The coronavirus disease 2019 (COVID-19) has seen a violent and fast spread worldwide. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a predominantly respiratory transmission through droplets and aerosol with serious implications for dental settings. This article is based on recent research, guidelines issued by relevant authorities, as well as on the authors’ experience acquired through their involvement in setting up an emergency dental care hub in Cluj-Napoca, Romania, during the COVID-19 lockdown. The present article aims to provide a brief description of COVID-19 implications in dental office and to recommend preventive protocols for dental practitioners to ensure a safe and healthful workplace. The recommendations for infection control presented in this article address the specific risks of exposure to SARS-CoV-2. The article provides a special customized guideline covering patient triage and entrance into the dental practice, personnel protection, dental treatment, and after-treatment management. The implementation of strict preventive measures has been found to be efficient in the prevention of SARS-CoV-2 contamination because no infections have been reported among our staff or patients. COVID-19 is a major emergency worldwide marked by a rapid evolution and warranting a need for further assessment of the implications of COVID-19 outbreak in dental practice. Severe complications include respiratory distress syndrome, arrhythmia, and shock.2 Many SARS-CoV-2 positive patients have demonstrated mild or no symptoms, which makes the clinical diagnosis challenging during the incubation period and, therefore, facilitates an accelerate spread of infection.7During this pandemic circumstance, we all witnessed the terrible expansion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its dramatic consequences. The respiratory disease deriving from SARS-CoV-2 infection was named coronavirus disease 2019 (COVID-19).8Although community spread of the disease has somewhat decreased during the lockdown period, currently, the situation is far from being contained. On the contrary, COVID-19 has seen a violent and fast spread worldwide. There are over 34 million declared COVID-19 cases and over 1 million deaths globally at 1 October 2020.9 As the COVID-19 crisis seems to prolong, the entire management of dental settings should focus on delivering safe conventional dental treatments to mitigate its impact on the patient’s oral health status. Reports from dental emergency settings indicate an increase in extractions and a decrease in endodontic treatment acceptance in patients presenting with more severe disease, possibly due to the clinical and economic consequences of the COVID-19 crisis.10 An increased number of antibiotic prescriptions before referral to the emergency clinics, sometimes incongruent with official recommendations,11 has also been reported.10Dental professionals are at especially high risk of contracting the COVID-19 due to the unique nature of dentistry.12 In addition to the latest research on COVID-19 and to the various opinions produced by clinicians, public health officials, and the authorities, it is essential to assemble the data into utile protocols to run a long-term reliable dental clinical practice.The spread of infection requires effective long-term infection control protocols to be implemented in dental settings to prevent SARS-CoV-2 contamination of medical personnel and patients. Dentists should use a combination of algorithms and teledentistry for patient triage and evaluation, as well as adapted treatment and organizational protocol for patient safety and minimal occupational hazards.This article is based on recent research, guidelines issued by relevant authorities, as well as on the authors’ experience acquired through setting up an emergency dental care hub in Cluj-Napoca, Romania. The purpose of the present article is to offer a brief description of SARS-CoV-2 transmission, its implications for dental offices and to recommend preventive, ready-to-use protocols for dental practitioners. The recommendations presented in this article aim to provide an update of the already existing infection control plans of dental settings enabling the assessment of the specific exposure risks and of the other unique characteristics of SARS-CoV-2 transmission, as well as to offer guidance to dental personnel in providing a safe and healthful workplace.15 Splatter was defined by Micik and colleagues as airborne particles larger than 50 μm in diameter.18 These particles are too large to become suspended in the air and are airborne only briefly before contacting the floor.19Based on recent findings, it appears that the major route of transmission of SARS-CoV-2 is by means of respiratory secretions in the form of large respiratory droplets or splatters containing viral particles, produced when an infected person coughs, sneezes, or talks, propagated at a short distance, rather than by means of small aerosols.9 and can remain suspended in the air for an extended period of time before they settle on environmental surfaces.18 Aerosols are formed by particles less than 50 μm in diameter.18 The nose typically filters air particles above 10 μm.20 The particles that are less than 10 μm can enter the respiratory system, whereas smaller particles can reach the alveoli.20 However, even if it is potentially possible, infection through small aerosolized particles is not the main route of SARS-CoV-2 transmission.21Aerosolized viral particles by cough, sneeze, or dental care procedures can potentially travel across greater distances, up to 6 m,14 but it is not considered a main route of transmission either. It has been reported that SARS-CoV-2 can persist on various surfaces for a few hours up to several days depending on environmental conditions.21Contact transmission through contaminated surfaces is also possible,22 The fecal-oral and vertical transmissions of SARS-CoV-2 are about to be confirmed.24The virus persists up to 72 h after application to plastic and stainless-steel surfaces, up to 24 h on cardboard surfaces, and is viable up to 3 h in suspended aerosols.13 but asymptomatic carriers should also be considered as a potential source of infection.26Patients with symptomatic disease have been the main source of transmission,27A dose-dependent clinical manifestation between SARS-CoV-2 load on contact and severity of the disease has been suggested. Patients with severe COVID-19 had a 60 times higher nasopharyngeal viral load than the patients with mild disease.13However, despite the research findings summarized above, we need to agree that “COVID-19 is a new disease, and we are still learning about how it spreads and the severity of illness it causes”.19 Recently, To et al. (2020)28 recognized saliva as a reservoir of SARS-CoV-2 in infected individuals. In these circumstances, dental professionals appear at high risk of contagion.15The potential routes for SARS-CoV-2 transmission in dental settings are contact with airborne infectious particles, direct contact with body fluids of an infected patient, and contact with contaminated environmental surfaces.29 The ultrasonic scaler has been shown to produce the greatest amount of airborne contamination, followed by the air-driven high-speed handpiece, the air polisher, the air-water syringe, and the prophylaxis angles.34Most dental procedures use mechanical instrumentation and, thus, produce airborne particles.29 which means that immediate removal of the respirator/mask exposes the practitioner to a potential contact with airborne contaminated material.19A true aerosol or droplet nuclei may remain airborne in the dental practice for up to 30 min after a dental procedure,35 Hydrogen peroxide vapor has been shown to be virucidal (>4-log reduction) against some experimental viruses including a SARS-CoV surrogate,36 which suggests that 1.5% peroxide preprocedural rinsing could diminish oral and pharyngeal viral load. Preprocedural rinses could reduce, but not eliminate, the extent of contamination in dental practice because antiseptic rinses do not penetrate subgingivally. Consequently, this will not affect blood coming directly from the operative site or microorganisms harbored in the nasopharynx. While the use of the rubber dam is a standard protective gesture in restorative and endodontic procedures, it is not feasible for periodontal hygiene and surgical procedures. Periodontal procedures are always performed in the presence of blood and rely mostly on the use of ultrasonic scalers, which create the greatest amount of aerosol contamination.37 One recommended method to remove airborne contamination is the ultraviolet (UV) system, but it is cost prohibitive for most dental offices19 and proof of efficacy against SARS-CoV-213 has not yet been reached. It seems more practical to take immediate measures to remove airborne contamination in the proximity of the generation site. The use of a high-volume evacuator reduces aerosol contamination from the operative site by more than 90%.31 In addition, during aerosol-generating procedures, high-volume saliva ejectors and 4-handed technique are beneficial for controlling infection.39Preoperative antimicrobial mouth rinse reduces the number of bacteria generated by means of dental procedures.13 Most dental-related articles released in PubMed provide general information on SARS-CoV-2 outbreak and recommendations for infection control in the dental office. Only 1 article referred to COVID-19 infection among dental personnel.15 The information presented comes from the School and Hospital of Stomatology, at Wuhan University, and reports 9 COVID-19 positive persons among 1098 staff. Except for 2 cases, no obvious epidemiological aggregation was identified for the other COVID-19-positive persons and cross-infection was unlikely. No further COVID-19 infection has been reported among staff. Moreover, 169 staff were involved in duty of dental emergency and treated more than 700 patients. No one developed COVID-19, which confirmed the effectiveness of infection control procedures within dental settings.15The Centers for Disease Control and Prevention (CDC) update from August 4, 2020, informed that there were no available reports on dental personnel testing positive for COVID-19.During the national emergency status declared in Romania, a 5-unit dental setting was organized in Cluj-Napoca to treat non-COVID-19 patients. The dental setting functioned for 6 wk (April 3 to May 15) during a period when only 3 other private dental settings were functioning.Strict circuits for personnel and patients, disinfection, donning and doffing personal protective equipment (PPE) protocols were developed and implemented through effective instruction.The medical care was provided by 31 dental specialists and more than 200 residents. There were 2 shifts per d, 7 d per week, except Sundays with only 1 shift. The personnel were planned to work in groups of 1 senior dentist and 3 residents per shift, so that a 14-d isolation interval for each medical person could be calculated.40During the above-mentioned period, more than 1000 patients with emergency dental problems were provided effective treatment. All the dental procedures were recorded daily. In addition, 1600 patients received dental phone consultations. Even under the SARS-CoV-2 threat, emergencies continued to be a real problem. In Beijing, China, the overall dental emergency patients count reduced by only 38%, between February 1 and February 10, 2020.41 only the following pathologies were considered emergencies: tooth pain-related pathologies, dental or periodontal abscesses, pericoronitis, postextractional alveolitis, cellulitis/abscesses, mandibular fractures, temporo-mandibular joint dislocation, dentoalveolar traumas; ulceronecrotic gingivostomatitis.41 Traumatic disorders were treated in a surgical establishment.According to the Covid-19 safety planning framework for emergency dentistry interventions, adopted by the Romanian College of Dentists, 17/3/BExN/2020,Protocols were elaborated for each treatment approach and learned by each team member. Aerosol-generating procedures were strictly minimized. Based on our clinical experience during this outbreak, pulp exposure was made under rubber dam isolation and a high-volume saliva ejector after local anesthesia as well as a high-speed handpiece were used most of the time to access cavity preparation. The filling material was zinc oxide eugenol temporary filling due to its higher resistance in comparison with other provisional materials.15 on systematic reviews43 and relevant guidelines provided by different authorities such as the US Department of Labor (2020),44 the CDC,13 and the Association Dentaire Française (2020).9 Although these protocols have been designed for an emergency dental practice, they can be extrapolated and adapted by all dental settings, on a long-term basis.Present recommendations are based on our current experience, on the experience reported by our colleagues,To prevent SARS-CoV-2 contamination, the function of dental office should rely on administrative and infection control measures  and 2.Precheck phone triage is an important step that decreases the time spent by the patient in the dental office. During the phone triage, potential patients are asked a set of standard clinical questions about the COVID-19 symptoms and contact or travel history to detect any potential risk of SARS-CoV-2 infection. Determining the dental problem is another target of the phone triage.13 When this is not feasible, the accompanying person is asked to wait outside.45A dental visit is subsequently scheduled. When unnecessary, no accompanying visitors are advised.13 An essential step is to provide the personnel with adequate information and training, while emphasizing the proper use of PPE .e of PPE . A cleare of PPE . Informa45Hand-washing should be performed for at least 60 s, using a 60 to 85% hydroalcoholic solution, before dental treatment, before wearing gloves.46).Preparation of dental staff for clinic is based on PPE including gloves, goggles, face shields, face masks, and respiratory protection . To be p47 A N95 respirator filters at least 95% of airborne particles, but it is not resistant to oil.48 During disposable N95 filtering facepiece respirators shortages, consider using other respirators that provide greater protection such as R/P95, N/R/P99, or N/R/P100 filtering facepiece respirators or FFP3 masks.47As respiratory droplets are the main route of SARS-CoV-2 transmission, particulate respirators such as N-95 masks, authenticated by the US National Institute for Occupational Safety and Health, or FFP2-standard masks set by the European Union are recommended for routine dental practice.49 UV germicidal irradiation and vaporous hydrogen peroxide seem to be extremely promising methods for face filtering respirator decontamination.50 Some shortcomings related to these methods have been reported, especially the paucity of evidence relating to their effectiveness specifically against SARS-CoV-2 and the possible modifications of the filtering capacity.49Although disposable respirators, such as N95, are not approved for routine decontamination, due to shortage of stocks, their disinfections and reuse have been discussed.The special respirator shall be worn at all times during a work shift; this is the last PPE to be removed during the doffing procedure. A face full shield may also be worn in front of a respirator to prevent bulk contamination of the respirator and to avoid eye contamination. Protective glasses are also recommended.A long-sleeve impermeable surgical gown or protective clothing is used to cover personal clothing and skin. A second disposable paper gown is worn over the top. Disposable gowns are discarded after each use. Two pairs of gloves should be used, the exterior pair being removed after each patient.Clinical staff clothing includes a complete set of PPE: special respirators—at least a N95 or a FFP2, protective glasses, a face shield, an impermeable gown plus a paper gown, gloves, shoes-covers, and a surgical cap . Due to Personnel doff PPE before entering dental practice .All the necessary materials and instruments should be prepared in advance to make the procedure faster. Disposable protections should be placed on unit surfaces and single-use instruments should be used at all times, whenever possible.25Instructions (in appropriate languages) about hand hygiene, cough etiquette, and facemask coverage during the visit period should be displayed in the waiting room. A minimal number of patients should be allowed in the waiting rooms and distanced chairs should also be considered.51  in restorative dentistry and periodontology should be prioritized.38 to limit atmospheric microbial contamination.52High-volume saliva ejectors and 4-hand work are highly recommended15Panoramic radiograph is an appropriate alternative to intraoral radiograph as it minimizes saliva secretion and coughing.They reapply the face mask and remove the protective barriers when exiting the dental office .46 and stored or disposed of, to avoid contamination.53 Thorough hand washing is performed after the removal of PPE.45 There is no evidence to support the effectiveness of sanitizing tunnels in reducing the spread of COVID-19 and they could cause skin, eye, or respiratory irritation or damage.At the end of the working day, the clinical staff follow a strict protocol for doffing PPE, that takes place in a special decontamination/doffing room. PPE should be carefully removed, eventually disinfected,54Cleaning and disinfection of the dental office after the exit of a nonconfirmed COVID-19 patient should start 15 min after completion of clinical care. This is recommended to allow for droplets to sufficiently fall from the air after a dental procedure.55The disposable protection of the surfaces is to be removed. Strict disinfection protocols for dental units and for the other office surfaces using the recommended cleaning and disinfection solutions are crucial due to the long persistence of SARS-CoV-2 on surfaces.Shields and glasses are disinfected with 70% isopropyl alcohol.45 Also, air control through frequent disinfection of air conditioning is recommended.13 UV decontamination can be used  and PPE upgrades can amount to 16,000 Euros, with 2 shifts per day and 4 medical staff per shift.The present article provides an overview of the management of SARS-CoV-2 transmission mostly in relation with the dental office, as well as new guidance that will enhance the organization of dental settings to prevent SARS-CoV-2 contamination and brief information on the economic impact of preventive measures in dental settings. The provided protocols are based on former or very recent evidence or draw upon the experience of the team of dental professionals who delivered emergency dental care during COVID-19 lockdown and after the restart of the activity.41 Recent evidence suggests that even nonsymptomatic persons can spread COVID-19 with high efficiency44 ; thus, every healthy patient has been considered potentially contagious and additional measures beyond standard precautions15 have been implemented to limit and combat SARS-CoV-2 contamination in our settings.According to the US Occupational Safety and Health Act, dentists are considered a very high-risk category for SARS-CoV-2 transmission.Given its high preventive efficiency, our team strongly recommends the implementation of the present detailed guideline. Even after the lockdown period, the same preventive protocol was extended to 3 other settings that were part of the Dental Ambulatory at the Emergency County Clinical Hospital. None of the medical staff developed COVID-19 symptoms, except a nurse who tested positive for SARS-CoV-2 due to family exposure, but remained asymptomatic. Also, 2 residents developed mild symptoms and tested positive during their vacation period. No seropositive staff was reported after random antigen testing of the personnel.51 used seemed to be relatively efficient in avoiding SARS-CoV-2 contamination. It is our opinion that the same intensive care equipment and the strict organizational measures used by clinical workers during the emergency care period should become the practice standard for everyday clinical activity. To reduce dental aerosol contamination, dental teams should rely on multiple precautionary strategies such as the use of personal protection barriers, the reduction of aerosol-producing procedures, the use of preprocedural antiseptic rinses and the routine use of a high-volume evacuator. Although inexpensive, the last 2 strategies are rarely used in most dental settings.19 The extreme dynamicity of the outbreak and of the related information may lead to a sudden shift in views and recommendations for preventing SARS-CoV-2 contamination.The available literature to date and the actual clinical experience of health-care professionals still fail to establish high-certainty, ideal protective measures that could prevent SARS-CoV-2 contamination in dental settings. In the meantime, the infection control protocols that we, as well as other teams,45 in place. During the 45-d functioning period of our emergency dental setting, around 10,000 Euro from the total amount was spent on single-use equipment for personal protection, such as special respirators (FFP2 or FFP3), surgical masks, impermeable gowns plus paper gowns, double gloves, shoes-covers, and surgical caps. Thus, in response to additional protective measures, an average of 28 Euro per medical staff per day was spent. It has been reported that 4 sets of PPE  per day was needed for each health-care personnel working in a high-risk respiratory infection group during the H1N1 influenza pandemic.56 Over a 2-mo period during the influenza season, the incremental cost to prevent a clinical respiratory illness of health-care personnel with continuous use of N95 respirators when compared with surgical masks ranged from US$490 to US$1230, depending on the type of respirator (fit non-fit) or manufacturer. However, due to limited resources, changing of the respirator during a working day is difficult to conceive. In the case of highly pathogenic pandemic, respirator use for health-care workers would likely be a highly cost-effective intervention.57Beyond the infectious risk, COVID-19 also has important economic consequences due to the extreme protective measures7 as well as on dental personnel. It is possible that, from now on, patients could become more careful with their oral health and more likely to adhere to prophylactic measures. An increasing demand for computer aided design and manufacturing (CAD/CAM) and 3D-printing technology is also anticipated.7 On the contrary, due to the fear of contamination or to economic difficulties patients might, for instance, prefer extractions over a prolonged root canal treatment. The difficulties associated with dentist visits are a significant factor in the initiation or the recurrence of periodontal disease. Moreover, many team members have reported a higher level of work-related stress and anxiety due to heavy workload, the fear of becoming a SARS-CoV-2 victim, of being an asymptomatic spreader, and the risk of infecting their family members.10 With the COVID-19 outbreak, teledentistry became a very effective tool for patient triage, consultations, diagnosis, and patient monitoring. Dentists have also been able to prescribe medication, such as pain killers and antibiotics. Overall, teledentistry proved to be a very efficient way of limiting office visits for patients seeking dental advice, additionally reducing infection-related stress for both patients and doctors.58 Teledentistry could also be a very effective way of promoting preventive measures for dental hygiene, reducing the risk of periodontitis and dental disease. Our team initiated a preventive care program directed to periodontitis patients receiving initial therapy or in maintenance phase. Patients received personalized oral hygiene advice from specialists on a virtual platform. However, it is still too early to appreciate the cost-benefit ratio of this approach. Also, the psychological impact of an indirect contact and the consecutive efficiency of teledentistry advice should be further evaluated.COVID-19 also has a long-term impact on clinical practice, patients, dental education, and dental researchIt could eventually be argued that the COVID-19 pandemic marks the beginning of a new era for the organization of dental settings and for the further implementation of infection control measures.Dental professionals are highly exposed to the risk of SAR-CoV-2 infection. Due to the unique characteristics of dental procedures, generating a potentially large number of droplets and aerosols, the standard protective measures are insufficient to prevent the spread of COVID-19 in everyday clinical work settings. Considering the high contagiousness of COVID-19, it is important to underline that wearing N95/FFP2 or FFP3 respirators is mandatory to prevent SARS-CoV-2 infection. The underestimation of the persistence of the risk of viral transmission might have disastrous consequences on patients and on the medical personnel.The implementation of strict preventive measures proved to be efficient in the prevention of SARS-CoV-2 contamination because no infections have been reported among our staff or patients.


In this work, the photochemical reduction method was used at 440 or 540 nm excitation wavelengths to optimize the deposition of silver nanoparticles on the diatom surface as a potential DNA biosensor. The as-synthesized nanocomposites were characterized by ultraviolet-visible spectroscopy (UV-Vis), Fourier transforms infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS), scanning transmission electron microscopy (STEM), fluorescence microscopy, and Raman spectroscopy. Our results revealed a 5.5-fold enhancement in the fluorescence response of the nanocomposite irradiated at 440 nm with DNA. The enhanced sensitivity comes from the optical coupling of the guided-mode resonance of the diatoms and the localized surface plasmon of the silver nanoparticles interacting with the DNA. The advantage of this work involves the use of a low-cost green method to optimize the deposition of plasmonic nanoparticles on diatoms as an alternative fabrication method for fluorescent biosensors. Biological nanomaterials have gained importance in biomedicine due to their large variety of bioresources, synthesis methods, versatility, and the possibility to further enhance their features through material functionalization ,2. They Naturally occurring biosensors doped with plasmonic nanoparticles are increasingly used to detect physiologically important analytes in real biological samples  ,6. BioseDiatoms are low-cost and biocompatible 3D materials that show interesting and remarkable optical properties ,11. DiatSeveral methods have been reported to optimize the properties of diatoms, as their surfaces can be functionalized and decorated with different materials depending on the desired characteristic to be improved ,20. ThesIn this work, a simple low-cost photoreduction method to optimize the deposition of silver nanoparticles on diatoms was employed and a preliminary study as a potential DNA fluorescence-detecting biosensor was carried out. The novelty relies on controlling the silver nanoparticle growth and deposition on the diatom surface by irradiating the samples with 440 or 540 nm excitation wavelengths, respectively. The fluorescence properties and plasmonic resonance signals of silver nanoparticles on diatoms were enhanced, demonstrating potential applications as DNA fluorescence-detecting biosensors.2/g and 0.22 cm3/g, respectively. The diatom surface provides a suitable environment for the photochemical reduction of the silver nanoparticles on the diatom surface.After the photochemical reduction process with 540 nm or 440 nm wavelengths, the sample solutions changed from colorless to purple for the samples irradiated with 440 nm (Ag Blue) and yellow for the sample irradiated at 540 nm (Ag Green). X-ray photoelectron spectroscopy was employed to measure the silver nanoparticle binding energies and atomic concentrations over the diatoms after the photochemical process. XPS measurements were carried out in the range of 0–1200 eV; the results are presented in In  bending . These sding [−1 .Raman spectra of the diatoms are shown in The fluorescence enhancement of the diatoms irradiated at 440 nm in In the first part, we evaluated the silver nanoparticle’s photoreduction over the diatom’s surface using ultraviolet-visible spectroscopy (UV-Vis) by the surface plasmon resonance peak at 424 nm . In thisIn the second part, we added a drop of DNA to the nanocomposites. We characterized them using FTIR and Raman spectroscopy, identifying the main peaks related to the interaction between the DNA and the nanocomposites through the N-H and C-N binding . FinallyPrevious studies  have demplanktonic species and genus Aulacoseira. Hydrogen peroxide  accessory and resolution of 4 cmIn summary, we describe the photochemical reduction method to optimize the deposition of silver nanoparticles over the diatom surface, as a potential nano-plasmonic biosensor, providing high-density hot spots with an enhanced optical field for DNA detection. Our findings reveal that excitation radiation at a wavelength of 440 nm promotes the formation of silver nanoparticles on diatoms with uniform size, enhancing the fluorescence properties of the resulting nanocomposite. This discovery has potential applications in developing DNA fluorescence-detecting biosensors, biomarkers, and diagnosis.


Ultrasound-guided nerve blocks are fast becoming a core part of opioid-sparing, multimodal, acute pain management in the emergency department (ED) setting. The ultrasound-guided erector spinae plane block (ESPB) has been shown to be effective in treating a variety of musculoskeletal and neuropathic painful conditions in the ED.Here we report the effective use of the ESPB for pain control in four patients who presented with acute abdominal pain related to biliary obstruction in a resource-limited setting.The ESPB may be helpful in treating abdominal pain related to biliary obstruction, which is a novel indication for this well-established technique. This application is particularly relevant in resource-limited settings with significant delay in definitive surgical management. Further research is needed prior to widespread adoption. Ultrasound-guided nerve blocks (UGNB) are a core component of opioid-sparing, multimodal analgesia in the emergency department (ED). The erector spinae plane block (ESPB) is a technique that has been shown to be effective in a variety of painful conditions. The use of this UGNB in the ED was first reported in 2017 by Luftig et al. as an improved alternative to the serratus anterior block for posterior rib fractures.7There is continued uncertainty regarding the exact mechanism of action of the ESPB. The most widely accepted theory is diffusion throughout the fascial plane below the erector spinae muscles and direct action on the ventral and dorsal rami of the spinal nerves.Here we present four cases where an ultrasound-guided ESPB was used successfully for visceral pain control in a spectrum of disorders related to biliary obstruction: biliary colic; choledocholithiasis; and gallstone pancreatitis. To our knowledge this is the first report of its use in the ED for pain secondary to biliary obstruction.A 36-year-old male with no past medical history presented to the ED of a Peruvian hospital for right upper quadrant (RUQ) abdominal pain. He described seven days of intermittent pain that had become constant and more severe for the prior three days. On review of symptoms he also noted dark-colored urine. On physical exam, the patient had jaundice and a positive Murphy’s sign. Laboratory results were notable for elevated white blood cell (WBC) count, normal lipase, elevated bilirubin, and elevated alkaline phosphatase. Point-of-care ultrasound (POCUS) revealed gallstones and a dilated common bile duct, concerning for choledocholithiasis. Subsequent magnetic resonance cholangiopancreatography confirmed the diagnosis of choledocholithiasis.The patient’s ED course was complicated by severe abdominal pain, subjectively rated 10/10, despite treatment with 100 milligrams (mg) intravenous (IV) tramadol and 1 gram (g) of IV metamizol . Given the patient’s refractory pain to opioid and non-opioid IV medications the decision was made to perform an ultrasound-guided ESPB. A high-frequency linear transducer was used to identify the transverse processes at the sixth thoracic (T6) level. Bilateral ultrasound-guided ESPBs were performed using 20-gauge Quincke spinal needles  to inject 10 milliliters (mL) of 0.25% bupivacaine and 10 mL of normal saline (NS) using an in-plane approach as shown in A 25-year-old female, pregnant at 28 weeks estimated gestational age, with a past medical history significant for cholelithiasis, presented to the ED with RUQ abdominal pain. Her pain was described as intermittent and colicky in nature, having been present for one day, and associated with nausea and vomiting. On physical exam, she had tenderness to palpation in the RUQ without rebound or guarding. Lab exams including WBC count, liver enzymes, and lipase were all within the normal reference range. Point-of-care ultrasound was notable for multiple gallstones without signs of cholecystitis or choledocholithiasis. The patient was diagnosed with symptomatic cholelithiasis.What do we already know about this clinical entity?The erector spinae plane block (ESPB) is an ultrasound-guided regional anesthesia technique useful for treating pain in the emergency department.What makes this presentation of disease reportable?Here we report the successful use of the ESPB to treat abdominal pain related to biliary obstruction, which is a novel indication for this technique.What is the major learning point?The ESPB can be used to provide pain control for patients with pain from biliary obstruction in the emergency department.How might this improve emergency medicine practice?The ESPB is a promising technique that expands the tool kit for multimodal, opioid-sparing analgesia in the emergency department.She continued to endorse severe abdominal pain, subjectively rated as 10/10, despite receiving 2 g IV metamizol. An ultrasound-guided, right-sided ESPB was performed using 20 mL of 0.25% bupivacaine and 10 mL of NS. Thirty minutes after the block her pain reduced to 2/10 severity, and she was subsequently discharged home.A 30-year-old female, with a past medical history pertinent for gallstones and a prior episode of gallstone pancreatitis (10 months prior to presentation), presented to the ED with RUQ abdominal pain and vomiting. Abdominal exam revealed tenderness to palpation in the RUQ and a positive Murphy’s sign. Lab exams revealed elevated lipase and hepatic panel dysfunction with a classic cholestatic pattern. On POCUS, multiple gallstones were visualized without signs of cholecystitis; however, the common bile duct was not visualized. The patient was diagnosed with presumed gallstone pancreatitis.The patient continued to endorse severe abdominal pain, rated 10/10 severity, despite receiving 100 mg of IV tramadol, and 2 gm of IV metamizol. An ultrasound-guided ESPB on the right side was performed at the T6 level using 20 mL of 0.25% bupivacaine diluted with 10 mL of NS using a similar in-plane approach as previously described. The patient’s pain decreased to a 2/10 severity following the block. She was subsequently admitted for definitive management with endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy.A 29-year-old female with no significant past medical history presented to the ED with a two-day history of RUQ pain, associated with nausea and vomiting that started after eating a meal of high fat content. She was noted to be jaundiced, with a positive Murphy’s sign. Lab exams revealed elevated lipase and a cholestatic pattern of liver dysfunction. A POCUS exam demonstrated gallstones. The patient was diagnosed with presumed gallstone pancreatitis.The patient continued to endorse severe abdominal pain, rated 9/10 severity, despite receiving tramadol 100 mg IV and metamizol 2 g IV. A right-sided, ultrasound-guided ESPB was performed at the T6 level using 20 mL of bupivacaine 0.25% diluted in 10 mL of NS using a standard in-plane approach. Thirty minutes after the procedure the patient’s pain reduced to a level of 2/10. She was subsequently admitted to the hospital for endoscopic retrograde cholangiopancreatography, followed by delayed laparoscopic cholecystectomy.The ESPB was first described in 2016 by Forero et al. in the anesthesia literature as an effective technique for controlling thoracic pain.Control of acute pain is of paramount importance in the practice of emergency medicine. The emergency physician is charged with balancing the goal of patient-centered and syndrome-specific pain control against the risks of pharmacological analgesics, particularly the adverse effects associated with opioid use. Ultrasound-guided nerve blocks have emerged as an important tool for achieving this goal. Additionally, the American Academy of Emergency Medicine and the American College of Emergency Physicians recognize UGNBs as a core component of multimodal analgesia in the ED.12Performing an UGNB requires a baseline knowledge of POCUS and procedural skills. The cases reported here were performed by emergency physicians during their POCUS fellowship training at a hospital in Peru that has a POCUS fellowship training program, thereby limiting the ability to generalize our findings to other settings with clinicians less experienced in the use of POCUS.Regional anesthesia techniques such as the ESPB are particularly relevant in resource-limited settings. These patients presented to an urban ED in Lima, Peru, where there is often delay in definitive surgical management due to resource limitations , and patients experience extended ED boarding times. However, these conditions are certainly not limited to Peru, and we believe this technique to be very useful wherever it can be safely performed.In this case series we report successful pain control of visceral abdominal pain related to biliary obstruction with ultrasound-guided erector spinae plane block, a novel indication for this technique in the ED setting. This adds to the mounting body of evidence that ESPB is a useful opioid-sparing technique to control visceral pain in the ED. It is particularly well suited to resource-limited settings, where there may be a significant time delay prior to definitive surgical management of various intra-abdominal conditions. While use of this technique offers great promise to the emergency physician, further research is needed to compare it to other methods of pain control in terms of effectiveness and safety, and to define the optimum technique in terms of vertebral level, right sided vs bilateral, and the quantity of local anesthetic instilled.


Global warming in the 21st century will alter the frequency of extreme climatic events, such as high-temperature anomalies and “heat waves”. Observations of extreme high temperatures during recent decades have detected upward trends in their frequency of occurrence, and recent state-of-the-art Global Climate Models (GCMs), e.g., Climate Model Intercomparison Projects (CMIPs), notably CMIP5 and CMIP6, have predicted acceleration of temperature trends and high-temperature events by 2100 under projected greenhouse-gas emission scenarios. Hence, the 21st century is expected to experience substantial shifts in the occurrence of extreme events, where present-day, extreme-but-rare high-temperature events will become common during the summer months. The increasing frequency of extreme heat may affect the health and resiliency of social, biological, and infrastructure systems in many regions worldwide, underscoring the need for accurate and reliable long-term assessments of climatic change across global and regional scales. So far, many investigations of high-temperature extremes have been carried out under end-point scenarios, e.g., by comparing GCM-projected changes in the frequency of high-temperature extremes expected in the late 21st century to the late 20th century. In this study, we use extreme value theory and decades of observations of high-temperature extremes at thousands of meteorological stations across North America to investigate continuous shifts in the frequency of extreme high-temperature events due to projected local warming trends. We find that the odds of exceedance of 50-year extreme high-temperature events increases exponentially with increases in mean local temperature. At a majority of the stations studied here, a local mean temperature increase of 0.5–1  This rise is linked to the growing concentration of atmospheric greenhouse gases2, predominantly from anthropogenic sources since the mid-20th century7. Increased concentrations of greenhouse gases and global warming trends also affect extreme climatic events9, such as high-temperature extremes, which can have a multitude of ecological and societal impacts13.Earth’s global average surface temperature has risen 1.09 14. Further, anthropogenic emissions16 can also drive fundamental, non-linear changes to extreme climatic events . In a warming climate, the occurrence of extreme high-temperature events is expected to increase with time, such that rare  events can become common  in the future17.A simple increase in mean temperatures can lead to increases in the frequency and intensity of extreme temperature events18), a branch of statistics to model extreme events and their probability distributions, typically using historical observations24.Investigations of extreme temperature events in the literature are primarily assessed via two different approaches: (1) climate-extreme indices, which represent pre-defined, relatively frequent annual or monthly climatic events, and (2) extreme-value theory  and Phase 6 (CMIP626), coordinated by the World Climate Research Programme (WCRP), have projected increases in the frequency and intensity of high-temperature extremes and extended heat waves under the majority of emission scenarios . For the contiguous U.S., a significant increase in the frequency of extreme high temperatures has been observed during recent decades34, and a persistent upward trend in the frequency of high-temperature extremes and heat waves is projected by the end of the 21st century.Global Climate Models (GCMs) have played a central role in assessing historical and future changes in global and regional climatic extremes, including temperature extremes27) have focused on end-point scenarios, e.g., comparing GCM-derived late 21st-century extreme high-temperature events to late 20th-century events. Fewer studies have investigated the continuous trend in the frequency of extreme high-temperature events in the coming decades. Here, we use stationary Generalized Extreme Value (GEV)18 and empirical probability distribution based on decades of historical temperature observations to demonstrate an exponential increase in the frequency of extreme high-temperature events throughout Northern America  driven by local temperature projections under a range of emission scenarios .Many studies investigating the transformation of extreme high-temperature events  of the GEV parameter estimates . Although the stations are not directly classified/clustered based on their geographic locations, the clustering analysis reveals consistent geographical patterns in the GEV parameters, which are driven by the underlying patterns of temperature extreme across North America , which is a close alternative to the “probability of exceedance” (E) and is calculated via Eq.  and projected (2081–2100) extremes via CMIP5 models, and similarly, Li et al. (2021)22 found changes in the frequency of 50-year temperature extremes, by comparing periods of 1985–2014 and 2071-2100 using CMIP6 models. We have taken a slightly different approach to study extreme temperature end-members in the current analysis. As shown in Fig. Many studies investigating changes in temperature extremes do not assess the continuous shift in the frequency of temperature extremes. For example, Kharin et al. 2013)01327 idek), and as such, the current approach is subject to limitations, discussed below.Further, in this study, we also examine continuous shifts in temperature extremes by adopting a stationary statistical approach, which assumes that the underlying probability distributions  describing extreme high-temperature events will remain roughly constant over time, except for a shift in the mean caused by local warming. Hence, we do not consider the potential effects of non-stationary, future changes to distribution’s variability  may not be entirely valid since climate change can alter the variability and upper bounds  of extreme events13. The alternative, non-stationary approach51 allows for the probability distributions (and their associated parameters) to vary with time. However, the non-stationary methods generally require either longer-term historical observations or the use of climate models  to project future extremes. When applying historical observations, the performance of stationary versus non-stationary approaches is problem-specific52, although the two approaches often return similar results. Studies that fit model-predicted extreme temperature data, as opposed to historical observations, to obtain extreme value distributions are also subject to sources of error (53). For example, the model-predicted extreme temperatures may not resolve micro-climates (such as urban heat islands) in ways that they can be resolved using observations. Furthermore, many GCMs do not run continuous simulations but are instead often separated into 10-, 20-, or 30-year-long historical and future projected periods. Also, modes of climate variability ) that are historically found to amplify the extreme high-temperature events across North America55, are a form of non-stationarity that alter the tail behavior of extreme temperature distributions. Capturing the influence of ENSO on temperature extremes would require realistic projections of future ENSO events into the 21st century, which is currently beyond the state of the art of most  GCMs , rendering the assessment of how future ENSO variability affects the statistics of future extreme temperatures beyond the scope of this study. There are, however, many aspects of extreme high-temperature change that can only be investigated using models. Some evidence indicates that the processes governing the extreme temperatures are partly independent of the ones affecting the mean temperatures; thus, temperature extremes and mean temperatures need not adhere to identical trends59. Moreover, the relationship between shifts in the mean temperatures and the corresponding changes in the probability of extreme temperatures is inherently nonlinear14. Along these lines, it is predicted that changes in extreme high temperatures may outpace the changes in annual mean temperatures over the majority of the land areas globally60. Nevertheless, the data-driven, stationary statistical approach adopted here can complement the plethora of complex climate model-driven studies10, particularly for investigating near-term, continuous shifts in extreme high temperatures over the next several decades, over which time scale the projections of increased regional mean temperatures are more robust/certain compared to the projections of climate modes, such as ENSO.Stationary statistical models potentially oversimplify the behavior of future extreme climatic eventsk) and find significant spatial coherence. As expected, there is a latitudinal dependence on the mean temperature  are evident across the U.S. Midwest and the Appalachian Mountains regions, as shown in the blue cluster in Fig. k values are generally the highest. This is potentially driven by the tendency for anomalously large, yet rare, high-temperature extremes occurring in the blue-clustered region .The vast number of stations analyzed here allows for sub-regional investigations of the behavior of extreme high temperatures. In Fig. mentclass2pt{minimmentclass2pt{minimmentclass2pt{minimk values) represent higher susceptibility to temperature rise impacts compared to cities on the West Coast, which is also evidenced by the higher number of extreme heat waves causing heat-related mortality on the Eastern and Midwestern U.S. historically .A very small percentage (1.4%) of our locations, which mostly fall inside of the blue cluster, exhibit positive values of the GEV shape parameter  emission scenarios and their projected local warming levels . Although it is likely that society has yet to fully comprehend the consequences of global temperature rise, we offer that the information provided here can aid in the development of prevention and mitigation plans at regional and global scales.Projections of increasing global surface temperature lead to significant transformations in the behavior of high-temperature extremes. Trends in global and local temperatures will transform present-day “once-in-a-lifetime” high-temperature events into frequent  occurrences in the next several decades. We show that projected temperature trends will exponentially increase the odds of exceeding the 50-year extreme high-temperature events across North America  with a doubling time scale of approximately 13–17 years. This doubling time scale is equivalent to a doubling temperature scale of 18) is a commonly employed method to analyze the occurrence of rare events using probability distributions of a random variable, x, which corresponds to the magnitude of an extreme event, i.e., the extreme temperature in the current study. The probability that the event level x is exceeded is estimated by E(x), which is the so-called “exceedance probability distribution” and is given byF(x) is the cumulative probability distribution of the random variable x.Extreme Value Theory  distribution, which is given byk represent the location , scale , and shape (skewness/tail behavior) parameters, respectively18. The parameter k is of particular importance here since it defines the tail behavior of F(x). The probability distribution’s tail exhibits an upper bound when k parameter values, i.e., Gumbel distribution (F(x) is a monotonically increasing function from 0 to 1, E(x) represents a monotonically decreasing function from 1 to 0. When the shape parameter is close to zero (E(x) decays exponentially with event level x  of an extreme temperature event  subject to a mean temperature increase . For the sake of simplification, we take advantage of the exponential form 41), the variables In Eq. , \documeO(x), defined as the ratio of the exceedance probability for a given threshold relative to the probability of that event not exceeding that given threshold, instead of the exceedance probability. Mathematically, the odds of exceedance, O(x), is given byAn alternative way to estimate g to Eq. , we can E(x) has the upper bound of 1, which narrows the range over which 41.Similar to the increase in the exceedance probability in Eq. , the simEquation  because t represents the time, and So far, we have considered an exponential form that grows with a shift in the mean  and the World Data Centre for Climate (WDCC)43 database, obtained from CMIP626 simulations (https://www.wdc-climate.de/ui/cmip6?input=CMIP6.ScenarioMIP.DKRZ.MPI-ESM1-2-HR.ssp585). The KNMI and WDCC databases provided a total of 15 different global RCP 8.5 projections up to 2300, from which we calculate and apply their ensemble average to utilize as the intermediate RCP 8.5 scenario in our analysis. The low- and high-end RCP 8.5 projections are constructed by taking the ensemble minimum and maximum projections at each time (year) among the 15 projections, respectively. To exclude the inter-annual anomalies present in the temperature projections (which are often associated with climate modes such as ENSO), we apply a low-pass filter  to each ensemble time series. Applying the low-pass filter to local temperature projections ensures that the derived growth rates in the odds of exceedance are not dependent on any unknown future phase of ENSO events realized in GCM simulations. Unfiltered temperature projections  show quite similar (but more noisy) results in terms of the doubling time scale In the current study, we apply temperature projections under a range of probabilistic RCP 8.5 emission scenarios  obtained from the Royal Netherlands Climate Institute (KNMI) Climate ExplorerE(x), i.e., an increase in the exceedance probability results in a decrease in the return period of a given threshold, and it follows asIt is often more intuitive to assess changes in the return period [Equation  depicts https://www.ncei.noaa.gov/products/land-based-station/global-historical-climatology-network-daily). For the current analysis, we obtained these temperature data set via their API data access protocols. The hourly/daily maximum temperature record for 18,698 stations across U.S., Canada, and Mexico were downloaded, with the longest records containing data from 1840 to 2018 (178 years). All stations that provided only hourly temperature records were converted to daily maximum temperature records for the analysis described below. Only stations with more than 50 years of data and at least 80% data coverage are retained in this analysis. Additionally, stations with less than 80% coverage during summer periods (June-July-August) were removed from the analysis. This process filters out 41, to obtain the parameter estimates for the GEV distribution  the time series of historical temperatures. The choice of the top three annual events ensures that the influence of large, isolated extreme high-temperature events is restricted.NOAA’s National Centers for Environmental Information (NCEI) archives the hourly/daily temperature observations across North America  in the NOAA-GHCND database (23). GEV is highly sensitive to the length of the available observational data, where limited records return less reliable estimates of extreme events. However, the GEV model is generally capable of assessing the statistical behavior of rare events  even when the observational time series available is shorter than the return period of those events 23. Fortunately, in the case of our analysis, all stations have records of 50 years of data or more, lending confidence to the estimates of GEV model parameters.GEV has proven to be a robust model for analyzing temperature extremes; however, it is not without limitations  level, according to the equationmentclasspt{minimaentclass1pt{minimaHaving calculated the required temperature difference for each station under the two above-mentioned scenarios, we find the time (year) in the future that each of these two scenarios is expected to take place for each location based on projections of local temperature rise under a range of RCP 8.5 emissions scenarios (described in section “Supplementary Figures.Supplementary Information.


Intrinsically disordered regions (IDRs) are widely distributed in proteins and related to many important biological functions. Accurately identifying IDRs is of great significance for protein structure and function analysis. Because the long disordered regions (LDRs) and short disordered regions (SDRs) share different characteristics, the existing predictors fail to achieve better and more stable performance on datasets with different ratios between LDRs and SDRs. There are two main reasons. First, the existing predictors construct network structures based on their own experiences such as convolutional neural network (CNN) which is used to extract the feature of neighboring residues in protein, and long short-term memory (LSTM) is used to extract the long-distance dependencies feature of protein residues. But these networks cannot capture the hidden feature associated with the length-dependent between residues. Second, many algorithms based on deep learning have been proposed but the complementarity of the existing predictors is not fully explored and used.In this study, the neural architecture search (NAS) algorithm was employed to automatically construct the network structures so as to capture the hidden features in protein sequences. In order to stably predict both the LDRs and SDRs, the model constructed by NAS was combined with length-dependent models for capturing the unique features of SDRs or LDRs and general models for capturing the common features between LDRs and SDRs. A new predictor called IDP-Fusion was proposed.Experimental results showed that IDP-Fusion can achieve more stable performance than the other existing predictors on independent test sets with different ratios between SDRs and LDRs.The online version contains supplementary material available at 10.1186/s12915-023-01672-5. Intrinsically disordered regions (IDRs) are protein regions lacking stable three-dimensional structure , 2. IDRsWith the rapid increase of the number of proteins in recent years, we need to develop faster and more effective methods to identify IDRs. With the help of machine learning algorithms, several computational models have been proposed. For example, DISOPRED  uses theIDRs are divided into short disordered regions (SDRs) and long disordered regions (LDRs). Generally, LDRs are defined as disordered regions with more than 30 residues, while SDRs are shorter than 30 residues . LDR proBased on the similarities between the natural languages and protein sequences, algorithms derived from the field of natural language processing (NLP) have been successfully applied to protein sequence analysis . RecentlIn order to compare the performance of IDP-Fusion with the other competing methods, IDP-Fusion was evaluated on several independent test datasets with different ratios between SDRs and LDRs, including MXD494, SL329, DISORDER723, CASP, and DISPROT504. The performance of different methods was shown in Additional file From Table In real-world applications, for the test datasets, the ratio between LDR proteins and SDR proteins is unknown. For such a situation, a predictor with stable performance for predicting both SDR proteins and LDR proteins is preferred. In this regard, we randomly selected 400 protein sequences from MSDCD, and then these proteins were predicted by different methods. This process was repeated 50 times, and the results were shown in Fig. SPOT-Disorder2 is another efficient method for IDR prediction, achieving the state-of-the-art performance. However, SPOT-Disorder2 failed to generate results for longer proteins because of the limitation of its feature extraction methods. For fairly comparing the performance between SPOT-Disorder2 and IDP-Fusion, we removed the protein sequences which are not able be predicted by SPOT-Disorder2 from MSDCD, resulting in 999 LDR proteins and 1193 SDR proteins. These proteins were then used to evaluate the performance for both SPOT-Disorder2 and IDP-Fusion, and the results were shown in Fig. To further explore the performance of IDP-Fusion, we evaluated the results of IDP-Fusion on the CAID1 . IDP-FusFrom Table We further explore the contribution of different base methods to the performance of IDP-Fusion. We visualized the prediction results of protein 1a95D predicted by different base methods see Fig. . From FiIn nature, about 20–55% proteins among all the proteins are disordered proteins –46. FullEight datasets with different ratios between disordered proteins and fully ordered proteins were constructed. The statistical information of these eight datasets is listed in Additional file The performance of the same method varies greatly among different datasets, and various methods are ranked differently on different datasets. In order to solve this problem, we proposed a new predictor based on deep learning called IDP-Fusion. Compared with the other methods for predicting IDRs, it has the following advantages: (1) the neural architecture search employed by IDP-Fusion can capture the hidden information of the protein sequences, overcoming the disadvantages of the manually designed models only capturing the experience features; (2) the multi-objective genetic ensemble algorithm fully considers the influence of the different ratios between SDRs and LDRs on the final performance, improving the stability of IDP-Fusion; (3) we incorporate the fully ordered proteins into the training dataset to accurately predict both the IDPs and the full ordered proteins.https://disprot.org/, https://www.mobidb.org/). We removed protein sequences in The training dataset included 614 LDR proteins, 3024 SDR proteins, and 616 fully ordered proteins, which is constructed based on ved from  and 17]\documenthttps://disprot.org/) .Figjth feature node, and The different nodes in the normal cell and reduction cell shown in Fig. cument}o .14\documAfter the search is completed, the operation with the largest weight is selected as the specific operation between r, its prediction probability is the sum of the weighted probabilities of the six base methods.:The prediction probabilities generated by the six complementary base methods should be fused to make the final prediction. The currently fusion strategy ignoring the stability of the model on independent test datasets with different ratios between LDRs and SDRs, such as the average fusion strategy . In ordeCompared with the average fusion strategy, the performance of MOGA is better and more stable on independent test datasets with different ratios between LDRs and SDRs (see Additional file TP, FP, TN, and FN represent the number of true positives, false positives, true negatives, and false negatives, respectively.The evaluation indicators used in this study are as follows:Additional file 1: Supplementary Tables. The statistical information of six independent test datasets is listed in Table S1. Performance of various methods on MXD494, SL329, DISORDER723, Disprot504 and CASP is listed in Table S2-S6 [le S2-S6 , 15–26.


Chronic lymphocytic leukemia (CLL) is the most common adult leukemia in the western world. It is characterized by a high dependency on interactions with the surrounding immune landscape, highlighting its suitability for immune-mediated therapeutic interventions. We recently revealed that the cytokine IL-27 exerts a strong anti-tumor role in CLL through a T-cell-mediated mechanism. Analogous to most immune mediators, whether IL-27 promotes or hinders malignant growth seems to be a matter of context.2 Nevertheless, given its clear effects on tumor progression, exploring the role of this cytokine in the setting of different cancer types represents an attractive research pursuit.Harnessing the power of the immune system against cancer probably represents one of the most clinically meaningful scientific breakthroughs of this century in the field of cancer research. For solid and hematological malignancies alike, the immune landscape surrounding the tumor has emerged as a powerful modulator of malignant fate and patient prognosis. Consequently, it comes as no surprise that cytokines, the so-called messengers of the immune system, have received increasing research attention during the last decade, already yielding remarkable results in the clinic.ex vivo without mimicking the stimulation from its native microenvironment, highlighting the intrinsic importance of these complex interactions in the pathobiology of CLL.3 We previously performed the first characterization of the CLL tumor microenvironment using mass cytometry in the widely used Eµ-TCL1 mouse model of CLL, where we reported a deeply immunosuppressive environment at the tumor niche.4 Moreover, we evidenced the clinical potential of restoring effective tumor immunity in this malignancy by successfully reducing tumor load while targeting the immune checkpoints PD-1 and LAG3.5 Recently, we also characterized the T cell landscape within different immune compartments of CLL patients using multi-omics technology, and further explored the translational potential of immunotherapies for the treatment of this malignancy.6While most cancers interact with their surrounding environment to some extent, some malignancies heavily rely on these interactions to receive the signals necessary to survive and thrive. This is the case of chronic lymphocytic leukemia (CLL), an incurable hematological malignancy commonly regarded as the most prevalent adult leukemia in the western world. One of the defining features of CLL is its inability to survive Despite the need for the development of effective immunotherapies for the treatment of CLL, as well the recently unraveled promise of IL-27 in cancer therapeutics, the role of IL-27 in the development and progression of CLL remained largely unexplored. In our recent publication, we employed a range of transgenic mouse models as well as clinical samples to elucidate the role of this cytokine in the complex immune landscape in CLL.7 Interestingly, our data8 uncovered a significant and consistent decrease in IL-27 serum levels as the disease progresses in both pre-clinical and patient CLL samples, suggesting an anti-tumor effect of IL-27 in the development and progression of this malignancy. To evaluate the translational implications of this observation, we conducted a series of pre-clinical trials by adoptively transferring TCL1 leukemic cells into C57BL/6 and transgenic mouse models, as well as through the neutralization of this cytokine in vivo. For this purpose, we employed a constitutive KO murine model of the IL-27 subunit EBI3 , hence rendering cells unable to produce this cytokine. The EBI3KO model was used to generate its leukemic counterpart, the TCL1-EBI3KO model, which spontaneously develops CLL and lacks the production of IL-27. As expected, all the aforementioned in vivo studies reported an increased tumor growth in the absence of this cytokine, conclusively pointing toward a strong anti-tumor role of IL27 in CLL. The decrease in tumor load was accompanied by the partial restauration of the anti-tumor immune response, evidenced by a less immunosuppressive leukemic immune landscape in the presence of IL-27, and in consonance with our previous publications.Levels of soluble mediators are known to be disturbed in oncology patients depending on whether they favor or hinder tumor growth, increasing or decreasing respectively when compared to healthy individuals.9 our data strongly suggests that T cells are the main mediators in the observed IL-27-driven anti-tumor immunity in CLL. This is evidenced by the ability of isolated T cells to control CLL progression more efficiently in the presence of this cytokine in an immunodeficient mouse model. Of particular importance, patient-derived T cells treated with IL-27 displayed a higher cytotoxic ability toward leukemic cells than their untreated counterparts; highlighting the potential of this cytokine to reactivate anti-tumor immunity in CLL patients. Finally, gene expression profiling analysis of T cells in the presence and absence of IL-27 shed light on the molecular mechanism involved in this process, underlining the role of the synapse-formation-modulator profilin 1,10 and the amino acid transporter SLC7A5 among others. Identifying and connecting the molecular underpinnings of this pathway remains an exciting area of research that must be explored by future investigations.While previous investigations have reported a direct cytotoxic effect of IL-27 in several malignancies,Overall, we demonstrated that IL-27 is an important mediator in CLL pathology . Moreove


Guillain–Barre syndrome (GBS) is a complication that occurs in patients with Coronavirus Disease (COVID-19) infection. The spectrum of symptoms varies from mild to severe symptoms, even death. The study aimed to compare the clinical manifestations in GBS patients with and without COVID-19 comorbidity.p = 0.03) and the presence of facial nerve involvement . Demyelinating type GBS or AIDP was more common in the COVID-19 positive group . COVID-19 in GBS significantly increased the need for intensive care  and the use of mechanical ventilation .A systematic review and meta-analysis of cohort and cross-sectional studies was conducted comparing the characteristics and course of GBS disease in the COVID-19 positive and COVID-19 negative groups. Four articles were selected with a total sample of 61 COVID-19 positive and 110 COVID-19 negative GBS patients. Based on clinical manifestations, COVID-19 infection increased the likelihood of tetraparesis (OR: 2.54; 95% CI 1.12–5.74; GBS following COVID-19 infection showed more severe variations in clinical characteristics compared to the group of GBS patients without COVID-19. Early detection of GBS, especially the typical manifestations post COVID-19 infection, is very important to carry out intensive monitoring and early management before the patient's condition worsens. Since early 2020, the World Health Organization (WHO) has designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease COVID-19) infection as a pandemic. To date, up to 585 million confirmed cases of COVID-19 have been found, with 6.4 million deaths globally [9 infectiCOVID-19 is known to have respiratory symptoms. Based on the development of research, many manifestations in other organ systems were found, one of which is the nervous system, both the central and peripheral nervous systems. The SARS-CoV-2 receptor, Angiotensin Converting Enzyme (ACE)-2, is also expressed in neural tissue. Nervous system involvement associated with COVID-19 is common, particularly in the form of headache, anosmia, dysgeusia, nausea and vomiting, dizziness, and impaired consciousness. Neurological complications found can be in the form of stroke, seizures, meningitis, encephalitis, and muscle involvement .Guillain–Barre syndrome (GBS) is a form of nervous system involvement in COVID-19, where peripheral nerve damage has occurred . GBS is Two-thirds of the total GBS cases were correlated with the presence of a previous infection. The GBS phenomenon is often associated with epidemics in the world, such as the Zika virus and Middle East respiratory syndrome (MERS) virus epidemics, as well as other viral or bacterial infections , 6. TherSeveral systematic reviews and meta-analyses of GBS cases in COVID-19 have also been carried out in previous studies. However, there have been no systematic reviews or meta-analyses comparing the clinical characteristics and outcomes of GBS patients infected with COVID-19 and GBS without previous COVID-19 infection, especially from observational studies.Therefore, this systematic review and meta-analysis aims to describe the clinical characteristics of GBS associated with COVID-19 from observational studies, and to compare them with the group of GBS not associated with COVID-19 infection. By knowing the comparison between the two groups, it is hoped that it can help health practitioners understand the typical clinical manifestations of GBS with COVID-19, and be able to establish an initial diagnosis accompanied by appropriate management.A systematic literature search was conducted in the PubMed, Proquest, and Science Direct databases using the keywords “Guillain–Barre syndrome” combined with “COVID-19”, “SARS-CoV-2”, and “coronavirus” published in the year of 2019 until the first half of July 2022. Article selection was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method  based on the selection criteria, comparability, and outcomes of the study  and forest plots. Random-effect analysis was performed if heterogeneity based on Through the article selection process in Fig. There were 171 total GBS samples in this study, with 61 samples from the GBS group positive for COVID-19 and 110 samples from the GBS group negative for COVID-19. Demographic data of patients were the mean of age and gender. Patients’ comorbidities were also obtained in both groups. Specifically for the COVID-19 positive group in the cohort study, data on the average interval of days from being infected with COVID-19 before the first manifestation of GBS were shown (Appendix 1).Regarding the clinical characteristics of GBS, there were manifestations of weakness in the form of tetraparesis or paraparesis as well as a GBS disability score  and a muscle strength score based on Medical Research Council (MRC). Parameters of cranial nerve involvement are seen generally and specifically on the oculomotor nerve, facial nerve, or bulbar nerve. The presence of autonomic dysfunction is also included. Electrophysiology examinations were included to determine the variant of GBS, and examination of cerebrospinal fluid to see the presence of cytoalbuminologic dissociation. The patient's clinical outcome was assessed based on the need for intensive care in the intensive care unit (ICU) and the use of a mechanical ventilator. Two studies showed mortality data.Descriptive data of the clinical characteristics are described in Table A meta-analysis was conducted on each variable to analyze whether COVID-19 infection affected the clinical picture of patients with GBS. The results of the analysis presented can be seen in Table p = 0.01). Meanwhile, based on comorbidity, there was no difference between the case group and the control group.In demographic data, it was found that the GBS group with COVID-19 tended to be older than the GBS group without COVID-19 . Whereas in GBS without COVID-19, it significantly showed paraparesis type of weakness . There were no significant differences in MRC scores and high disability scores between the two groups. In the analysis of cranial nerve involvement, the only significant difference was found in the manifestation of facial nerve involvement which tended to be more common in GBS with COVID-19 . The incidence of autonomic dysfunction was the same in both groups.The manifestation of GBS weakness in COVID-19 tended to show the tetraparesis type . Meanwhile, axonal GBS such as acute motor axonal neuropathy (AMAN) and acute motor sensory axonal neuropathy (AMSAN) tended to occur more frequently in GBS without COVID-19 .The GBS variant based on electrophysiological examination also showed significant analysis results. GBS in COVID-19 tended to have a variant type of acute inflammatory demyelinating polyneuropathy or AIDP , and more likely to require the use of mechanical ventilation . Mortality between the two groups were the same, but this cannot be confirmed, because studies examining GBS mortality in COVID-19 and the number of participants were smaller.Outcome of GBS cases in COVID-19 was assessed based on the treatment the patient underwent. COVID-19 in GBS significantly increased the need for intensive care (OR: 3.32; 95% CI 1.48–7.46; GBS is the most common neuromuscular complication of COVID-19 infection . In someThere is no certainty regarding the pathophysiological mechanism of GBS in COVID-19. The hypothesis of GBS in COVID-19 is suspected to occur through the post-infection inflammatory process. COVID-19 enhances the immune response facilitated by T cell activation accompanied by an increase in inflammatory markers and pro-inflammatory cytokines . In addiIn previous reports and studies, most of the patients were over 50 years and dominated by men. Older age and male gender are associated with more severe COVID-19 conditions . In thisGBS has a variety of clinical presentations, which are generally characterized by bilateral flaccid weakness with a course of weakness from the lower extremities upwards or ascending paralysis . This stTetraparesis is associated with a more severe GBS outcome, with more frequent cranial nerve involvement and more severe lower extremity weakness than paraparesis. In a cohort study, 98% of patients with paraparesis were significantly more recoverable and able to walk unaided than patients with tetraparesis . This isThe mechanism of autoimmune neuropathy in COVID-19 is associated with cranial nerve weakness [This is consistent with the data in Table Examinations which help establishing the diagnosis of GBS are electrophysiological and cerebrospinal fluid examinations. The demyelinating variant or AIDP is mostly found in GBS with COVID-19. AIDP is associated with the infiltration mechanism of T lymphocytes and macrophages that erode the myelin structure. Autoimmune processes and the formation of antibodies against myelin glycolipids lead to demyelination . Axonal Examination of the cerebrospinal fluid in GBS usually shows an increase in protein with normal white blood cells, otherwise known as cytoalbuminologic dissociation. Previous studies have not found the presence of the SARS-CoV-2 virus in the cerebrospinal fluid . So thatEarly detection of GBS, especially the typical manifestations of post COVID-19 infection, is very important in efforts to carry out intensive monitoring and early management before the patient's condition worsens. Giving therapy such as immunotherapy is said to have a better response in the first 2 weeks, especially in patients with GBS disability scores ≥ 3 . TherefoCOVID-19 infection that preceded GBS showed a more severe variation of clinical manifestations than the group of GBS patients without COVID-19. The limitation of this study is that there were very few observational studies regarding the comparison of GBS patients with and without previous COVID-19 infection. Outcomes showing the mortality rate and prognosis of GBS patients in COVID-19 are also limited; therefore, further analysis is needed to obtain results that are more representative of conditions in the field.


Previous studies have shown that COVID-19 inpatients exhibited significant attentional deficits on the day of discharge. However, the presence of gastrointestinal symptoms (GIS) has not been evaluated. Here, we aimed to verify: (1) whether COVID-19 patients with GIS exhibited specific attention deficits; (2) which attention subdomain deficits discriminated patients with GIS and without gastrointestinal symptoms (NGIS) from healthy controls. On admission, the presence of GIS was recorded. Seventy-four physically functional COVID-19 inpatients at discharge and sixty-eight controls underwent a Go/No-go computerized visual attentional test (CVAT). A Multivariate Analysis of Covariance (MANCOVA) was performed to examine group differences in attentional performance. To discriminate which attention subdomain deficits discriminated GIS and NGIS COVID-19 patients from healthy controls, a discriminant analysis was applied using the CVAT variables. The MANCOVA showed a significant overall effect of COVID-19 with GIS on attention performance. The discriminant analysis indicated that the GIS group could be differentiated from the controls by variability of reaction time and omissions errors. The NGIS group could be differentiated from controls by reaction time. Late attention deficits in COVID-19 patients with GIS may reflect a primary problem in the sustained and focused attention subsystems, whereas in NGIS patients the attention problems are related to the intrinsic-alertness subsystem. The bidirectional connection between the brain and the gut has been a topic of great interest in the last decade . The braCOVID-19, a respiratory disease at origin, has emerged as a systemic disease related with several extrapulmonary manifestations, including gastrointestinal symptoms (GIS) ,11,12. AIt has been hypothesized that after invading the gastrointestinal tract, SARS-CoV-2 may reach the central nervous system through the vagal nerve, vascular, and/or lymphatic systems . BostancIn COVID-19 patients after hospital discharge, delayed cognitive deficits may operate independently or instead secondary to reductions in lower order domains, such as basic attention . AttentiThe present study aimed to verify whether COVID-19 patients with GIS at baseline exhibit specific attention subdomain deficits on the day of discharge from the hospital. We also verified which attention subdomain deficits discriminated COVID-19 patients with GIS and without gastrointestinal symptoms (NGIS) from the control group.COVID-19 patients (positive RT-PCR) for SARS-CoV-2 were recruited from two reference hospitals in Rio de Janeiro, Brazil. Thirty patients were recruited at the University Hospital and assessed by Aureo do Carmo. This subsample is detailed by Do Carmo et al. (2022) . The pooled within-group correlations identified large correlations with the discriminant model: VRT and RT (2 (1) = 42.54, p < 0.001]. The pooled within-group correlations identified that CV alone was capable of discriminating the control group from the NGI group, with 73.4% accuracy.For the NGI group, considering the CVAT variables , there were two significant discriminant dimensions . The pooled within-group correlations identified large correlations with the discriminant model: OE and VRT. Therefore, OE and VRT discriminated GIS patients from controls, and the subjects were correctly classified with 90.7 % accuracy. When VRT and RT were replaced by CV, we still found two significant dimensions for the GIS group . The pooled within-group correlations identified that CV and OE were capable of discriminating the control group from the GIS group with 90.7% accuracy. The results based on the discriminant analyses are summarized in For the GIS group, there were two significant discriminant dimensions [χp = 0.17).The inspection of the standardized scores based on the control group indicated that in the NGIS group, RT was the most affected variable. In the GIS group, OE and CV were primarily affected. In the GIS group, an increase in CV reflected an increase in VRT independent of RT, as indicated by a non-significant correlation between CV and RT  of the individual’s RTs. Previous studies based on a wide range of different RT tasks have described a linear relation between RT mean and SD ,36. Our Young suggested that SARS-CoV-2 may damage the brainstem through viral invasion, inflammation, and vascular activation . As a reWe suggest that in the NGIS group, the systemic inflammation might be linked with lung dysbiosis. Indeed, a recent study found that COVID-19 patients present higher levels of dysbiosis in the respiratory microbiota compared to healthy controls .The cerebral underpinnings of VRT have been studied less extensively than those of RT itself . PreviouIt should be mentioned that GIS may also be a result of dysfunction of the nucleus tractus solitarius and dorsal motor nucleus of the vagus due to its afferent and efferent neuronal projections with the gastrointestinal tract . In addiThe higher VRT exhibited by GIS patients might be caused by deficits associated with the sustained attention subdomain, because the VRT variable reflects the stability of response times as the test progressed. The number of omission errors (OEs) was also found to be increased in GIS patients, which indicates a further deficit in the focused-attention subdomain. Simultaneous deficits in OE and VRT might reflect lapses in attention during slow RTs . In the Bifidobacterium was associated with frontoparietal attention networks in healthy subjects [An alternative hypothesis is related to gut dysbiosis and disrupted microbiota–gut–brain axis. Current evidence suggests that microbiota abnormalities are present even after virus clearance and that gut microbiota of COVID-19 patients mirrors disease severity . In addisubjects .In addition to the brain, gut dysbiosis also affects the lungs . Since SThis article has some limitations. Due to the small sample size, we did not reach statistical power to analyze the influence of other cofactors such as fatigue status, medication use, and comorbidities. In addition, the lack of microbiota and immunological analyses limit the interpretation of the current data. Finally, the study design  poses a further limitation to the data interpretation. An important strength of this study is the use of an education- and culture-free test.In conclusion, the present findings suggest that cognitive problems, commonly observed in COVID-19 patients with GI symptoms, may reflect a primary problem in the sustained and focused attention subsystems. The adequate assessment of the different attention subdomains affected by early GIS would allow a better comprehension of later cognitive consequences of this condition.


Sarcopenia risk was not identified in examined athletes, and sarcopenia indicators did not change markedly over the 4-year period (p > 0.05). Participants with a history of SARS-CoV-2 infection did not differ from non-infected subjects in terms of body composition. Training cessation during the COVID-19 pandemic and SARS-CoV-2 infection did not induce long-term changes in body composition of Master swimmers. Life-long participation in swimming activities appears to delay negative changes in body composition, including sarcopenia symptoms.The long-term effect of physical activity on body composition in Master athletes is rarely presented in the literature. The aim of this study was to identify possible changes in body composition of Master swimmers over a period of 4 years, including during the COVID-19 pandemic. Additionally, we wanted to discover if sarcopenia symptoms would occur in Master athletes during the analyzed period. The body compositions of one hundred and sixty-seven Master swimmers were assessed with the InBody 270 analyzer in 2018. In 2022, the measurements were repeated in forty-six men and fourteen women. The Muscle Mass Index and the Skeletal Muscle Index were calculated to identify sarcopenia-related changes in body composition. We surveyed participants to gather data on their training patterns and SARS-CoV-2 infection history. No significant changes in body composition parameters were noted in Master swimmers during the analysis period ( Physical activity (PA) is a key prerequisite for healthy aging. Specific recommendations concerning the duration and intensity of PA for various age groups are provided regularly by well-known health organizations like the World Health Organization and the American Heart Association. People who follow these recommendations are considered physically active; otherwise, they are considered sedentary. Physical activity is considered a protective factor for cardiovascular disease, stroke, and diabetes . PhysicaMaster athletes are typically individuals aged 40 years or older who regularly practice sports at a competitive level . InternaPhysical activity in all age groups was significantly restricted during the COVID-19 pandemic. Indoor and outdoor sports facilities were closed due to lockdown laws, making PA inaccessible for both recreational and competitive athletes. All sports events, including the Olympic Games, were cancelled. In Europe, pandemic-related restrictions were imposed and lifted periodically between March 2020 and September 2021. Despite lockdowns, many athletes trained individually or online in reduced amounts . Access According to many studies, lockdown-related training cessation exerted varied effects on athletes. The COVID-19 lockdown adversely impacted training routines for football players globally. Regardless of this fact, professional players experienced fewer disruptions compared to amateur and semi-professional players . PhysicaSome studies reported the decline in PA of Master athletes during the COVID-19 pandemic . HoweverThe study was conducted during the Polish Master Swimming Championships in November 2018 and June 2022. Female and male athletes participating in these events were randomly selected and invited to participate in the study. The participants were informed about the purpose of the study and the research protocol, and they signed informed consent forms. Participants older than 35 years at baseline (November 2018) were included in the study. One hundred and sixty-seven athletes (112 men with a mean age of 52.3 ± 14.5 years and 55 women with a mean age of 48.6 ± 13.6 years) were examined in November 2018. Out of those, 46 men and 14 women participated in the examination in June 2022, and their data were taken into consideration in the present study . The parThe examinations were conducted in the morning 8:30–11:00 AM) in a separate room in the indoor swimming pool. The temperature in the room was 24.6–25.2 degrees centigrade, and the humidity was set at 48–51 per cent. First, the participants completed the survey questionnaire and provided information about their age, competitive experience, training loads, and diet for the last six months before the examination . Then, t–11:00 AMThe same examination procedure  was utilized during the Polish Master Swimming Championships in June 2022. The athletes surveyed in June 2022 were also queried to provide information about their history of SARS-CoV-2 infection in a standardized questionnaire developed by the Polish Ministry of Health . The queBased on the report of the European Working Group on Sarcopenia in Older People , the folThe training intensity index was calculated as follows:For example, if the athletes covered an average distance of 3000 m in a single training session and had three training sessions in a week, their training intensity index was 3000 × 3 = 9000 .p = 0.05 and a test power value of 80%. The recommended sample size comprised 36 men and 13 women.The sample size was calculated a priori with a web-based ClinCalc calculator . Sample size calculations were performed based on the study of Benelli et al. , where 1t-tests for dependent samples. In addition, Cohen’s d indicator was used to assess the effect size of these differences. The interpretation of Cohen’s d indicator for sports sciences is as follows [p < 0.05.The Statistica for Windows software  was utilized to perform statistical calculations. For all tested parameters the Shapiro–Wilk test did not indicate significant deviations from normality. Therefore, differences between anthropometric measurements performed in November 2018 and June 2022 were assessed by Students’  follows : trivial follows . StatistThe training regimes and the demographic characteristics of Master swimmers are presented in The changes in the body composition and the sarcopenia indicators of Master swimmers over a 4-year period (November 2018—PRE to June 2022—POST) are presented in As shown in Correlations between the training intensity index and body composition parameters of the Master swimmers are presented in Inconsequential correlations were noted between training loads and body composition parameters in female athletes. However, during the second examination, the training intensity index was positively and significantly correlated with total body water, fat-free mass, skeletal muscle mass, basal metabolic rate, and sarcopenia indicators in male athletes .Sports experience was not correlated with any body composition parameters. Female and male participants with a history of SARS-CoV-2 infection did not differ from non-infected subjects in terms of body composition.In the survey conducted in June 2022, 23 men (50%) and 6 women (42.8%) declared to have been infected with SARS-CoV-2 during the pandemic. The most frequently reported symptoms were decreased exercise tolerance (37%), headache (31%), arthritis pain (31%), olfactory and taste impairment (24%), and chronic cough (24%). Six percent of the examined athletes reported no symptoms accompanying the infection. The majority of infected athletes (62%) did not take any medications, whereas others took paracetamol (27%) and ibuprofen (11%). None of the examined athletes was hospitalized for COVID-19.The main finding of our study is that the four-year period covering the COVID-19 pandemic did not have an impact on body composition parameters in middle-aged Master swimmers. Moreover, participants with a history of SARS-CoV-2 infection did not differ notably in terms of body composition from those who did not suffer from infection. In fact, the participant’s body mass index (BMI) and body fat percentage were below the values recommended for healthy Caucasian women and men of the same age . The waiWhen analyzing the results of this study, it is important to bear in mind the COVID-19 pandemic context. The analyzed four-year period included the COVID-19 pandemic when access to sports and recreational activities was limited. All swimming pools were closed between March 2020 and May 2020. In the following months, local restrictions on the use of indoor swimming pools were imposed temporarily based on the local incidence rate of SARS-CoV-2 infection. During this period, swimming pools were accessible in certain parts of the country but closed in other regions. The mitigating strategies for swimming-related activities were lifted in the summer of 2021. The COVID-19 lockdown resulted in the suspension of sports and recreational activities for many weeks, which led to the atrophy and diminishing functionality of muscles, especially in untrained older adults . HoweverIn the current study, the examined swimmers did not train regularly at home during subsequent lockdowns, and their body composition parameters did not change markedly during the 4-year period. Moderate, positive correlations were found between training intensity index and skeletal muscle mass, as well as basal metabolic rate and sarcopenia indicators among male swimmers in 2022. Based on the data, we conclude that long-term swimming training, performed with proper physiological load, could delay negative age-related changes in body composition. It is plausible that the mild case of the SARS-CoV-2 infection in our swimmers was related to their low body fat parameters, as shown in the study conducted by Yoshiji et al. . The stu2). A difference amongst genders in sarcopenia indicators was observed, as noted by Lee et al. [2. Moreover, our female Master swimmers presented higher values concerning the Muscle Mass Index and Skeletal Muscle Index compared to healthy, normal-weight young women  [In the pre-pandemic era, Macek et al.  reportede et al. , but valctively) . These oThe present study includes certain limitations. Firstly, the number of participants examined in 2022 decreased markedly when compared to the baseline. More than one hundred and sixty Master swimmers were evaluated at baseline, but the final analysis involved only the results of sixty participants. Reasoning is yet to be determined as to why so many Master athletes did not participate in the most important national event of 2022. Secondly, we implemented guidelines contained in the European Working Group on Sarcopenia in Older People (EWGSOP1) instead of the newer version EWGSOP2. According to Wallengren et al. , there aOur study showed that a period of 4 years covering several COVID-19 lockdowns did not have an impact on body composition parameters in middle-aged Master swimmers. No significant changes in any of the body composition parameters were detected. Moreover, body composition parameters did not differ in participants with a history of SARS-CoV-2 infection when compared to the non-infected ones. Thus, the SARS-CoV-2 infection did not affect body composition parameters in assessed swimmers. Sarcopenia symptoms were not detected in examined athletes on both dates of examination. Based on the aforementioned observations, it can be concluded that regular swimming training appears to promote healthy aging. Further research involving a larger population is needed to validate these observations.