc-OA plates, 64 CSF samples were used, belonging to SAS, OND, PPMS and RRMS individuals. The clinical characteristics of the cohort are depicted in miRNAs were classified according to the percentage of CSF samples in which they were detectable . From thAmong those miRNAs that were detectable in at least 70% of samples, the 20 most abundant miRNAs  in CSF were identified by ranking the average Cq values of all samples as shown in Exploring the association of these miRNAs with diseases in the Human MicroRNA Disease Database , all of The potential tissue and cellular origin of the 20 most abundant miRNAs in CSF was examined using different repositories. First, Ludwig et al. determined the abundance of miRNA in tissue biopsies of two individuals . Using tAfter analyzing miRNA expression across primary cells using the FANTOM5 atlas , the preAlthough a normalization method based on the mean expression value of all miRNAs has been proposed and validated for qPCR data from array-based approaches (screening phase), the search fora candidate reference endogenous miRNAs is necessary for futurestudies, and thus we evaluated a limited panel of miRNAs in a wider cohort  . To dateThose miRNAs detected in at least 70% of samples were selected. Three different algorithms were used to identify stable miRNAs: Normfinder , geNorm Despite selecting the best endogenous candidates for CSF samples, the establishment ofthe optimum number of reference miRNAs must be experimentally determined. geNorm also generates a pairwise stability measure to determine if adding more reference miRNAs for the normalization process is beneficial. As shown in CSF is a clear liquid located around and within the CNS, and it maybe analyzed through lumbar puncture . One of miRNAs have been detected in different biological fluids as plasma, serum or CSF, where they remain highly stable, unlike the case of cellular miRNAs . For thiSome of the unsolved challenges in miRNA profiling studies include the existence of heterogeneous and conflicting results as well as the lack of replication among studies . In factThis study presents the first analysis of CSF miRNA levels using TaqMan Advanced miRNA technology from Applied Biosystems with the final aim of designing CSF-enriched miRNA panels to be used in a wide spectrum of neurological diseases. In 2017, Wang et al. defined a specific CSF–miRNA panel to be used in the study of AD . They cuThe performance of cc-OA plates was tested in order to determine their suitability to be used as a tool to identify new molecular signatures in CSF. First of all, the detectability of each assayed miRNA was measured by calculating the percentage of samples in which it could be detected. This analysis showed that miR-143-3p and miR-23a-3p were present in all samples, while another 80 miRNAs could be detected in at least 70% of samples, representing 38.1% of miRNAs. Second, the 20 most abundant miRNAs in the studied CSF samples were chosen by ranking their mean Cq value. All of them belonged to this 38.1% of miRNAs detected in 70% of samples. Surprisingly, only four of them  were included in the CSF panel described by Wang et al. . It shouWhen examining the potential source of the most abundant miRNAs in CSF, some of them were highly expressed in the brain, spinal cord and different CNS cell types. These miRNAs have been found to be associated with some of the most common CNS disorders in the contexts of tumors (glioblastoma) , neurodeAn essential step in qPCR experiments is the normalization procedure, which enables the control of variations in extraction and RT yield, as well as increased efficiency of amplification. It is required before any comparison in miRNA concentrations between different samples and biological groups is performed . The seamiR-23a-3p, miR-26b-5p and miR-125a-5p were found to be the most stable miRNAs in the whole cohort of CSF samples. However, when analyzing the stability in the different groups of individuals, miR-26b-5p, miR-92b-3p and miR-335-5p might seem the most promising miRNAs to be used as endogenous normalizers. This reinforces the necessity of the experimental validation of any endogenous miRNAs as normalizers for particular tissues, cell types or biofluids and specific experimental designs . AlthougAs the interest in high-throughput platforms is increasing in the field of miRNA biomarkers, a panel of CSF-enriched miRNAs was presented and a set of endogenous controls to be used in neurological diseases was proposed.These cc-OA plates with 215 loaded miRNA assays allowed the detection of approximately 38.1% of these miRNAs in at least 70% of CSF studied samples, withmiR-770-5p having the lowest Cq values. Although the use of eight endogenous controls in CSF samples is highly recommended, miR-26b-5p, miR-335-5p and miR-92b-3p are the most stable miRNAs in CSF.These OpenArray plates might be a suitable and efficient tool to identify and characterize new molecular signatures in different neurological diseases and would improve the yield of miRNA detection in CSF.