This is a cross-sectional study of 29 published cases of acute myopericarditis following COVID-19 mRNA vaccination. The most common presentation was chest pain within 1–5 days after the second dose of mRNA COVID-19 vaccination. All patients had an elevated troponin. Cardiac magnetic resonance imaging revealed late gadolinium enhancement consistent with myocarditis in 69% of cases. All patients recovered clinically rapidly within 1–3 weeks. Most patients were treated with non-steroidal anti-inflammatory drugs for symptomatic relief, and 4 received intravenous immune globulin and corticosteroids. We speculate a possible causal relationship between vaccine administration and myocarditis. The data from our analysis confirms that all myocarditis and pericarditis cases are mild and resolve within a few days to few weeks. The bottom line is that the risk of cardiac complications among children and adults due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection far exceeds the minimal and rare risks of vaccination-related transient myocardial or pericardial inflammation. The mRNA vaccines  and Moderna ) demonstrated excellent safety and clinical efficacy profiles in clinical trials in adults in less than one year from the identification of the virus which is unprecedented in the history of vaccinology . The CenPost-vaccination myocarditis has been reported as early as 1957 after smallpox vaccination . PreviouThe American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have endorsed CDC recommendations and reiterated the potential benefits of COVID-19 vaccination, which outweighs rare myocarditis or pericarditis risks and recommend the vaccination for anyone 12 years of age and older ,14. VeryAs of 26 June 2021, a total of 322 million doses of vaccine were used, and thus far, 79 children aged 16 or 17 years, and 196 young adults aged 18–24 years have been confirmed by the CDC as having myocarditis/pericarditis following mRNA COVID-19 vaccination after analyzing data in the VAERS . The adjAs of 30 May 2021, only few cases have been reported in the EEA from the EudraVigilance database: 38 for Vaxzevria (previously COVID-19 vaccine AstraZeneca) and 0 for Janssen vaccine Ad.26.COV2.S) . There is absence of myocarditis and rare cases of pericarditis after receiving the non-mRNA COVID-19 vaccines, such as Vaxsevria or Janssen but conversely, cases of myocarditis and pericarditis in young men after mRNA vaccination are rising. This raises the question of why this only occurs after the vaccines based on an mRNA platform? Several mechanisms have been hypothesized. It has been speculated from the data reported in the initial trials of mRNA vaccines in adults that mRNA vaccines might generate a very high antibody response in a small subset of young people, thus eliciting a response similar to multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. . The mRN.COV2.S (The The common clinical presentation of COVID-19 vaccine-associated myopericarditis includes chest pain, fever, palpitation, shortness of breath, fatigue, nausea, vomiting, abdominal pain or unusual symptoms such as forceful or thumping heart beats. Common signs of myopericarditis include tachypnea, tachycardia, murmur, gallop, diminished pulses, hypotension, hepatomegaly, edema and signs of low cardiac output . The labIn most cases, COVID-19 vaccine-associated myocarditis is transient and self-limited; it is not justifiable to obtain an endomyocardial biopsy. Furthermore, the clinical impact of myocarditis varies widely due to the range of etiologies and the unpredictable physiologic responses depending upon the host’s response to the inciting agent. Elevated cardiac troponin may indicate acute cardiac injury, but not specific to the diagnosis of myocarditis, as many myocarditis patients are asymptomatic and are subclinical. Furthermore, features of myocarditis and pericarditis may overlap and commonly present as myopericarditis. Because of variable clinical manifestations of myocarditis, it is essential to follow the CDC definition of acute myocarditis  and acutAcute myopericarditis associated with COVID-19 vaccine can be associated with arrhythmia. Anticipatory care includes judicious triaging of the disposition of patients seen in ambulatory or emergency setting for work-up or management of probable myopericarditis patients. Whenever possible, serology and PCR for common viral causes of myocarditis such as parvovirus B19, herpesvirus type-6, adenovirus, enterovirus, Epstein–Barr and cytomegalovirus should be obtained to rule out common causes of viral myocarditis. The treatment considerations for COVID-19 vaccine-associated myopericarditis include anti-inflammatory medications and guideline-directed medical therapy if left ventricular function is reduced . No dataIt is prudent to maintain regular follow-up of patients with COVID-19 vaccine-associated myocarditis patients especially those with documented inflammation on CMR. Pending publication of long-term outcome data after SARS-CoV-2 vaccine-related myocarditis, we suggest adherence to the current consensus recommendation to abstain from competitive sports for 3 to 6 months with re-evaluation before sports participation ,33.The preliminary data published suggest that all myopericarditis cases are mild and clinically resolve within a few days to a few weeks. The bottom line is that the risk of cardiac complications due to SARS-CoV-2 infection far exceeds the minimal and rare risks of vaccination-related transient myocardial or pericardial inflammation. The CDC accepts all reports through VAERS from everyone regardless of the plausibility of the vaccine causing the event or the clinical seriousness of the event. The VRBPAC will follow up on all reported cases to the VAERS and VSD and adjudicate the cases as per the CDC case definition of myocarditis and pericarditis. In the future, with continuous monitoring and evaluation of the reported data, we will have evidence-based information available to guide us for proper management and find a specific strategy to mitigate vaccine-associated myocarditis and pericarditis.


ObjectivesSurgical instrumentation teaching is included as an essential part of surgical training in the core surgical training syllabus. Access to formal teaching is variable, and opportunities for informal teaching have been further reduced by the COVID-19 pandemic. We aimed to design a course to fulfil these local trainees' needs. A move away from face-to-face teaching has occurred successfully during the pandemic, but little literature exists on how face-to-face courses can be best designed during this time. We aimed to describe the practicalities of running a face-to-face course with COVID restrictions.MethodsJunior doctors and nurses rotated around five stations led by theatre nurses and senior doctors, each with common instruments from different surgical subspecialties. Social distancing was observed, and level 2 personal protective equipment (PPE) was worn throughout the course. Matched pre- and post-course tests allowed evaluation of learning.ResultsThe course had 20 attendees, and the test scores improved following the course by an average of 9% (p = 0.009). All attendees (100%) found the course improved their knowledge and confidence. Feedback was overwhelmingly positive, and the significant improvement in the multiple-choice question (MCQ) scores demonstrates that this was an effective method of delivering teaching despite the COVID-19 restrictions on social distancing.ConclusionThis course shows that instrumentation training is valuable to trainees and provides a good example to other educators, showing the workings of how a practical course may be run face-to-face during the pandemic. Surgical instrumentation teaching is an essential part of a core surgical trainee’s education . It is tA trainee’s experience of surgical instrumentation differs depending on the time spent in theatre and the availability and quality of teaching. Operating theatre exposure for junior trainees is increasingly limited; a recent large-scale audit demonstrated that only 5% of orthopaedic core surgical trainees met the Joint Committee on Surgical Training standards for minimum weekly clinical exposure . The COVGiven the lack of specific surgical instrument teaching sessions at our university teaching hospital, a course was developed to introduce trainees to instruments they may commonly encounter. Two sessions were run for junior doctors (Foundation Year (FY) 1/2, Core Surgical Training Year 1) and junior theatre nursing staff. The course involved a structured teaching program with clear learning objectives.COVID-19 has resulted in many successful adaptations to traditional teaching courses to minimise social contact and reduce viral transmission risk. Examples of this include online learning ,6, remotThe primary aim of this prospective study was to determine whether lecture- and practical-based instrument workshop teaching led to a significant improvement in knowledge. The secondary aim was to assimilate qualitative evidence about the strengths and weaknesses of the teaching methods used. We hypothesised that the course participants would achieve higher scores as a result of the teaching session.Two surgical instrumentation teaching sessions were held in the hospital’s education centre in September 2020. The inclusion criteria were the completion of the pre- and post-teaching assessments, full attendance of the teaching session and being either a doctor at Foundation Year 1 or Senior House Officer grade or a junior nurse working in operating theatres. One attendee was excluded from the study, as both pre- and post-course feedback were not completed. Institutional board review was not possible at the time of the study due to the COVID-19 pandemic. Independent review from the Departmental Audit and Research Lead advised no ethical approval was required. Informed consent was gained from participants for the data to be published.The education centre provided advice for courses carried out during the pandemic according to government social distancing guidelines. Firstly, course numbers were limited depending on room size to enable appropriate two-meter distancing according to UK government guidelines. The room used for the instrumentation course was risk assessed, allowing for a maximum of 18 people (13 attendees and five faculty). Secondly, level 2 personal protective equipment (PPE) was worn throughout the course, including face masks, aprons and gloves. The course was completed pre-rollout of the COVID-19 vaccine.The attendees were split into five groups and allocated to one of five demonstration tables. These stations were neurosurgery, head and neck , orthopaedics, general surgery and suturing. Each station consisted of demonstration and practical hands-on style teaching, so attendees could learn the names and uses for commonly used instruments within each specialty. The surgical models used in some stations allowed attendees to practice psychomotor skills such as knee arthroscopy and perform an approach to a craniotomy using the instruments they had been shown. The teaching was led by senior theatre nurses or surgeons. All stations were run for 20 minutes before alcohol gel was distributed and attendees rotated to the next station.An online 15-minute knowledge-based pre-course questionnaire was completed prior to starting the teaching stations. Following the completion of all five stations, attendees completed an online post-course questionnaire. This included Kirkpatrick level 1 subjective questions designed to gather information on how satisfied the attendees were with the way the course had been delivered. They then repeated the 15-minute questionnaire taken pre-course.Kirkpatrick identified six levels of medical and surgical education assessment. We used online pre- and post-course questionnaires (SurveyMonkey Inc.) that combined two Kirkpatrick levels to assess the effectiveness of our course. The questionnaires collected non-specific personal data to enable anonymous pre- and post-course feedback matching.Kirkpatrick level 1 analysisThe post-course questionnaire distributed to attendees collected subjective qualitative feedback. The response options were strongly agree, somewhat agree, neither agree nor disagree, somewhat disagree and strongly disagree.Kirkpatrick level 2b analysisThe same 26-part multiple-choice questions (MCQs) were completed by the attendees as part of both pre- and post-course questionnaires. There were five questions each on head and neck, and neurosurgery instruments and four questions each on orthopaedics and general surgery instruments, which were being demonstrated during the course. The last eight questions were images that the attendees had to correctly name from a list of options.www.statskingdom.com). A p value < 0.05 was deemed to be a statistically significant difference in pre- and post-course scores.The mean pre- and post-course scores were calculated and compared. The attendees’ pre- and post-course scores were analysed using a paired Student’s t-test  and four junior theatre nurses . The number of delegates was limited by the COVID-19 social distancing regulations. A larger number would yield increased feedback and data to analyse learning response to teaching and a wealth of evidence on which to base future changes to the course.This course combined practical demonstration and lecture-based teaching at specialty-themed stations to deliver effective teaching for an essential part of the core surgical curriculum. The course was delivered in September 2020, after the first peak of the COVID-19 pandemic in the United Kingdom, and there were benefits to running this course face-to-face, which included live feedback and questioning during trainee instrument interaction and the ability to practice practical skills. Significant efforts were made to accommodate the COVID-19 social distancing restrictions. The results of the pre- and post-course scores demonstrate a statistically significant improvement in knowledge. The results are relevant because junior trainees require good instrumentation training to facilitate improved knowledge of and performance in the theatre environment, which are difficult to replicate in online teaching. This course therefore serves as an example of an effective method for teaching instrumentation, which was well received by trainees.Our practical recommendations for running a course with social distancing restrictions are appropriate room size selection to allow for two-meter social distancing, an appropriate number of attendees to ensure no overcrowding, and wearing of level 2 PPE. Pre-course lateral flow tests could also act as an additional safeguard. The practical recommendations made in this study are likely to remain relevant as advice on social distancing and the restrictions on conducting face-to-face courses may continue. We therefore provide a practical method of continuing the delivery of such courses in this context.


Already at the very beginning of the COVID-19 pandemic, an extensive PCR and antigen testing strategy was considered necessary and subsequently also proved successful in order to limit the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on international and national levels. However, equally important will be the continuous monitoring of the seroprevalence status of populations from defined regions to detect—in a timely manner—any recurrence of infections or an eventual decline in antibody levels of vaccinated individuals, especially in the emerging post-pandemic situation. The aim of this study was to estimate the prevalence of SARS-CoV-2-specific immunoglobulin G antibodies in the federal state of Upper Austria (Austria) during the period of December 2020 until April 2021. To achieve this goal, we have analyzed anonymized data on the immune status of self-referral volunteers that have been determined at local pharmacies through a low-entry-barrier point-of-care analysis approach. The seroprevalence values for immunoglobulin type G antibodies against SARS-CoV-2 antigens obtained by rapid diagnostic testing on peripheral blood from volunteers reflect the current population-based estimates reported in the literature as well as the positivity rates detected by PCR-screening analyses. In conclusion, broad-based monitoring of IgG antibodies by means of a point-of-care testing network represents a valuable tool to assess the current immune situation within regionally defined populations. In Austria, the first case of COVID-19 was reported on February 26, 2020. On March 16, 2020, a general lockdown was implemented across the country, along with specific public health measures aimed at reducing the spread of infections. Nonetheless, by September 27, 2021, 732,259 cases of COVID-19 and 10,736 associated deaths have been reported (https://covid19-dashboard.ages.at/). Starting with December 27, 2020, highly effective vaccination regimes have been deployed in Austria, and as of September 27, 2021, already 63.88% of the population have received at least one dose of vaccine (https://info.gesundheitsministerium.at/). However, numbers of fatalities will continue to rise in the near future, and keeping an eye on the rate of new infections still represents a major task. Due to the high transmissibility of SARS-CoV-2 also in asymptomatic patients, diagnosis relying solely on symptoms and contact tracing alone has proven difficult already during the early days of the recent COVID-19 pandemic. This will also be a serious issue to consider when dealing with monitoring and controlling possible cases of infections during the post-pandemic period.Since December 31, 2019, and as of week 2021–37, 229,415,774 cases of coronavirus disease 2019  have been reported, including 4,699,359 deaths  for a time frame of 4 months. Data have been obtained from self-referral individuals by using a commercial SARS-CoV-2 antibody rapid test from Genspeed Biotech GmbH in pharmacies distributed throughout the federal state of Upper Austria (Austria). The data described could serve as an example for establishing potential monitoring networks for (post-) pandemic surveillance of regionally defined populations. Examples include the development of the immune status over time for selected antigens and/or the detection of sufficiently high antibody levels that might qualify as indicative for a potential neutralizing activity according to the current WHO standard (NIBSC 20/136).https://www.land-oberoesterreich.gv.at/statistik.htm). In 2021, Linz, the capital of Upper Austria, comprised 207,812 citizens  (https://www.linz.at/zahlen). In the course of this study, we have obtained and analyzed the results of a serological screening campaign performed in pharmacies throughout the federal state of Upper Austria (Austria) from December 18, 2020, until April 15, 2021. However, we are aware that a certain bias is inevitably introduced by this approach since we are dealing with non-random sampling in the sense of self-referral of individuals to the respective test sites. We have addressed this fact accordingly in the “As with 2020, the population of Upper Austria consisted of 1,490,279 citizens  . The test is a chemiluminescence-based multiplex micro-ELISA (μELISA) system in a point-of-care format and analyzes blood obtained from a simple finger-prick sample. The outstanding feature of the microfluidic chip architecture is the ability to facilitate a sequential capillary force–driven liquid flow of reagents. The chip itself is designed with a circular inlet port (4 mm diameter) that interconnects with a microfluidic reaction channel  and the waste reservoir . This architecture allows dispensing microliter volumes of different reagents to the inlet port sequentially which are immediately transported into the reaction channel through capillary forces. As soon as the inlet port is empty, the flow stops due to the surface tension at the proximal part of the reaction channel. When the next assay reagent is added, the flow resumes and the reagent in the reaction channel is displaced pushing the previous solution into the waste area.The commercial SARS-CoV-2 antibody rapid test from Genspeed Biotech GmbH (COVID19 IgG xPOC) was used to detect IgG antibodies against full length spike protein (S), the RBD of the spike protein as well as the nucleocapsid antigen (N) for SARS-CoV-2 . Results are available within 15 to 20 min and a performance evaluation study in terms of detecting SARS-CoV-2 antigens has already been published demonstrating sensitivity values of 100% and specificity values of 93% .The test system is based on proprietary technology combining microfluidic test chips with integrated microarrays, miniaturized optoelectronics, and automation of the assay procedure. The analyzer device itself is controlled and powered via the USB port of a tablet computer. Modular, Java-based software intuitively guides the user through the entire testing process.http://www.engenes.cc/) as described previously [The test chip is composed of an injection molded top part containing the microfluidic structures and a bottom foil (both polystyrol) onto which the respective antigens have been deposited. This homogeneous immobilization of the different viral antigens in the corresponding capture areas (1 × 2 mm) was accomplished using a sciFLEXARRAYER S12  by printing a pattern of spots  with 4 columns and 2 lines using proprietary printing buffers. Production processes for spike protein (S), receptor-binding domain (RBD), and nucleocapsid protein (N) were developed at the University of Natural Resources and Life Sciences Vienna and eventually established for commercial production at enGenes Biotech  and is used in combination with an appropriate analog digital converter to integrate chemiluminescence signals over time (150 s integration time) yielding high signal-to-noise ratios.For data readout, the detection of the photons generated by a chemiluminescence reaction is achieved by using a custom photodiode array placed below the reaction channel of the test chip. The one-dimensional detector array with a spatial resolution of 1 mm is composed of 32 pixels. It features a low-noise equivalent power (10https://www.nextgenmicrofluidics.eu/) [Standard multiplexing assays for the detection of different biomarkers or pathogens in a sample in one test run have already been successfully demonstrated, e.g., DNA/RNA-based assays for the detection of genes encoding antibiotic resistance traits . As a prics.eu/) .The assay from Genspeed Biotech GmbH used in the course of this study provides a readout in units of mean chemiluminescence intensity values. For our data analysis, we assigned samples that showed positive signals for both S/RBD and N antigens to the group that has encountered a previous SARS-CoV-2 infection. On the other hand, samples that showed only a positive signal for S/RBD antigen were assigned to the group of vaccinated individuals. Data have been analyzed with the software package MATLAB (version R2020b). Faulty data entries due to missing values have been removed automatically during a data sanity check. We binned the tests corresponding to their geographical origin by comparing the ID number of the testing equipment to its registered location of the respective pharmacies in Upper Austria provided by the manufacturer.https://covid19-dashboard.ages.at/) and data supplied by the federal state of Upper Austria (“Datenquelle: Land Oberösterreich—data.ooe.gv.at”) (https://www.land-oberoesterreich.gv.at/119786.htm).For data analysis and comparison purposes, public available data sets including PCR-test results, vaccination rates, and incidence values have been used from the following sources: the COVID-19 dashboard from the Austrian Agency for Health and Food Safety , the limit for a positive test result for the Genspeed Biotech GmbH assay used in the course of this study was set at 10.7 binding antibody units (BAU)/ml based on correlation with a recently published study describing the persistence of neutralizing antibodies following an infection with SARS-CoV-2 [6, the liThe open design of the point-of-care rapid test from Genspeed Biotech GmbH  should make it possible to adapt virtually any existing laboratory ELISA to point of care level with a typical turnaround time of less than 30 min Fig. . ELISAs In the current study, we have evaluated the presence of IgG antibodies directed against SARS-CoV-2 antigens from self-referred individuals obtained measured with the test system from Genspeed Biotech GmbH in pharmacies throughout the federal state of Upper Austria (Austria). By analyzing approximately 7500 samples, a prevalence value of roughly 30% was detected in this study group. We are aware that self-referral might introduce some bias within this analysis since people at risk for exposure or with medical health preconditions are more likely to have their antibody levels tested. However, we feel that for a general estimation of the seroprevalence in a given population, the sheer number of test results used for analysis should compensate for this limitation. In addition, such an approach represents a more life-like testing situation compared to clinical trials. The latter ones have to adhere to strictly regulated testing regimes and represent an optimal scenario that can hardly be achieved in reality.In a first analysis, we examined the effect of the vaccination program against SARS-CoV-2 launched in Austria at the end of December 2020. As demonstrated in Fig. The current gold standard for SARS-CoV-2 serology are neutralization assays that detect the presence of antibodies that can neutralize the virus and inhibit the infection by blocking access to the ACE2 receptor on the target cell by binding to the receptor-binding domain (RBD) on the viral spike protein. A major drawback of these neutralization assays is that they are highly laborious and expensive and can only be performed in specialized biosafety level 3 laboratories. Related tests such as pseudo-typed neutralization assays are also very labor-intensive and not suitable for high-throughput analyses , 15. To Additional reports have shown a significant correlation between the presence of spike protein binding antibodies and various forms of functional virus neutralization assays –23. One Resistance to infection with SARS-CoV-2 acquired through vaccination represents an impressive success story of biomedical research. Multiple studies have already reported that vaccination confers protection against reinfection and/or is able to reduce the risk of clinically significant outcomes. While patients that have recovered from past COVID-19 episodes have been estimated to demonstrate approximately 90% protection against reinfection , the valIn light of these reports, we have also used the respective binding antibody units (BAU)/ml for wild-type SARS-CoV-2 according to WHO standard NIBSC 20/136) from the data obtained in the course of this study [6 from thOn the other hand, the predicted protective effect of antibodies present in individuals following administration of one of the available vaccines (S/RBD-positive) was 27.12% for > 50% protection and 5.54% for > 90% protection, respectively. There are several reasons that can explain the lower numbers in vaccinated individuals seen in our analyses. For example, it has to be stressed that we have analyzed data that were obtained during the very beginning of the vaccination phase in Upper Austria. The target group at that time consisted mainly of aged individuals and people with pre-existing health conditions. Besides representing a group that might also respond not so well to the stimulation of the immune system by vaccination, most of these individuals will have obtained only the first dose of the respective vaccine at that time. In addition, it has previously also been demonstrated that different brands of vaccines are inducing varying levels of circulating antibodies that might also be reflected in our sample data. A follow-up study to characterize the presence of protective antibodies after completing a full vaccination program is therefore highly warranted.In the present report, we have demonstrated the benefits of seroepidemiological testing for the determination of the immunization status of a population in a given region through a commercial SARS-CoV-2 antibody rapid test from Genspeed Biotech GmbH. By identifying individuals that have obtained protective antibodies through natural infection as well as through vaccination, any change in seroprevalence values in a population could be used as an indicator to launch or intensify, e.g., local testing and/or vaccination efforts. Therefore, establishing national testing networks offering low-threshold access opportunities will generate a valuable additional effect when dealing with the challenges of the post-pandemic times ahead.


Peptostreptococcus anaerobius and Pseudomonas stutzeri and depletion of Sphingomonas yabuuchiae, Agrobacterium sullae, and Pseudomonas veronii. Based on the relative abundance of the oropharyngeal microbiota at the species level, we built a microbial classifier to distinguish COVID-19 patients from healthy controls, in which P. veronii, Pseudomonas fragi, and S. yabuuchiae were identified as the most prominent signatures for their depletion in the COVID-19 group. Several members of the genus Campylobacter, especially Campylobacter fetus and Campylobacter rectus, which were highly enriched in COVID-19 patients with higher severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and showed a significant correlation with disease status and several routine clinical blood indicators, indicate that several bacteria may transform into opportunistic pathogen in COVID-19 patients when facing the challenges of viral infection. We also found the diver taxa Streptococcus anginosus and Streptococcus alactolyticus in the network of disease patients, suggesting that these oropharynx microbiota alterations may impact COVID-19 severity by influencing the microbial association patterns. In conclusion, the low sample size of SARS-CoV-2 infection patients (n = 10) here makes these results tentative; however, we have provided the overall characterization that oropharyngeal microbiota alterations and microbial correlation patterns were associated with COVID-19 severity in Anhui Province.Coronavirus disease 2019 (COVID-19) remains a serious emerging global health problem, and little is known about the role of oropharynx commensal microbes in infection susceptibility and severity. Here, we present the oropharyngeal microbiota characteristics identified by full-length 16S rRNA gene sequencing through the NANOPORE platform of oropharynx swab specimens from 10 mild COVID-19 patients and 10 healthy controls. Our results revealed a distinct oropharyngeal microbiota composition in mild COVID-19 patients, characterized by enrichment of opportunistic pathogens such as  Coronavirus disease 2019 (COVID-19) was recognized as a global pandemic established at the end of 2019 and is an infectious disease caused by the SARS-COV-2 virus . Globallvia the oral-lung axis can affect the outcome of many infectious diseases by regulating host mucosal immunity . Serum samples were collected after routine diagnostic testing on patients admitted to the hospital who subsequently tested positive for SARS-CoV-2 via PCR. This study was conducted in accordance with the Declaration of Anhui Medical University.This prospective study involved 10 patients (five men and five women) with COVID-19 hospitalized with laboratory-confirmed SARS-CoV-2 infection patients (LCP) were admitted to the Anqing Municipal Hospital of Anhui Medical University and Affiliated Fuyang Hospital of Anhui Medical University from February 18 to 26, 2020, and 10 healthy individuals [healthy controls (HCs)] were admitted to the First Affiliated Hospital of Anhui Medical University from February 15 to 28, 2020. Accordingly, the 20 individuals incorporated into the study were recorded without using antibiotics within 2 months. SARS-CoV-2 infection was confirmed by 2 consecutive RT–PCR tests targeting the ORFlab and N genes. HCs were individuals with no past medical history or history of antibiotic intake in the past 3 months recruited SARS-CoV-2 detection was performed on the CFX96™ Real-Time PCR Detection System  using the NeoPlex™ COVID-19 Detection Kit  targeting viral ORFlab and N genes and the housekeeping gene of β-actin as an internal control, following the manufacturer’s instructions.® dsDNA BR Assay , and the quality was checked by running an aliquot on a 1% agarose gel stained with ethidium bromide, stored at −80°C, and used as needed. When the 16S rDNA PCR result was positive, sequencing libraries were prepared from the PCR products using the Rapid Barcoding Sequencing Kit . The input DNA was end-repaired and A-tailed using the Ultra II End Prep Enzyme  incubated at 20°C for 5 min and 65°C for 5 min. The end-prepared DNA was purified with AMPure XP , and the DNA was eluted in nuclease-free water followed by ligation with a 1D adapter using Blunt/TA Ligase Master Mix (NEB) at room temperature for 10 min. 1D adapter DNA purification was achieved with Adapter Binding Buffer (ONT) using a magnetic stand, and the DNA library was eluted with elution buffer (ONT). The presequencing mix was loaded onto an R9.5 flow cell (FLO-MIN107) in a mix of running buffer with fuel mix and library loading buffer (ONT). Finally, sequencing was performed for 2 or 3 h, and base calling was performed using MinKNOW software.Bacterial DNA was extracted from the throat swabs by using a QIAamp DNA Microbiome Kit  according to the manufacturer’s instructions and eluted with nuclease-free water. The DNA was quantified by using a Qubitrfcv function provided by the random forest package. The most highly discriminating species were identified by importance values characterized by “MeanDecreaseAccuracy” parameters. The microbial correlation networks were constructed using SparCC . The optimal number of species was determined by 10-fold cross-validation using the g SparCC . Signifivegan. Principal coordinate analysis (PCoA) was performed to highlight the discrepancy of the phylogenetic compositions of gut microbiota between the LCP and HC groups using the ade4 package in R. An analysis of similarities (ANOSIM) was used to assess the differences in gut microbiota among the groups using the R package vegan. An R value close to 0 represents no significant difference between inter- and intragroup differentiations. An R value close to 1 indicates that intergroup differentiation was greater than intragroup differences. p ≤ 0.05 reflects a statistical significance. For comparison analysis, a Wilcoxon rank-sum test was used for the comparison of gut microbial composition that did not fit the normal distribution between the two groups. Raw p-values were adjusted for multiple testing using the Benjamini–Hochberg method at a false discovery rate (FDR) of 0.05  , which was in accordance with previous research   could play an important role in driving the changes in microbial correlations in subjects with SARS-CoV-2 infection.Considering that gut bacteria are complex in both structure and function, this complexity can be well represented and modeled as networks. Network methods can be applied to microbiota studies to model the co-occurrence of bacteria, find microbial relationships essential for community assembly or stability, and deduce the influence of various associations on host health. To compare the microbial communities of the two groups at the network level, we constructed a species-level microbial correlation network for each group using the package SparCC  sparse  was leveCampylobacter and Roseburia were both identified as significantly anti-correlated with the viral load of SARS-CoV-2  but negatively correlated with the mean corpuscular hemoglobin concentration (MCHC) level  decreased in abundance in infected patients . Initially, the model constructed using the microbiota at the species level showed the best predictive accuracy of 80%  among all taxonomic levels, and species that could accurately identify differences between both groups were selected as the optimal marker set through fivefold cross-validation in the random forest model. This result indicated that the optimal number of bacterial signatures (species) was three  but increased Shannon biodiversity compared to the HCs, which showed inconformity to previous research . Nonetheogenesis , confirmogenesis . Hence, carditis . Though lication , that thS. anginosus, S. alactolyticus, and P. stutzeri) that played a key role in driving the changes in microbial correlation networks between COVID-19 patients and HCs. S. anginosus/alactolyticus has previously been shown to colonize the upper respiratory, digestive, and reproductive tracts. However, under certain stimuli, such as SARS-CoV-2, disordered S. anginosus directly induces non-invasive infections and causes invasive infections after entering normal sterile sites in the body, including the blood and serosal cavity, which eventually affect the tissues and organs of various systems of the body  would be a valid alternative to the current frequently used specimens  to assess the microbiota compositional differences in disease, giving reliable insights into subject susceptibility. There are limitations to our study: 1) the low number of subjects involved, especially the loss of severe SARS-CoV-2-infected patients; 2) the lack of shotgun metagenomics to ascertain genes and/or pathways; and 3) the inability to confirm whether the observed oral dysbiosis was already in action in COVID-19 patients when oral swab samples were taken. Despite these restrictions, our study leveraged full-length 16S rRNA gene sequencing technology to improve the observation of taxonomic variation at the species level. This research provides a hint at the importance of modulating the oral microbiota for the treatment or detection of COVID-19 symptoms.The present study might be the first to depict the alteration in the oral microbial composition of mild COVID-19 patients during hospitalization by nanopore technology based on the full-length 16S rRNA gene, despite the limited sample size. Nanopore sequencing would accelerate and aid the identification of maladjusted bacteria and would promote accuracy in taxonomic classification. In addition, the links between unbalanced oral microbiota and viral load in patients have denoted the potential of intervention in the prevention and treatment of SARS-CoV-2-infected patients based on the modulation of the oral microbiome.The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.The studies involving human participants were reviewed and approved by the Ethics Committee of Anhui Medical University . The patients/participants provided their written informed consent to participate in this study.S-HH and YS conceived and designed the experiments and revised the manuscript; M-ZHe performed the experiments, analyzed the data and wrote the manuscript; H-YG, PW, J-LY and Y-LG collected the samples; Y-LS and M-ZHa performed bioinformatic analysis and interpreted the data. All authors read and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (81974306) and Emergency Research Project of Novel Coronavirus Infection of Anhui Province (202004a07020004 and 202004a07020002).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Many studies have tested the relationship between demographic, clinical, and psychobiological measurements and clinical outcomes in ultra-high risk for psychosis (UHR) and first-episode psychosis (FEP). However, no study has investigated the relationship between multi-modal measurements and long-term outcomes for >2 years. Thirty-eight individuals with UHR and 29 patients with FEP were measured using one or more modalities . We explored the characteristics associated with 13- and 28-month clinical outcomes. In UHR, the cortical surface area in the left orbital part of the inferior frontal gyrus was negatively associated with 13-month disorganized symptoms. In FEP, the cortical surface area in the left insula was positively associated with 28-month global social function. The left inferior frontal gyrus and insula are well-known structural brain characteristics in schizophrenia, and future studies on the pathological mechanism of structural alteration would provide a clearer understanding of the disease. A meta-analysis showed that female sex, higher education, working history, shorter duration of untreated psychosis, milder positive and negative symptoms, and premorbid adjustment, are predictors of a better prognosis in FEP3. For individuals at ultra-high risk for psychosis (UHR), which is defined as an earlier clinical stage of the psychosis spectrum with ~25% of the individuals transitioning to psychosis in 2 years4. a number of studies have attempted to identify the risk factors for later transition to psychosis (UHR-P)5. Furthermore, the predictive factors for clinical outcomes in UHR have become the focus since nearly half of the individuals with UHR without transition to psychosis (UHR-NP) still have a poor prognosis7. Similar to FEP prognosis studies, female sex, older age, milder subthreshold symptoms, greater cognitive function, and better global function are the predictors for better functional outcome8.Schizophrenia mainly manifests in late adolescence and adulthood and continues to affect young people life-long. The outcomes of schizophrenia are heterogeneous, and nearly half of the patients with first-episode psychosis (FEP) achieve symptomatic remission and functional recovery13. Previous magnetic resonance imaging (MRI) studies in FEP have mostly attempted to reveal the relationships between brain characteristics and treatment response in the short term11, Gyrification pattern studies in FEP have shown that non-responders to antipsychotic administration at 12 weeks had hypo-gyrification in the left superior and middle frontal gyrus and bilateral insula14, and reduced gyrification-based connectivity compared with the responders15. For UHR, although many MRI studies have focused on the difference between UHR-P and UHR-NP13, a structural MRI study with a 6-year follow-up showed that people with poor functional outcomes had smaller volume and cortical thickness in the right caudal middle frontal, orbitofrontal, frontal pole, and triangular part of the inferior frontal gyrus (IFG), and the left precuneus and rostral middle frontal gyrus, and smaller subcortical volume in the corpus callosum and nucleus accumbens, compared with those without poor outcomes16. A machine learning classification study with a 4-year follow-up revealed that people with poor functional outcomes had reduced cortical surface area in the left superior temporal gyrus and pericalcarine cortex, and the right opercular part of the IFG and cuneus17. These results suggest that brain alteration in the prefrontal and temporal cortex could be a factor for long-term prognosis in UHR and FEP.To understand the symptomatic and functional outcomes in UHR and FEP more clearly, a number of studies have investigated the relationship between the prognosis and psychobiological characteristics using neuropsychological, neurophysiological, and neuroimaging measurements18, suggesting that analyzing the relationship between the characteristics only from one modality and clinical outcomes could preclude an actual relationship. To the best of our knowledge, there has been no study that investigates the relationship of multi-modal measurements with long-term outcomes in UHR and FEP. A multi-modal investigation was proposed for a better understanding of clinical prognosis and the objective markers20.Although previous studies have attempted to investigate the prognosis using one modality, very few studies have used multi-modal measurements. We recently reported that the deficits in verbal fluency mediated the relationship between the cortical surface area in the right banks of the superior temporal sulcus and 4-month negative symptoms in UHR21. In this project, we obtained multi-modal psychobiological measurements including a cognitive battery, electrophysiological response during mismatch negativity (MMN), structural MRI, and brain activity using functional near-infrared spectroscopy (fNIRS) for UHR and FEP. For the correlational analyses using future prognosis, we previously reported the relationship of brain activity in the middle frontal gyrus with the later global function score in FEP22, duration MMN with later symptomatic remission and frequency MMN with later cognitive function in UHR23, and attention/processing speed in UHR-NP and executive function in FEP with 12-month global function24. Multisite MRI studies revealed that UHR-P showed higher gyrification in the left occipital lobe compared to UHR-NP25. We also reported that the use of a manual tracing method of the IFG subregions that reduced gray matter volume in the triangular part of the IFG was a disease-specific feature of the schizophrenia spectrum , whereas reduced gray matter in the opercular part was a feature of autism spectrum disorder28. A multi-modal study showed that the volume in the triangular part of the IFG was associated with fNIRS brain activity in the IFG during a verbal fluency task30. Now, the data of all modalities at baseline and the clinical follow-up assessments for >2 years are available.The Integrative Neuroimaging Studies in Schizophrenia Targeting for Early Intervention and Prevention (IN-STEP) research project was designed as a prospective observational study to explore the pathophysiological features around the onset of psychosis and investigate the possible predictive biomarkers for clinical use since 2008The present study aimed to explore which demographic, clinical, and psychobiological characteristics derived from multi-modal measurements are associated with symptomatic and functional outcomes at the 13-month and 28-month follow-ups in UHR and FEP .The UHR group had greater 13-month emotional factor scores assessed using the Positive and Negative Syndrome Scale (PANSS) compared to the FEP group . In the FEP group, the cortical surface area in the left insula was positively associated with the 28-month Social and Occupational Functioning Assessment Scale (SOFAS) score  have more severely reduced gray matter volume in the triangular part of the IFG compared to that in the opercular part31. Patients with FEP without response to antipsychotic administration at 12 weeks had hypo-gyrification in the bilateral insula compared with the responders14. The insula plays a role in interoceptive function, which measures the body and emotional state of the self, and has a connection with a variety of other cortical and subcortical regions32. Therefore, the insula function may be related to longer-term outcomes in FEP.A smaller cortical surface area in the left insula was associated with the 28-month symptomatic and functional outcomes in the FEP group. A longitudinal volumetric MRI study showed that patients with FEP had smaller gray matter volume at baseline and progressive volume reduction in the left insula, and the reduction was correlated with positive and negative symptoms at the 2-year follow-upThe significant relationships with clinical outcomes were observed in the structural characteristics, which have been well discussed in the schizophrenia spectrum; however, the significant regions were different between the groups. Several reasons could be attributed to the clinical stages and progressive brain pathology. UHR is an earlier clinical stage and most of the participants in this study did non-transition to psychosis in the follow-up, while most of the patients with FEP were diagnosed with schizophrenia. Therefore, the UHR group could demonstrate a more heterogeneous effect on the relationship between the IFG cortical surface area and the 13-month disorganized symptoms. In the FEP group, the progressive brain pathology in the insular cortex could influence the relationship with the 28-month symptomatic and functional outcomes.22, MMN23, and the BACS24 and clinical outcomes, there was no correlation with longer outcomes in this study. The longer gap between biological measurements and outcomes could be more related to trait characteristics, such as structural brain images, and repeated functional measurements could be more useful to assess the present condition and short-range prediction22.Although we previously reported the relationship between functional measurements using fNIRS34. Second, we were unable to obtain detailed symptom severity information, such as that provided by the PANSS, at the 28-month follow-up owing to the naturalistic clinical follow-up. This concern exists especially for young people since they experience more social milestones. In the future, naturalistic longitudinal studies should consider web-based interviews and evaluation methods. Third, we were unable to assess the genetic contribution to the results of this study. Biomarkers from blood collections, such as the polygenetic risk score35 may be more useful as a trait marker, and DNA methylation37, RNA-seq38, and blood metabolism39 may be more useful as state markers.Several limitations should be mentioned. First, some correlational analyses had small sample sizes, especially for the structural MRI and outcomes in FEP, and future studies with larger sample sizes are warranted to confirm the findings. In this exploratory study, we demonstrated the candidate relationships between structural brain characteristics and future outcomes; we can subsequently need a confirmatory study in the multi-sites obtained on brain images and long-term clinical outcomes in UHR and FEP. Furthermore, future studies should use more sophisticated methods, such as machine learningIn conclusion, the present study showed the relationship between structural characteristics in the left IFG and insula, and symptomatic and functional outcomes at the 13- and 28-month follow-ups in UHR and FEP. These regions manifest well-known brain pathology in schizophrenia and their alteration in the early course of the illness could affect long-term outcomes. Future replication studies in multi-sites are warranted for the application of new therapeutic targets and clinical biomarkers for a better prognosis, and for revealing the pathological mechanisms of structural alteration in these regions.In the IN-STEP project, we registered 53 individuals with UHR and 37 patients with FEP. Of these, 38 71.7%) individuals with UHR and 29 78.4%) patients with FEP who were measured using one or more modalities within 90 days of registration  and were assessed at 12-month and/or 28-month follow-ups were included 41 by expert psychiatrists, and evaluated using the UHR or psychosis criteria . The onset of psychosis, UHR-P condition, was defined according to the SIPS criteria during the 18-month follow-up period, else defined as UHR-NP23. Psychosis in the SIPS criteria is the same as psychotic disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition42. All the diagnostic assessments and clinical severity assessments were checked in the routine meetings in the project, and any concern and inconsistent ratings were discussed and rated by the project psychiatrists and psychologists.The participants were recruited from the outpatient and inpatient units of the University of Tokyo Hospital, University of Tokyo Health Service Center, psychiatry clinics, and internet referrals44, (4) previous and/or present alcohol addiction, (5) previous and/or present continuous substance use, and (6) clear comorbidity with autism spectrum disorders according to the DSM-IV criteria. The detailed inclusion and exclusion criteria of this study are described in the protocol paper21.Exclusion criteria were as follows: (1) previous and/or present severe brain injury and/or neurological illness, (2) previous history of electroconvulsive therapy, (3) a premorbid IQ of 70 or less using the 25-item version of the Japanese Adult Reading TestThis study was approved by the ethics committee of the Faculty of Medicine, University of Tokyo , and all the participants, and their caregivers if the participants were under 20 years of age, provided written informed consent to participation in the project and the required measurements following a complete explanation of the experiment.45. Self and parental socioeconomic status were assessed using the Hollingshead scale46. For the FEP group, we defined duration of untreated psychosis as the time period between the onset of the first psychotic symptoms and the initiation of antipsychotic treatment, and this information was obtained from a detailed review of the clinical records or from interviews with patients and their family members using the Nottingham onset schedule48.Demographic, clinical, and psychobiological characteristics used in this study are listed in Table 50 for global symptoms and functions, and the PANSS51 for symptom severity by the expert psychiatrists and psychologists in the project. The PANSS scores were categorized into five categories: positive, negative, disorganized, excitement, and emotional symptoms52. If the patients were taking any antipsychotic, antiparkinsonian, anxiolytic, and/or antidepressant agents, we calculated the chlorpromazine, biperiden, diazepam, and imipramine equivalent doses, respectively53.Clinical assessments at baseline were obtained using the Global Assessment of Functioning (GAF)54. The CES-D comprises 20 items with a 4-point Likert scale (0 [no symptoms] to 3 [severe]), and the total score was used for subjective depressive symptoms (range 0 to 60). Subjective quality of life (QOL) was obtained using the 26-item brief version of the WHO Quality of Life Scale (WHOQOL-BREF)56. The WHOQOL-BREF comprises 26 items with a 5-point Likert scale (1 [poor] to 5 [good]). Five factors were calculated in an average score of corresponding items: physical domain, psychological domain, social relationships, environment, and general impression of QOL.The participants reported their subjective depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D)We used the Brief Assessment of Cognition in Schizophrenia Japanese version (BACS-J) for the cognitive battery, duration and frequency MMN, T1-weighted structural MRI, and brain activity in the frontotemporal cortical area during a verbal fluency task using fNIRS, for the psychobiological measurement.58 measures six cognitive subdomains thought to be affected by schizophrenia: (i) list learning as verbal memory, (ii) digit sequencing task as working memory, (iii) token motor task as motor speed, (iv) category, and letter fluency as verbal fluency, (v) symbol coding as attention and processing speed, and (vi) the Tower of London task as executive function. Trained psychologists conducted the examinations. We used z scores for each category standardized by Japanese age-clustered participants57.The BACS-J60. As in the previous studies62, electroencephalogram was recorded using a 64-channel Geodesic EEG System . We used two types of auditory oddball paradigms using duration and frequency deviant stimuli. Each paradigm had 2000 stimuli consisting of 90% standard tones  and 10% deviant tones . The auditory stimuli were delivered at an 80-dB sound pressure level, 1 ms rise/fall time, and 500 ms stimulus-onset asynchrony. We calculated the duration and frequency of MMN amplitudes as the mean amplitudes from 135 to 205 ms and from 100 to 200 ms post-stimulus, respectively. We used average amplitudes in seven electrodes around the frontocentral electrode as the MMN amplitude 62.MMN is a negative component of electrophysiological response elicited by infrequent deviant stimuli occurring within a series of frequent standard stimuli, and it is considered a promising biomarker among other componentsn = 46 and 17, Supplementary materials). Abnormalities and anomalies were checked by a trained neuroradiologist using T1- and T2-weighted images. We excluded images from further analyses if there were abnormalities and anomalies, or substantial head motion and poor quality that could affect preprocessing. After visual inspection, we also excluded one participant because of the failure of preprocessing using FreeSurfer 6.063. Finally, 43 images were used in this study. We extracted cortical and subcortical structural information from preprocessed images and applied 150 variables of the cortical surface area, cortical thickness, and subcortical volume to the analyses . In the preprocessing phase, we also checked outliers and inspected the segmented region of interest images using the ENIGMA quality control protocol64. Since the effect size between scan procedures would affect the analysis, we applied ComBat65 to the preprocessed data set to harmonize the data sets .Through the project, we used two T1-weighted structural brain image scanning procedures using 3.0-Tesla MRI machines (66. Near-infrared light (650–1000 nm) emitted from a source probe on the human scalp is partially absorbed by the hemoglobin in small vessels (<1 mm), and the remaining light is scattered. A detector probe can subsequently perceive the scattered near-infrared light placed 3 cm away from the source probe in adults66.fNIRS is a portable functional neuroimaging instrument used for the convenient and non-invasively measurement of hemoglobin changes over the surface of the cortex67. The obtained activity was checked using automatic rejection software for visible artifacts derived from the body and head movements68, and two measurements were excluded from further analyses. The location of fNIRS measurements for each channel was estimated using a probabilistic location by a virtual registration from the MRI measurements with an fNIRS probe attachment70. Relative brain activities according to the task were obtained from the 16 frontotemporal regions30. We recorded the total number of correct words during the task period as task performance. Following the measurement, subjective sleepiness during the task was assessed using the Stanford Sleepiness Scale71.Brain activity in the prefrontal and anterior temporal cortical surface area during a 160-s block-designed version of the phonological verbal fluency task was obtained using a 52-channel fNIRS instrument  49 in the IN-STEP project procedure21. We conducted the long-term clinical outcome assessments during Jan 2018 and Dec 2019.We set seven outcome measures: 13-month PANSS five factor scores (mean [SD] = 398.7 [57.3] days from registration), and 28-month SOFAS and symptom subscale score of the GAF (mean [SD] = 857.0 [382.4] days). For the 28-month outcomes, we used the SOFAS and symptom subscale of the GAF with more detailed anchor pointsp < 0.001 was considered significant according to the exploratory MRI studies using FreeSurfer features74 since there was no consensus on the significance threshold set in multi-modal analyses and the sample sizes were too small to tolerate Bonferroni or false discovery rate corrections.All analyses were performed using R version 3.6.2 . We explored which of the demographic, clinical, and psychobiological measurements listed in Table Further information on research design is available in the Supplementary InformationReporting Summary


Since COVID-19 currently has no proven cure but high morbidity and mortality, many people are living in fear of the virus along with other mental health challenges induced by the lockdowns and social distancing. Hence, this study aims to provide evidence on the co-occurrence and inter-relations between the fear of COVID-19, post-traumatic stress symptoms, and psychological distress in adherence to preventive health behavior among Nigerians. It also seeks to determine whether this process differs for men and women. The sample comprised 1,172 consenting young adults  selected using a snowball sampling technique. Structural equation modeling (SEM) was used to test the mediation model of post-traumatic stress symptoms and psychological distress as parallel and serial mediators of the relationship between the fear of COVID-19 and preventive health behavior. The indirect effect of the fear of COVID-19 on preventive health behavior across gender was tested using moderation analysis. Results showed that post-traumatic stress symptoms and psychological distress serially and fully, in causal order, mediated the association between the fear of COVID-19 and preventive health behavior, and gender moderated the mediation effects. The research provides evidence that the fear of COVID-19 could trigger preventive health behavior through post-traumatic stress symptoms but reduces it through psychological distress, whereas the fear of COVID-19 has a slightly more positive impact on preventive health behavior among men. The COVID-19 pandemic confirmed that an infectious disease can travel from one continent to another in a matter of hours. As of August 9, 2020, there were 19,718,030 cases of COVID-19 resulting in 728,013 deaths worldwide, whereas Nigeria had 46,867 confirmed cases and 950 deaths.,,As efforts at establishing effective treatments and developing a vaccine for the disease are ongoing, preventive health behavior is currently the major means of curbing the spread of the novel coronavirus.,,Taylor suggested that an outbreak of an infectious disease could lead people to cultivate anxiety-related distress behaviors such as fear of infection, fear of isolation, fear of strangers, and post-traumatic stress.,,,Research has also suggested that infectious diseases are likely to contribute to psychological distress and consequently poor mental health.,Diagnostic Statistical Manual of Mental Disorder (DSM 5); it has persisted over time (since the beginning of the year 2020), threatened people’s lives, and interfered with their social and occupational functions .The relationship between the fear of COVID-19 and preventive health behavior can be further corroborated by the presence of symptoms of post-traumatic stress. Experience of traumatic events such as rape, accidents, mass conflicts, epidemics, or natural disasters is most frequently associated with symptoms of post-traumatic stress disorder (PTSD).,,,,Based on the novel nature of the coronavirus disease and its negative impacts on Nigerians’ mental health status, as well as the psychological effects of the fear of infectivity of the virus, engaging in preventive behavior and abiding with social distancing rules, more evidence-based studies on how the relationships between demographics, mental health status, and the fear of COVID-19 relates to preventive health behavior are needed. Besides, Nigeria, being a non-WEIRD society, is not well represented in the literature on the relationship between mental health during the COVID-19 pandemic.H1: The fear of COVID-19 will be positively associated with preventive health behavior.H2: Post-traumatic stress symptoms and psychological distress will in parallel mediate the relationship between the fear of COVID-19 and preventive health behavior.H3: The relationship between the fear of COVID-19 and preventive health behavior will be serially mediated by post-traumatic stress symptoms and psychological distress.H4: Gender will moderate the effect of the fear of COVID-19 on preventive health behavior among Nigerians.A summary of the hypotheses and conceptual model of the expected moderated mediation is described in Figure The restrictive governmental measures of social distancing and movement necessitated the use of online survey methodology. Participants were recruited using a snowball sampling technique via WhatsApp, Telegram, Facebook, and Google groups of students in The Polytechnic Ibadan, Nigeria, and they were encouraged to invite their family and friends to participate. Factors considered for the selection included proximity to the researchers, access to the Internet, providing informed consent, and so on. Google form was used to host the survey questions and the link shared on social media by the researchers. The study was conducted in compliance with the Declaration of Helsinki. Informed consent was obtained from all participants included in the study. Participation was voluntary, anonymous, and confidential. Participants were assured that they are at liberty to withdraw from the study at any time they so wish. The study did not collect any personal data through which an individual could be identified. Upon completion of the survey, participants were directed to a counseling website to help with likely stress caused by talking about this issue.Participants completed a questionnaire that included the aims of the study and information on confidentiality and voluntary participation, and 43 items that covered five areas: sociodemographic factors , preventive health behavior, the fear of COVID-19, post-traumatic stress symptoms, and psychological distress.strongly disagree, 7 = strongly agree) was used to measure items such as “I frequently sanitize/wash my hands with soap and water.” A composite preventive health behavior score is calculated by adding up each of the 12 item’s scores (ranging from 12 to 84). Higher scores indicate the greater practice of preventive health behavior. The authors reported a reliability coefficient of 0.82. Its goodness of fit indices were found to be acceptable  and the Cronbach’s alpha observed in the present study was 0.85.The Infectious Diseases Preventive Health Behavior Scale (ID-PHBS) was used to assess the levels of compliance with recognized preventive protocol against infectious diseases such as COVID-19.In the third part, the fear of COVID-19 scale (FCV-19S), a seven-item one-dimensional scale, was used to measure the fear of COVID-19 among the general population.The fourth section of the questionnaire contains the General Health Questionnaire-12 (GHQ-12), a screening instrument for “psychological distress” among the general public.The last section of the questionnaire included the shortened Impact of Event Scale-6 (IES-6) used to measure post-traumatic stress symptoms.r = 0.76). Arguably, with the correlation coefficient below 0.80, we could proceed with the analysis assuming relative independence among the dependent variables. Similarly, the obtained collinearity statistics (variance inflation factor [VIF] > 10 and tolerance < 0.1) do not reach critical values.2/df < 5, GFI, CFI, NFI, TLI > 0.90, SRMR, and RMSEA < 0.08 as the model fit index evaluation standards.https://osf.io/3bpxf.Data were analyzed using the JASP 12.2  software package. For the preliminary analysis, descriptive statistics of the demographic data were computed and normal distribution assumptions were verified. The absence of multicollinearity between studied variables, checked by conducting a bivariate correlational analysis, showed a moderately positive correlation coefficient  in Nigeria responded to the survey. The majority of participants were women (54.5%), aged between 15 and 21 years (47.2%) . There were more unmarried persons (51.2%), Christians (61.7%), from a poor financial background (54.4%), and not so educated  in the sample , and post-traumatic stress symptoms , but negatively with psychological distress . Furthermore, the fear of COVID-19 was positively associated with post-traumatic stress symptoms  and psychological distress . Psychological distress was positively associated with post-traumatic stress symptoms . Also, results indicated that skewness ranged from −0.79 to 0.52 and kurtosis ranged from −0.81 to 0.21 and was within the criteria of normality. All reliability coefficients were found to range from 0.70 to 0.84 and therefore acceptable.The descriptive statistics, reliability, and correlations of our variables are presented in Table 2  = 418; P < 0.001; χ2/df = 4.37; GFI = 0.95; CFI = 0. 96; NFI = 0.96; TLI = 0.96; SRMR = 0.069; RMSEA = 0.080.In the SEM analysis, the goodness of fit indices of the study mediation model were found to be significant (χP < 0.001). When the two mediating variables were included in the analysis, this coefficient was reduced but was still statistically significant   and the consequent mediation by post-traumatic stress symptoms had a positive predictive effect on preventive health behavior  and a significant indirect effect on preventive health behavior (β = 0.333 P < 0.001). Simultaneously, the fear of COVID-19 also predicted psychological distress  and the mediation by psychological distress negatively predicted preventive health behavior  with the indirect effect of the fear of COVID-19 on preventive health behavior through psychological distress also significant  . For example, the fear of COVID-19 could increase post-traumatic stress symptoms, which could in turn increase psychological distress and thus decrease preventive health behavior . The relationship has a significant standardized effect  , with a specified direction flow. Added effect of psychological distress on post-traumatic stress symptoms, the relationship was significant with a significant standardized effect . Also, the fear of COVID-19 recorded a slightly higher positive effect on preventive health behavior for males  than females . The stated hypothesis that gender will moderate the effect of the fear of COVID-19 on preventive health behavior among Nigerians is therefore supported with a statistically significant difference between males and females.This is to assess if the indirect effect of the fear of COVID-19 on preventive health behavior is moderated by gender. Outcomes in Figure ,,Although a plethora of research has explored the patterns of association between preventive health behaviors, the fear of COVID-19, and the mental health status since the start of the pandemic as well as the complex pathways through which they influence each other.,,,The first hypothesis that the fear of COVID-19 will be positively associated with preventive health behavior is supported. The findings indicated that high levels of the fear of COVID-19 were more likely to trigger engagement in frequent preventive health behavior. The result is consistent with previous studies that identified preventive health behavior as being enhanced by the fear of COVID-19.The findings from this study further expand upon previous ones by exploring the effects of post-traumatic stress symptoms and psychological distress. As hypothesized (H2), the relationship between the fear of COVID-19 and preventive health behavior was mediated simultaneously through post-traumatic stress symptoms and psychological distress. This means that post-traumatic stress symptoms and psychological distress serve as pathways through which the fear of COVID-19 may be translated into preventive health behaviors, such that higher levels of post-traumatic stress symptoms are likely to lead to higher levels of preventive health behavior; whereas higher levels of psychological distress are more likely to lead to lower levels of preventive health behavior in persons with a fear of COVID-19. Although the mediation of post-traumatic stress symptoms in the relationship between the fear of COVID-19 and preventive health behavior encouraged preventive health behavior, the mediation of psychological distress potentially reduced preventive health behavior. This means that in the presence of post-traumatic stress symptoms, the fear of COVID-19 is more likely to translate into higher levels of preventive health behavior while for individuals experiencing higher levels of psychological distress, the fear of COVID-19 is likely to translate into lower levels of preventive health behavior. The double-edged effect of fear in the presence of post-traumatic stress symptoms and psychological distress demonstrates the need to pay attention to early intervention and prevention of psychological disorders among the general public, as the world tries to curb the pandemic.,,,,Our hypothesis of serial mediation was also supported. We observed positive associations between the fear of COVID-19 and post-traumatic stress symptoms as well as psychological distress in this study, implying that participants with high levels of the fear of COVID-19 were more likely to report increased levels of post-traumatic stress symptoms and psychological distress. The results show that it is possible to experience post-traumatic stress symptoms and psychological distress concurrently, and both in combination could serially mediate (in any order that is) the relationship between the fear of COVID-19 and preventive health behavior. This is not surprising as the fear of COVID-19 has been reported to facilitate the development of a wide range of psychopathologies among those without prior mental illness.,,,Our hypothesis that gender will moderate the effect of the fear of COVID-19 on preventive health behavior among Nigerians was supported. Gender has a small significant moderation effect on the association of the fear of COVID-19 with preventive health behavior, suggesting that the pathway in which the fear of COVID-19 is translated into preventive health behavior is slightly higher in men than in women. This implies that the fear of COVID-19 has a slightly more positive impact on preventive health behavior when gender is male. Our results contradicted previous studies that found that women tend to report higher preventive health behavior than men because of the fear of COVID-19.In lay terms, the fear of COVID-19 could encourage preventive health behavior, slightly more among males than females. Also, the fear of COVID-19 could lead to the concurrent or separate expression of post-traumatic stress symptoms and psychological distress whereby the resultant post-traumatic stress symptoms could trigger engagement in frequent preventive health behavior, whereas psychological distress could elicit less preventive health behavior. Policies concerning the general public in times of the pandemic should reflect gender sensitivity, bear in mind the possibilities of underlying comorbidities in individuals, and reflect these as well. Health authorities should incorporate psycho-educative interventions in their response to the COVID-19 pandemic. Direct acts to reduce COVID-19 induced psychological distress and campaigns that promote adequate knowledge and attitude toward preventive health behavior are very essential.The present study had some limitations. It used a cross-sectional design that will not allow us to draw inferences about the causal associations among variables nor provide strong evidence for causality. A longitudinal study and/or diary method would be better at demonstrating whether the correlations between the variables in this study are stable over time. Pierce and colleguesa priori hypotheses were supported. The relationship between the fear of COVID-19 and preventive health behavior was mediated positively by post-traumatic stress symptoms and negatively by psychological distress. Also, the fear of COVID-19 tends to slightly promote preventive health behavior among males than females. Although sampling bias means our results should be interpreted with caution, confirmation of these findings could assist in developing targeted interventions to improve preventive health behavior.In summary, this study provides some of the first empirical data examining the degree to which post-traumatic stress symptoms and psychological distress may mediate relationships between the fear of COVID-19 and preventive health behavior in a gender-sensitive manner. Our


We map single energy CT (SECT) scans to synthetic dual-energy CT (synth-DECT) material density iodine (MDI) scans using deep learning (DL) and demonstrate their value for liver segmentation. A 2D pix2pix (P2P) network was trained on 100 abdominal DECT scans to infer synth-DECT MDI scans from SECT scans. The source and target domain were paired with DECT monochromatic 70 keV and MDI scans. The trained P2P algorithm then transformed 140 public SECT scans to synth-DECT scans. We split 131 scans into 60% train, 20% tune, and 20% held-out test to train four existing liver segmentation frameworks. The remaining nine low-dose SECT scans tested system generalization. Segmentation accuracy was measured with the dice coefficient (DSC). The DSC per slice was computed to identify sources of error. With synth-DECT (and SECT) scans, an average DSC score of  The automatic segmentation of the liver and associated tumors from single energy computed tomography (SECT) exams remains a challenge because of limited training data and overlapping intensity values of tissues or materials with different elemental compositions ,2. Most We test the hypothesis with a comparison study between AI systems trained with SECT and then again with the synth-DECT MDI scans to segment the liver from each respective patient CT scan. Similar to previous works ,20, we tWe define an image translation paradigm for creating synth-DECT MDI scans from SECT scans. This is performed by using co-registered DECT scan pairs to train a system that maps SECT scans to the synth-DECT MDI scans.We study the benefits of using the synth-DECT MDI scans for liver segmentation in CT scans. We analyze their utility with four existing semantic segmentation algorithms. We found that the synthetic scans yielded superior performance over the original SECT scans when used as input.We hypothesized that synth-DECT MDI scans would provide greater benefit when less training data were available compared to SECT scans, and we confirm that this hypothesis is generally supported in a study.We additionally observed that the public dataset we used had distortions throughout the ground truth annotations of several scans, but the systems trained with the synth-DECT MDI scans correctly outlined the true extent of the liver for most scans, despite errors in the ground truth used for training.Our primary contributions are summarized as follows:DL-based image to image translation to infer DECT image types: The feasibility of generating synth-DECT image types from SECT scan data using DL-based methods is reported throughout the literature ,25,26,27An overview of our approach is shown in Institutional review board approval was obtained for this Health Insurance Portability and Accountability Act-compliant retrospective study. The requirement for informed consent was waived. All data were collected retrospectively.In this subsection, we describe how we generated the synth-DECT MDI scans using a 2D Pix2Pix system. Pix2Pix is a conditional generative adversarial network (cGAN) that requires co-registered images with pixel-wise correspondence for training. With rapid switching DECT, paired SECT and DECT MDI image types are not available. However, the attenuation pattern observed on the DECT VMI 70 keV image is similar to SECT scans acquired with an X-ray energy of 120 kVp ,32,33. DTo train Pix2Pix, we used 100 unique DECT patient scans for which paired reconstructions were available. The dataset was divided into a training, tuning, and test set, each of which had 80, 10, and 10 paired DECT scans, respectively. Each patient received a routine DECT scan between June 2015 to December 2017 to evaluate the liver. The scans were acquired on a 64 slice CT scanner  with rapid switching DECT following the intravenous administration of 150 mL of iodinated contrast  at 4.0 mL/s. The scan parameters and patient characteristics are displayed in x and output domain y is expressed as follows: G is the generator loss that minimizes the objective against the discriminator D, which contrarily tries to maximize loss [To generate synth-DECT MDI scan types, we trained Pix2Pix to learn the transform between DECT VMI 70 keV and DECT MDI scans. We considered the slices of each DECT VMI 70 keV scan as the input domain, ize loss . Ex,y isi and i with those in layer Pix2Pix was trained for 100 epochs using an Adam optimizer with a learning rate of 0.0002, ix paper .The image preprocessing steps were similar to past studies in which similar datasets were used ,35. SincThree-dimensional u-net with two residual connections ,37. ThisSegResNet  without Dynamic u-net (DynUNET)  is basedV-Net ,46 incluOur goal is to evaluate the value of the synth-DECT MDI scans with four existing DL-based semantic segmentation systems. The four networks were chosen due to their success in organ segmentation:We implement each network as described in the associated references or using the default parameters defined by the Medical Open Network for AI (MONAI) . AdditioAll models were trained from scratch. The loss for each model was the sum of the Sorensen DICE coefficient (DSC) score and cross-entropy loss.on works ,48, eachirically .The intensity values of the synth-DECT MDI scans were clipped to be between 50 and 180 and then normalized to zero mean and unit variance. The SECT scans were processed similarly, but the intensity was clipped to be between 50 and 255. These values were determined empirically. No additional data augmentations were performed during training or testing of the liver segmentation networks.We divided the publicly available CT-ORG: CT volumes with multiple organ segmentation dataset ,31 into The 131 scans were divided into five non-overlapping folds that consisted of 60% for training, 20% tuning, and 20% for the held-out test. Then, we performed stratified 5-fold cross-validation with the same division of scans across the four segmentation systems. The tuning dataset was processed every two epochs. We did not apply any additional data augmentation during training or testing.We compare the performance of systems trained to segment the liver from SECT and then the synth-DECT MDI scans. The global DSC score was computed across each scan volume in the held-out and generalization test sets. The per-slice DSC score was also computed to identify the location of the errors in the scanned volume . The reported DSC scores reflect the average and standard deviation across the 5-fold cross-validation. We used the Mann–Whitney U test, with We evaluate the quality of the mapping from DECT 70 keV VMI to the synth-DECT MDI scans using the held-out test set. To perform this, we compute the structural similarity index (SSIM)  between Across the nine test set scans, the average SSIM was computed as The translation outcomes for two sample scans from the training and generalization test sets are shown in The DSC score achieved by each system is shown in We hypothesized that the synth-DECT scans would provide greater benefit when the size of the training dataset was small. To test this hypothesis, we used the best performing system from our main results: the 3D u-net. The DSC score on the held-out and generalization test sets as a function of training set size for the 3D u-net is shown in To determine the source of the 3D u-net’s lowest DSC scores, we computed the DSC score per slice for each scan in the held-out and generalization test sets. Examples of slices from scans within the dataset with the lowest DSC values  are displayed in Moreover, each pixel intensity value in the synth-DECT MDI scans was transformed based on the amount of iodinated contrast it possessed. Iodine-rich pixels were brighter, whereas iodine-depleted pixels were less intense. As a result, the edges or boundaries of the liver tissue in the synth-DECT MDI scan types were improved. The improved boundary delineation explains why the performance of the 3D u-net trained with the synth-DECT MDI scan types outperformed that of the SECT scans in Additional factors that contributed to the lower DSC score are also illustrated in This paper develops a method to generate synth-DECT MDI scans and demonstrates the benefits of using them to train neural networks for liver segmentation. Furthermore, we show that the 3D u-net trained with synth-DECT scans surpasses the performance of the same system trained with the SECT scans when less training data are available. We also found that the systems trained with synthetic scans were less susceptible to distorted annotations and their performance at the margins of the scan was better than the system trained with the SECT scans. The reduced performance at the margins of the scan may be due to a combination of factors, such as partial volume artifacts and class imbalance. The former could be addressed by scanning with smaller voxel dimensions . Since tThe precise mapping of a SECT scan to an synth-DECT MDI scan type could also enable the possibility of realizing the benefits of DECT at institutions without DECT scanners. However, the influence of clinical variables such as the type of DECT scanner, patient size, position, iodine content, and scan parameters could dictate the quality and accuracy of the synthetically generated DECT scans ,53. For Failure mode analysis showed how scanning practices and dataset quality issues could impact the proposed method. Training medical-grade AI systems with imprecise ground truth annotations could cause misdiagnosis. Including nonliver tissue increases the risk of learning to correlate features unrelated to the target task with the class labels. As a result, systems presumed to be working would fail to generalize when used clinically, or they would appear to be working, but for the wrong reasons . In addiAI systems continue to grow in complexity and applications. Clinically reliable and trustworthy AI systems have yet to gain mainstream adaptation. Considering the imprecise ground truth annotations throughout the training dataset, we recommend more rigorous quality control standards that include a comprehensive verification of dataset annotations, including scan parameters within the meta-data, and identifying and reporting artifacts in scans. In conclusion, we exploited the diagnostic task, human physiology, and medical imaging physics to generate synth-DECT MDI scans that improved the performance of the tested liver segmentation systems with limited datasets.


The work highlighted the preliminary efficacy and safety of immune checkpoint inhibitor (ICIs) treatment for patients without a pathological complete response (pCR) in adjuvant settings, hoping to extend this benefit to additional patients.A recent studyPatients included in the CheckMate-577 study were diagnosed with resected stage II or III esophageal or GEJ cancer and received nCRT. Detailed inclusion criteria include age ≥18, resected stage II or III, residual pathological disease, and histological confirmation of adenocarcinoma or squamous cell carcinoma after chemoradiotherapy and operation. The primary and secondary endpoints were disease-free survival (DFS) and overall survival (OS). In all, 794 participants were randomized and assigned to a 1-year course of adjuvant therapy of anti-PD-1 antibody nivolumab versus placebo in the proportion of 2:1 following adjustments to assure baseline comparability. The results showed that the median DFS of the nivolumab group  was significantly improved compared with the placebo group , and the hazard ratio for disease progression or death was 0.69 (96.4% CI: 0.56–0.86). Nivolumab demonstrated an acceptable toxicity profile, and the occurrence rate of grade 3 or 4 adverse events was 13% in the nivolumab group versus 6% in the placebo group. In addition, patients’ health-related quality of life improved similarly in both the nivolumab and placebo groups.Importantly, the authors observed profoundly improved survival for nivolumab versus placebo, especially for patients with esophageal squamous cell carcinoma (ESCC)  compared with adenocarcinoma (EAC) .2 Failure to achieve pCR remains a major challenge related to ESCC treatment. Many patients experience treatment failure with poor outcomes and severe adverse reactions from chemoradiotherapy, which lacks a bystander tumor-killing effect. Therefore, comprehensive investigation of effective adjuvant treatments for non-pCRs after nCRT represents an urgent and unmet need. In fact, studies have tried to add more systemic chemotherapy or chemoradiotherapy postoperatively to the non-pCRs, with marginal benefit.3 In this study, the introduction of adjuvant nivolumab to nCRT direct caused the median DFS to double; this is a huge new treatment advance for non-pCR patients.This led us to think about the Chinese population. Here, ESCC is the predominant tumor type and accounts for more than 90% of cases. ESCC imposes a heavy disease burden and advances in its treatment have been frustratingly slow. Modest survival benefits were observed in the combined-modality therapy of nCRT followed by surgery, over surgery alone, for patients with locally advanced esophageal cancer. The effectiveness of this treatment was well-established by the CROSS-study results. It was not until the appearance of NEOCRTEC5010 that nCRT followed by surgery was recommended as a first-line therapy for ESCC in China. However, the outcomes of this combined therapy were inconsistent, and only about a third of ESCC patients achieve pCR.4  assessed the efficacy of preoperative chemoradiotherapy and pembrolizumab in neoadjuvant and adjuvant settings for patients with locally advanced ESCC.5 The authors indicated that adjuvant nivolumab therapy had similar efficacy, regardless of PD-L1 expression. However, the authors failed to consider the relationship between immunotherapy benefit and PD-L1 expression stratified by different histology types. We also suggest the authors reevaluate the predictive value of PD-L1 for exclusive ESCC. Besides, while the reported DFS could partly explain the positive efficiency, constant and close follow-up is necessary to achieve durable and convincing improvements in OS.Several issues require resolution before widespread application of this approach. PD-L1 remains a widely validated and accepted biomarker for patients with ESCCs who receive anti-PD-1/PD-L1 monoclonal antibody therapy.2 Although the benefit of adjuvant nivolumab was observed in this clinical trial, most patients will not benefit from adjuvant nivolumab therapy. Thus, identifying biomarkers to effectively predict who would derive benefit from a signal or combined approach is necessary, and exploration of more contemporary biomarkers should be keep going in this study.Our team sought to reveal the association between tumor immune status and occurrence and development of ESCC. We successfully constructed the first individualized and well-validated immune signature to effectively predict ESCCs treated with nCRT. Our signature has strong prognostic accuracy and may greatly improve prognosis.Progress in improving the prognosis of non-pCRs with locally advanced esophageal cancer has been arduous and challenging. The success of the CheckMate 577, achieved by ICIs therapy in an adjuvant setting, absolutely revolutionized the landscape of cancer treatment and provide a new standard of care, especially for patients with ESCC who are non-pCR status.