N = 214,505) and multivariable logistic regression to test whether lifetime use (yes/no) of classic psychedelics was associated with lowered odds of OUD. Lifetime psilocybin use was associated with lowered odds of OUD . No other substances, including other classic psychedelics, were associated with lowered odds of OUD. Additionally, sensitivity analyses revealed psilocybin use to be associated with lowered odds of seven of the 11 DSM-IV criteria for OUD (aOR range: 0.66–0.83). Future clinical trials and longitudinal studies are needed to determine whether these associations are causal.Opioid use disorder (OUD) is a major source of morbidity and mortality in the U.S. and there is a pressing need to identify additional treatments for the disorder. Classic psychedelics  have been linked to the alleviation of various substance use disorders and may hold promise as potential treatments for OUD. The aim of this study was to assess whether the aforementioned classic psychedelic substances conferred lowered odds of OUD. Furthermore, this study aimed to replicate and extend findings from Pisano et al. (2017) who found classic psychedelic use to be linked to lowered odds of OUD in a nationally representative sample. We used recent data from the National Survey on Drug Use and Health (2015–2019) ( Opioids, including heroin, fentanyl, and prescription opioid compounds, are responsible for approximately 70% of all overdose deaths in the United States3. Additionally, over the course of the COVID-19 pandemic, mortality related to opioid overdoses has reached alarming new highs4, with the largest increases among members of racial and ethnic minority groups, as well as in areas of socioeconomic disadvantage5. Two gold-standard pharmacological treatments exist for opioid dependence—methadone and buprenorphine, both of which are synthetic opiate derivatives. Unfortunately, these common interventions come with high risk of dependence, therefore often trading one addiction for another. There is a clear need to identify more effective interventions for OUD as well as to explore protective factors that may increase the likelihood of abstinence from these addictive compounds8.Opioid use disorder (OUD) is a major public health crisis, with nearly 70,000 opioid-related deaths in the United States in 2017 alone, representing a 292% increase since 20019. The major compounds included in this class of substances include: lysergic acid diethylamide (LSD), psilocybin, ayahuasca, dimethyltryptamine (DMT), peyote, and mescaline. Following a several-decade hiatus, recent years have seen a promising revival of research on the use of psychedelics in the treatment of addiction. A strong body of preliminary work has emerged to support psychedelic-assisted therapy for substance dependence and abuse, with studies supporting the efficacy for psilocybin as a smoking cessation treatment, as well as LSD as a treatment for alcoholism12. Additionally, in a sample of patients who self-administered psychedelics  in a naturalistic context and reported the effects of psychedelics before and after administration, 96% met substance use disorder (SUD) criteria before psychedelic use, whereas following psychedelic use, only 27% met criteria for a SUD13. These findings offer preliminary support for classic psychedelics as a treatment for addiction.Classic psychedelics (Greek for “mind-manifesting”) represent potential treatments for OUD; furthermore, studying these substances can potentially help to identify protective factors for OUD as well. Classic psychedelics are a group of psychoactive compounds found in nature or synthesized from natural precursors. Such compounds often produce mystical-type or ego-dissolution experiences in users13. Recently, Argento and colleagues14 analyzed a longitudinal cohort of 3813 people who use drugs and found naturalistic psychedelic use to predict lowered odds of daily opioid use. Additionally, Pisano et al. conducted a landmark study in this line of inquiry, examining the association between the use of classic psychedelics and incidence of OUD within a large population sample of illicit drug users. Using data from the National Survey of Drug Use and Health (NSDUH) (2008–2013), Pisano et al. demonstrated that classic psychedelic use conferred 27% reduced risk of past-year opioid dependence and 40% reduced risk of past-year opioid abuse15.As limited as the literature on the relationship between psychedelics and addiction is, the body of research examining the associations between classic psychedelic use and OUD is even smaller. A few studies have hinted that the association is worth exploring, however. In an online study, Garcia-Romeu et al. found a decrease in opioid and cannabis cravings after naturalistic experiences with classic psychedelics19 found that different psychedelic compounds have differing patterns of association with mental health outcomes. Thus, examining the correlates between lifetime use of several commonly-used psychedelic compounds and OUD can help to identify the specific compounds best suited to treating OUD.Given the overall dearth of research into the association between psychedelic use and opioid dependence in a naturalistic context, it is crucial to examine whether such findings replicate. It is also necessary to understand the unique associations that individual classic psychedelics share with OUD. Work from Jones and NockThis paper uses the latest NSDUH data to replicate and extend the findings from Pisano et al. on the associations between naturalistic use of psychedelics and OUD, as well as to examine the associations between use of particular classic psychedelic substances  and OUD. To our knowledge, this study represents the first attempt since Pisano et al. to investigate this association in the context of a large, nationally representative sample.N = 214,505). This study was exempt from IRB review as NSDUH data are publicly available and all methods in this study were carried out in accordance with relevant guidelines and regulations.Data are from The National Survey on Drug Use and Health (NSDUH) (2015–2019), an annual survey that examines substance use and health outcomes within a nationally-representative sample of the United States population. Individuals experiencing homelessness, active-duty military members, and currently incarcerated citizens are not surveyed by the NSDUH. We included all adults aged ≥ 18 years from the NSDUH in our analyses . For any classic psychedelics associated with lowered odds of OUD, we conducted sensitivity analyses to assess the associations between these substances and each of the 11 DSM-IV criteria for opioid dependence and abuse21. This analytical approach utilizes virtually all OUD-related variables in the NSDUH and allows for detailed insight into the associations between classic psychedelics and OUD.We used a similar analytical approach to Pisano et al. We used the ‘Survey’ package in R to conduct survey-weighted multivariable logistic regression models that incorporated the complex survey design and weighting included in the NSDUHOur main independent variables were lifetime use (yes/no) of the four most frequently used classic psychedelics in the NSDUH: psilocybin, peyote, mescaline, and LSD. We also included the following demographic factors and substances as a priori covariates within our analyses: sex, age, race/ethnicity, educational attainment, self-reported engagement in risky behavior, annual household income, marital status, and lifetime use of various substances .DSM-IV diagnostic criteria for opioid dependence or abuse served as dependent variables in our sensitivity analyses. The criteria were as follows:Spent a great deal of time over a period of a month getting, using, or getting over the effects of opioids.Unable to keep or set limits on opioid use or used opioids more often than intended.Needed to use opioids more than before to get desired effects or noticed that using the same amount had less effect than before.Unable to cut down or stop using opioids every time he/she/they tried or wanted to.Continued to use opioids even though they were causing problems with emotions, nerves, mental health, or physical health.Reduced or gave up participation in important activities due to opioid use.Reported experiencing three or more opioid withdrawal symptoms at the same time that lasted longer than a day after opioid use was cut back or stopped .Serious problems at home, work, or school caused by using opioids.Used opioids regularly and then did something that might have put the user in physical danger.Use of opioids caused someone to do things that repeatedly got him/her/them in trouble with the law.Problems with family or friends caused by using opioids and continued to use opioids even though the user thought opioids caused these problems.The main dependent variable was past year diagnosis of OUD. Individuals met criteria for OUD if they abused or experienced dependence on heroin or prescription pain relievers in the past year. Additionally, each of the 11 For our sensitivity analyses, all aforementioned demographics and lifetime use variables served as covariates.Differences in the demographic characteristics of those with and without past year OUD are presented in Table The results from our main model testing the associations between lifetime use of classic psychedelics  and past year OUD are presented in Table DSM-IV criteria for opioid dependence and abuse are presented in Table DSM-IV criteria for opioid dependence and abuse as well .The results of our sensitivity analyses testing the associations between lifetime psilocybin use and past year presence of each of the 11 In addition to our sensitivity analyses, we also conducted post-hoc chi-squared analyses to assess whether there are significant demographic differences between psilocybin users who have versus have not ever misused opioids . Differences between these two groups would suggest that third-variable demographic variables partially mediate the associations between psilocybin and lowered odds of OUD, as this finding would suggest that there exists a unique population of psilocybin users that has never misused opioids and subsequently are at little to no risk for OUD. These findings are reported in Table 19. Additionally, the magnitude of the association between psilocybin use and OUD (30% reduction in odds) is comparable to that initially reported by Pisano et al. using NSDUH data from 2008 to 2013—allowing us to report that Pisano et al.’s findings replicate in a different (more recent) nationally-representative sample. The association between lifetime use of psilocybin and OUD was not driven by a few particular criteria for OUD; rather, lifetime psilocybin use was significantly associated with reduced odds of seven out of 11 DSM-IV criteria for opioid dependence and abuse.Psilocybin was the sole classic psychedelic substance associated with lowered odds of past year OUD in a large, nationally-representative sample of the U.S. population. These findings accord with other population-based survey research indicating that classic psychedelics share differing relationships to mental health outcomes in naturalistic contextsThese results are cross-sectional and correlational and so cannot be used to make causal inferences. However, this study offers an important contribution to the research literature by demonstrating the replication of Pisano et al.’s original finding that lifetime use of psychedelics conferred lowered odds of opioid dependence and abuse. As clinically minded researchers pursue trials aimed at demonstrating the therapeutic efficacy of psilocybin-based treatments for opioid addiction, our study provides a foundation for this line of inquiry with preliminary evidence from a naturalistic context. Furthermore, our findings suggest it is worth investigating the protective effects of psilocybin for all related diagnostic criteria for OUD, including overuse and tolerance, opioid-related emotional distress, and opioid-related social and work problems.These results should be interpreted in the context of several important limitations. Above all, given that our results are based on cross-sectional data, they cannot be used to draw causal conclusions. Casual investigations  are needed to better understand the nature of the association between psilocybin use and lowered odds of OUD. Additionally, all of the questions we drew from the NSDUH are based on self-report. As a result, for questions on both psychedelic use and OUD, under-reporting might be a confound in our analyses and conclusions.Next, although we controlled for many demographic covariates, there are many we likely could not control for due to the limitations of the NSDUH dataset. For instance, the NSDUH does not assess information about homelessness status nor collect information from individuals who are currently incarcerated or serving as active-duty military members. Not accounting for demographic factors such as these may lead to an overestimation of the strength of the association between psilocybin use and lowered odds of OUD. Future research should attempt to control for these factors to maximize the integrity of any observed relationships between psilocybin use and OUD.22.Finally, items assessing psychedelic use asked about “lifetime” use, but not recency or frequency, precluding examination of these features of psychedelic use. However, given that psilocybin has been shown to elicit lasting reductions in substance dependence after just two to three administrations, causal interpretations of our findings remain plausible even in light of this limitation2A) agonists, meaning that they bind to a receptor site typically targeted by serotonin23. Abnormal serotonin neurotransmission is linked to many aspects of addiction, such as craving and heightened responses to drug cues26. Furthermore, there is suggestive evidence that serotonin agonists may support the treatment of opioid addiction as they may indirectly inhibit the release of dopamine27, a key neurotransmitter that is implicated in the maladaptive reward system changes associated with opioid addiction28. At present, pharmacological explanations of our findings remain purely speculative. Future research on the pharmacology of psilocybin can potentially shed further light on the link between this compound and lowered odds of OUD.A number of potential mediators might underlie the current study’s findings. First, as mentioned in Pisano et al., the effects of psilocybin on the serotonin system might mediate its protective association with OUD. Classic psychedelic compounds, including psilocybin, act primarily as serotonin  that may simultaneously confer lowered odds of adverse mental health outcomes such as OUDAdditionally, demographic differences associated with psilocybin use and OUD may contribute to our observed associations. Our post-hoc analyses revealed significant demographic differences between psilocybin users who have versus have not misused opioids on all of the demographic dimensions we assessed . Although we accounted for these demographic variables in our analyses, as previously stated, there are possibly additional demographic factors that we could not control for that mediate our findings. Future research should more closely investigate how demographic differences impact the associations between psilocybin use and lowered odds of OUD. These investigations may have the additional benefit of identifying protective factors associated with the alleviation of OUD. Lastly, if these inquires reveal demographic differences associated with the use of specific psychedelic compounds (i.e. differing populations that use psilocybin versus peyote), these inquiries may also clarify why psilocybin—and no other classic psychedelic substance—conferred lowered odds of OUD.This study replicates Pisano et al.’s finding linking classic psychedelics to lowered odds of opioid use disorder across a broad spectrum of diagnostic criteria, but specifies that this link only exists for psilocybin, and not for LSD or phenethylamine psychedelics . Future clinical trials will be required to test whether this association is causal, and to identify which mediators may underlie this association. Longitudinal studies should also assess whether there is a causal link between psilocybin and OUD. These studies can also provide essential foundational evidence for the link between psilocybin and OUD and maximize the likelihood of ethical and safe clinical trials that assess the treatment potential of this compound. In conclusion, our study represents an incremental step towards a greater understanding of factors that may prevent or alleviate opioid use disorder.


Hypovolemia is a physiological state of reduced blood volume that can exist as either (1) absolute hypovolemia because of a lower circulating blood (plasma) volume for a given vascular space  or (2) relative hypovolemia resulting from an expanded vascular space (vasodilation) for a given circulating blood volume . This paper examines the physiology of hypovolemia and its association with health and performance problems common to occupational, military and sports medicine. We discuss the maturation of individual-specific compensatory reserve or decompensation measures for future wearable sensor systems to effectively manage these hypovolemia problems. The paper then presents areas of future work to allow such technologies to translate from lab settings to use as decision aids for managing hypovolemia. We envision a future that incorporates elements of the compensatory reserve measure with advances in sensing technology and multiple modalities of cardiovascular sensing, additional contextual measures, and advanced noise reduction algorithms into a fully wearable system, creating a robust and physiologically sound approach to manage physical work, fatigue, safety and health issues associated with hypovolemia for workers, warfighters and athletes in austere conditions. Hypovolemia is a physiological state of reduced blood volume that impairs physical work capability , cognitiWe previously reported the significance of measuring the compensatory reserve as a tool for advanced decision support in the clinical setting of life-threatening hemorrhage . In thisHypovolemia may exist as either absolute hypovolemia because of a lower circulating blood (plasma) volume for a given vascular space  or relative hypovolemia resulting from an expanded vascular space  for a given circulating blood volume . It is important to recognize that hypovolemia represents a compromise to an individual’s capacity to compensate for conditions of low circulating blood volume or flow. In many situations, both absolute and relative hypovolemia occur simultaneously, thus synergistically augmenting the circulatory and metabolic problems for a given level of blood volume reduction or systemic vasodilation (expanded vascular space), which can adversely impact health and performance. A body water deficit >2% of body mass  is defined as dehydration and can occur from sweat loss in warm or hot conditions and/or diuresis from cold, hypoxia and aquatic environment exposure or from sickness that causes vomiting or diarrhea ,16. DehyHypovolemia is common with exposure to heat , cold 1, high-alConversely, blood (plasma) volume expansion is an important heat acclimation adaptation that helps minimize cardiovascular strain and enable better sustainment of physical work capabilities . Plasma During high-altitude exposure, there is a marked blood (plasma) volume reduction (absolute hypovolemia) that is proportionate to the elevation ascended and duration of residence . This plDuring cold stress there is a marked diuresis (isotonic dehydration) and blood (plasma) volume reduction which is not altered by acclimatization status ,36 For ePhysical work increases the metabolic demands within active skeletal muscle, which induces vasodilation and reduction in total peripheral resistance. The drop in total peripheral resistance is proportional to the metabolic rate. To meet the metabolic demands of active skeletal muscles, cardiac output increases with work intensity as a product of elevated heart rate and stroke volume . Thus, pCardiovascular adjustments imposed by absolute and/or relative hypovolemia have many commonalities, such as reduced cardiac filling, altered cardiac mechanics, arterial pressures and arterial pressure waveforms. s)warming, the total peripheral resistance (TPR), right atrial mean pressure (RAMP), aortic mean pressure (AoMP), central blood volume (CBV) and stroke volume (SV) decrease, while heart rate (HR) is elevated to sustain cardiac output (CO). During heat exposure, this relative hypovolemia often can be coincident with dehydration (absolute hypovolemia). The combination of both relative and absolute hypovolemia in conditions of hyperthermia will accentuate the reduced cardiac filling and subsequently reduce cardiac output. As the metabolic demand for physical work increases, a progressive cardiac output reduction (relative to control conditions) occurs due to greater vasodilation in working skeletal muscles [ muscles . The hyp muscles  as the l muscles . Althoug muscles . HoweverFor many occupational, military and athletic situations, an individual may suffer marked hypovolemia, which impairs health, safety and performance. As discussed, hypovolemia can occur from dehydration or decreased total circulating protein and/or increased vascular space from cutaneous and skeletal muscle vasodilation induced by environmental exposure or performing physical work. It is important to note that the physiological responses to these conditions are highly individual, with some people exhibiting much greater tolerance and capacity to compensate for the conditions than others ,48,49.Decision-support wearable technologies are needed that can measure the integrated physiological compensation or decompensation providing ‘individualized’ assessment of progression towards hypovolemia-mediated compromised capacity, or degree of physiological adaptation to several stressors that protect against hypovolemia to sustain performance ,13,14. AThe compensatory reserve measure (CRM), a novel concept introduced by Convertino and colleagues, provides a single indicator, measured peripherally with noninvasive sensors, that could represent the sum of compensatory responses to hypovolemia and a validated index of potential cardiovascular instability . The CRMThe compensatory reserve measure has been shown to be sensitive to hypovolemia induced by heat stress, physical exercise, dehydration, resting recovery and rehydration. 2max). CRM progressively decreased with increasing exercise intensity to an asymptote at ~20%. This response is logical as a greater oxygen uptake should translate to greater active vasodilation or relative hypovolemia. The asymptote at 20% suggests that blood pressure regulation was not the limiting factor for maximal intensity exercise.Several studies have demonstrated that CRM changes are sensitive to vasodilation and cardiovascular perturbations associated with physical exercise ,53. FiguIt is reasonable to anticipate that if this exercise was performed during heat stress conditions, CRM would have deceased further indicating muscle oxygen delivery as a more limiting factor.Although the CRM has been validated in its ability to track physiological changes in many different scenarios, it is potentially limited for use in humans in ambulatory or field settings in its current form, as it requires the use of either a noninvasive continuous blood pressure monitor  or a transmissive (T) PPG sensor . ContinuOne advantage of adding SCG signals to the CRM could be to decouple changes in the signals used for deriving CRM that are related to peripheral effects—e.g., vasodilation and altered vascular stiffness—from changes that are related to central effects—e.g., reduced preload. The substantial reduction in CRM for the hyperthermic individuals in Encouraged by the results from CRM, a collaboration led by Inan and colleagues recently developed the blood volume decompensation status (BVDS) metric ,58. The The BVDS metric has thus far been limited to a single preclinical animal (pig) study and is thus at an earlier stage of development. In this study, the animals underwent both relative and absolute hypovolemia through graded vasodilation and hemorrhage, as well as resuscitation with whole blood. ECG, SCG and RPPG were recorded continuously through the experiment. As shown in Although the BVDS metric has only been validated in a single study thus far, it has shown promise as a globalized metric for predicting decompensation status in both relative and absolute hypovolemia as well as for resuscitation with whole blood following hemorrhage. The overall prediction results from this study are shown in The wearable chest-worn patch  that proThe BVDS metric requires validation in additional studies. As the initial algorithm was developed in an animal model, new datasets should be curated from human subjects with realistic progression of perturbations that includes both relative and absolute hypovolemia. Realistic noise sources should also be included in this development in the form of data from both free-moving subjects and those being transported in multiple classes of vehicles. Advanced modeling techniques, such as the graph analysis described for the heart failure study, and other techniques ,such as transfer learning and time series analysis, should be explored.The previously constructed wearable sensing patch for ECG, SCG and environmental context sensing was designed for use in patients with heart failure—a frail population of older patients that would wear the device around the home and during normal activities of daily living. To enable usage of this patch for wearable sensing in the context of human performance—i.e., occupational, military, and sports applications—the hardware should be ruggedized, appropriately miniaturized, and validated with a broad range of environmental testing scenarios. For example, the hardware and adhesives must be designed to tolerate high moisture levels such as heavy sweating. The mechanical coupling integrity of the sensing system to the chest should be evaluated at high levels of vibration that could result from motion artifacts or other external vibration sources, as well as in the presence of fluids such as sweat or blood. To this end, some initial testing and validation work has been conducted at Georgia Tech with healthy human subjects performing various exercise tasks both indoors and outdoors, and with signals being measured in the presence of external vibrations ,66,67.When it comes to addressing motion artifacts, there are two main stages that should be considered. The first is developing customizable signal quality indices (SQI) to remove portions of the recording that contain too much noise. The second stage then takes the output from the SQI and processes the signal in the presence of remaining noise. ‘Motion artifacts’ include any noise sources related to the user—physical movement, speech, interference from clothing or gear, etc. The SCG and PPG have been criticized for their susceptibility to motion artifacts; however, recent studies demonstrate that PPG and SCG can be ruggedized for free-range use. Clifford and colleagues have developed quality indices for hospital-grade ECG and PPG signals and shared them through their open-source cardiovascular waveform toolbox on PhysioNet . An SQI The problem of reducing the impact of external vibration sources, such as vehicles, on SCG and PPG recordings has been less-thoroughly explored than the problem of reducing motion artifacts in general. One group recorded the SCG of a single subject for an entire day, including commuting to and from the office in a subway train . To procIn terms of predicting specific physiological outcomes, additional context can help limit the number of false positive and false negative indicators output by the system. For example, activity recognition could keep the system from alerting to a supposed acute injury when the subject has simply climbed a long flight of stairs. The system could also use environmental context such as ambient temperature to better forecast a user’s reserve levels when the current level of activity is sustained in that temperature.With the inclusion of an accelerometer into the BVDS design comes the potential to perform activity recognition and monitoring to provide context for compensatory reserve predictions. Exploration of accelerometer and IMU-based activity recognition has spanned systems with a single sensor ,85,86 asAn et al. recently published a method called AdaptNet, in which they leverage the triaxial accelerometer data from a chest patch for robust activity recognition. Using data from multiple domains, they accurately identified subjects standing at rest, walking on level ground, walking at a decline, and walking at an incline both with and without stairs . Using tWe discussed how the impact of physical activity on the compensatory reserve can be adjusted due to environmental variables. Beyond activity recognition, additional context surrounding the environment as well as some more information from the user could be beneficial in estimating their true compensatory reserve. The first of these metrics is temperature ,97. IdeaWe envision a future that incorporates elements of the CRM with advances in sensing technology, multiple modalities of cardiovascular sensing (as seen in the BVDS metric), additional contextual measures and advanced noise reduction algorithms into a fully wearable system, creating a robust and physiologically sound estimation of the free-living user’s compensatory reserve or decompensation status during physical work and environmental exposure. Such a system would enable quantification and management of previously discussed hypovolemia issues to optimize health and performance. This wearable system could consist of a chest-worn patch, though it could also be contained in a watch, or include additional sensors and hardware in occupation-specific gear. If the entire system is contained in a watch, it should be noted that all signal measurements would not be fully continuous—the user would take measurements intermittently throughout the day during rest periods while pressing the watch against their sternum , need to be addressed. Additionally, there are challenges with processing and storing data from multiple sensors and questions about how to power the device(s), along with decisions to be made about how to interact with the user and others appropriately to maintain patient privacy.It is important to mention that a multitude of machine learning models have been developed to predict undesirable patient states with regards to hemorrhage detection and general cardiovascular instability. For example, support vector machines have been used in noninvasive estimates of simulated and actual hemorrhage severity ,101, thoIn parallel with developing the physical system, advanced machine learning models leveraging approaches such as graph analysis, transfer learning and time series analysis will need to be developed that incorporate both the CRM and BVDS methods along with additional contextual measures. To be most effective, these models will need to be created from rich datasets that are curated from a diverse population performing multiple tasks in austere environments. The datasets must contain real physiological challenges, true to life sensor noise, and gold standard reference measures for the physiological challenges.Heat strain is a common problem for workers, warfighters and athletes due to a combination of performing vigorous physical work, exposure to environment heat, and/or wearing heavy clothing, uniforms or protective equipment . CurrentAs discussed, hypovolemia from dehydration or environmental exposure and/or physical work can adversely affect health and performance, thus motivating the need for continuous physiological monitoring. We argue that the estimation of cardiovascular strain should incorporate mechanical measures that can include PPG and SCG signals such that the effects of reduced preload on cardiac performance can be more directly assessed. Moreover, single vital sign or feature-based approaches are insufficient, and thus machine-learning techniques should fuse multiple waveform features to capture the complex nature of the physiological response to hypovolemia. For example, blood pressure itself may be often regulated until physical or heat exhaustion, while arterial and pulse pressure instabilities or altered cardiomechanics might result much earlier due to afferent signaling representing baroreceptor unloading and changes in tissue perfusion and cardiac filling and vascular resistance. By sensing these cardiovascular instabilities, one could then predict impending physical exhaustion beforehand, which is what Convertino and colleagues  demonstrLikewise, diarrhea and vomiting induced dehydration are serious military and civilian problems during both combat deployments and humanitarian missions as they are a major cause of mortality in developing nations. Though a robust wearable system for measurement of compensatory reserve or decompensation status would not directly measure hydration status , monitorPhysiological adaptation to physical work  and heat stress (heat acclimation) both require blood volume expansion and central hemodynamic changes to overcome the vasodilation challenges and maintain cardiovascular stability associated with improved work capabilities ,38,39. SThe manuscript provides several examples of occupational, military and sports medicine hypovolemia problems that could be managed with wearable technology and machine learning for optimizing health, safety and physical work capabilities. We have discussed the biological rationale for compensatory reserve and decompensation status and shown their sensitivity to numerous hypovolemia perturbations in human and animal models. We have highlighted recent technology advances that will enable this approach for wearable monitoring—decision aid systems for free-living workers in austere conditions. Finally, we have described the needed technology and algorithm advances to make effective individualized management of hypovolemia for a variety of common occupational, military and sports applications.


Smartphone overuse and addiction is a growing concern worldwide. However, there are limited studies about smartphone addiction and its impacts on university students in Saudi Arabia. This qualitative study aimed to elicit students’ and university staff’s perspectives and experiences about smartphone overuse/addiction in Umm Al-Qura University (UQU), Saudi Arabia. Fifteen undergraduate students and 18 university staff  were recruited for the purpose of this study. The study data were collected using semi-structured interviews and analysed using thematic analysis. The qualitative data comprising 33 participants (students and staff) identified four major themes including the perception of smartphone use; causes of smartphone overuse; negative impacts of smartphone overuse; and strategies to reduce the overuse of smartphone. The overall findings confirmed that students and staff alike held both positive and negative perceptions about using a smartphone. Potential factors leading to smartphone overuse included personal factors ; smartphone factors , and engaging smartphone Apps); and social factors . The main negative impacts of smartphone overuse were found to be related to low academic productivity, poor physical health , compromised mental well-being (stress and negative emotions), and decreased socialisation . Our findings suggested that awareness campaigns about smartphone overuse, promoting family and social events, encouraging physical activities, and limiting internet use can reduce smartphone usage among university students. This finding has significant implications for decision-makers. Smartphone use has been exponentially increasing among university students worldwide , a recenDue to the flexibility and mobility of smartphones, students can access the internet anywhere; this allows them to search for their study-related materials or obtain general information . SmartphMobile learning is arguably the next phase of e-learning . The levAs smartphones have become ubiquitous, their use has increased significantly in recent years, particularly among the young . Many yoAccording to Ching, et al. , smartphThe existing literature reported that smartphone overuse can lead to social isolation ,49 or reThis was a qualitative study conducted among undergraduate students and university staff at Umm Al-Qura University (UQU) in Makkah, Westering Province, Saudi Arabia, between June 2019 and February 2020. Both students and staff were included to provide a comprehensive picture of smartphone use and its consequence in a university setting. A purposive sampling technique was used to collect qualitative data from the eligible participants. Purposive sampling allows the researcher to identify and select participants who meet the inclusion criteria for the purpose of a study . PurposiAll eligible participants were provided with a Participant Information Sheet (PIS) and Participant Consent Form (PCF) outlining the study’s aims and processes, voluntary participation, withdrawal right, confidentiality, publication of the research results, and data storage details, and benefits of research. Informed consent was obtained from all respondents prior to participation in the study. Data collection and recruitment were conducted between June 2019 and February 2020.The university students were asked for their views on the role of smartphones in their daily life; their thoughts on overusing a smartphone and its contributing factors; the signs of smartphone overuse; and their ideas/experiences on how to prevent smartphone overuse. The university staff was asked for their perspectives on smartphone addiction among students; whether they perceive smartphone addiction to be a problem among students; observed effects of smartphone addiction on their student’s performance; potential factors that could lead to smartphone addiction among students; smartphone addiction prevention; challenges students may face if they try to reduce their smartphone usage; and whether the university provides assistance for smartphone overuse/addiction among students. n = 12), and not gainfully employed (n = 14), participated in the qualitative data collection. A total of 18 university staff  participated in the interviews, aged 26–52 years old, most of them held PhD degrees (n = 12), and their teaching or professional experience ranged from 2–33 years. Thirteen were lecturers and five were professionals responsible for student academic performance and well-being.A total number of 33 eligible participants were interviewed. A total of 15 university students , aged 20–30 years old, mostly of single status  to be essential.Another emphasised how important it was for him to check his smartphone upon waking every morning:I see it (smartphone) has become one of the most important things. I mean when anyone wakes up, they directly check their phone. It is the first and the most important thing for everyone now.However, university students defended smartphone use as beneficial for communication, education, and entertainment. They described how the smartphone is used in keeping in touch, exchanging cultures with others, or keeping them updated. For example, one student indicated that: There is no doubt that the smartphone has a prominent role in our daily lives by keeping us in touch with others, keeping us informed about the cultures around us, and informing us about the most important news.Other university students provided examples of how they used the smartphone for education purposes in terms of reading books and doing homework; saving considerable time and effort. As one student explained: It (smartphone) has a big role in providing us with information, also facilitating access to books, references, and sources. It is saving time, effort, and money.In addition, one student remarked that they use smartphones to entertain themselves after completing their daily tasks:Sometimes when I have free time after finishing home tasks and work appointments, I use my smartphone to entertain myself.University students defended smartphone use as beneficial for communication, education, and entertainment. They described how the smartphone is used in keeping in touch, exchanging cultures with others, or keeping them updated. For example, one student indicated that: There is no doubt that the smartphone has a prominent role in our daily lives by keeping us in touch with others, keeping us informed about the cultures around us, and informing us about the most important news.The perspectives of the university staff echoed those of the university students. University staff maintained that the smartphone is now an essential tool for university students and the younger generation due to the many advantages embedded in its use. They concurred that smartphones enhance communication, provide access to entertainment, and a platform for sharing ideas and opinions. One staff member summarised why students use smartphones: A smartphone contains entertainment, gaming, and social communication. They (students) can contact anyone without any limitations. Students can contact social media figures, sports players, politicians, actors, or famous people. They (students) may also express their opinions.The university staff generally focused on the advantages of smartphone use within the education system, and as a useful tool that enables students to extend their learning and knowledge. As one staff member pointed out: The positive side (of using smartphones) is that students can use this technology to obtain information and facilitate their learning.Another staff member considered smartphone technology beneficial if correctly used by university students:If smartphones are properly used, they do not pose a problem. Students can use smartphones to communicate, access news, and entertain themselves all in one device.The university staff generally focused on the advantages of smartphone use within the education system, and as a useful tool that enables students to extend their learning and knowledge. As one staff member pointed out: The positive side (of using smartphones) is that students can use this technology to obtain information and facilitate their learning.Another outlined how smartphones are now regularly used by younger students as a tool to take notes, record lectures, access information, and even complete homework assignments: I have noticed that students are using (their) phones for taking notes, and recording lectures. No one uses a pen and paper anymore to write. They (students) are using their phones to access textbooks, and even to do homework.A staff colleague agreed that: They (students) use it (smartphone) for browsing international electronic libraries.The university students reported a range of negative views of smartphones, with four claiming they can be used for “evil” behaviours such as insulting others or watching inappropriate movies or pictures. They also admitted to using their smartphone to an excessive degree. Several participants claimed some students engage in illegal or forbidden activities which contravene acceptable local customs, traditions, or religious orthodoxy. For example, one university student indicated that: Smartphones may be used for evil ways like watching what our God would not be pleased with (forbidden) and obscene things to others.Another university student heartily agreed:I see it (smartphone) as more evil than good, depending on how we use it. You see people on the phone 24 h a day. It steals your time, your effort, and your health. Because you are constantly on the phone, you are not free to do anything else!University students reported feeling so attached to their smartphones that it is difficult to be away from it. As one student asserted:I cannot live without my phone. I mean, I use it everywhere; indoors and outdoors.Moreover, university students acknowledged that such smartphone overuse is now normal and habitual. One university student said:When I wake up in the morning, I must check the phone. Checking my phone has become a habit for me now.Another student agreed it was second nature:I see that it (using smartphone) has become a habit. When I wake up, I check my phone for one or two hours. I see it has become a habit.University students also reported that smartphones are being overused in class, at social events, and even while driving. For instance, one of the students stated that: They (excessive smartphone users) use the Bluetooth headset and cover it by wearing the Shemagh  to watch movies in class.Another university student expressed the anger he felt whenever he saw students absorbed in their smartphones during lecture time: I see many of them (students overusing smartphones) busy during the lectures with their smartphones. Today in the lecture, I saw one of them chatting via smartphone, during the lecture… Also, I saw some of the students are playing PUBG (video game) in the class!Some university students noticed that students using smartphones excessively at social events, even when it is not socially or culturally acceptable. For example, one student said: It is unacceptable to play with the phone during social events throughout the time and not to engage in pleasant conversations during these meetings; especially with parents.Surprisingly, some of the students openly admitted they even used smartphones in potentially life-threatening circumstances. One of the university students explained that he and his friends used their smartphones while driving: We are overusing it (smartphone). For example, when I am heading to the university, I have a magnetic phone holder for the car that I installed to watch videos while I am driving. Not only me! I noticed more than four, five, six, of my friends are doing the same, and watching YouTube videos. This is a big problem…Similarly, university staff had observed the increased usage of smartphones among university students.Smartphone usage spread among the students in an intensive manner that might even become an addiction. Students spend most of their day using their smartphones.Indeed, university staff agreed that smartphone addiction requires urgent intervention. As one staff member elaborated: Smartphone addiction among students is a huge problem. It wastes their time. It needs urgent intervention.University staff also noticed certain behaviours that reflect the overuse of smartphones among university students. One staff member complained that: Some students hide their phones below the table during lectures and keep chatting on WhatsApp.Another university staff member explained: Students spend their time mostly browsing smartphone applications; sitting near a power source to charge their smartphones. Even inside the class, where the rules do not allow it, and the punishments do not stop them. So how can we not see that it is an addiction?Also, two of the university staff expressed concern that using smartphones frequently exposes university students to cyberbullying activities: I noticed cyberbullying is spreading among university students due to access to smartphones.Smartphone usage might expose them (university students) to cyberbullying, racism, and other negative behaviours.The data indicated that three sub-themes or groups of factors which arguably contribute to the increasing use of the smartphone: namely, personal factors; smartphone factors; and social factors. Availability of extended free time, low self-confidence, and irresponsibility/escaping certain social gatherings/passing the time, were identified as the main personal factors. The availability of competitively priced smartphones and attractive applications of smartphones were also mentioned in relation to increases in the overuse of smartphones amongst students. Finally, a range of social factors was linked with the overuse of smartphones among students, including peer pressure, and fear of losing connection. These factors are delineated below from both student and staff perspectives. see .The data indicated that extended free time, low self-confidence, lack of responsibility, and passing time during certain social gatherings, appeared to play a pivotal role in the overuse of smartphones. Most of the university students agreed that the availability of long periods of free time contributed to and encouraged the overuse of smartphones. In my opinion, free time is the biggest factor that contributes to our excessive use of smartphones.Low self-confidence was also cited as a significant factor in overusing smartphones:who do not have the confidence to talk with people are more likely to use their smartphones all the time.(Students) Furthermore, students maintained that a lack of responsibility contributes to the overuse of smartphones among students: If someone (student) is careless and irresponsible. You will see them, a free guy without anything (responsibilities). They use a smartphone to keep themselves busy.Students also recognised that smartphones were sometimes used to avoid certain social interactions. For instance, one student admitted that: If I meet people I do not like to communicate with, I prefer to use my smartphone.The findings from the university staff found they largely agreed with university students in respect of most personal factors which can lead to the overuse of smartphones, including extended periods of free time, low self-confidence, and lack of responsibility. However, several staff drew attention to another significant factor: the lack of student knowledge regarding the impacts of smartphone addiction. Prolonged free-time, where the person (university students) cannot find useful stuff to do… they use their smartphone.University staff also linked the availability of prolonged free time with limited student participation in the usual social or entertainment activities. One staff member stated that: There are multiple factors that lead to smartphone addiction, such as an abundance of free- time for students and having no place to hang out.University staff maintained that low self-confidence could force students to choose online rather than interpersonal communication, which, in turn, could lead to smartphone overuse: feel comfortable presenting their ideas (via smartphone-online) without direct contact or disagreement(Students) Moreover, university staff pointed out that the university students’ frequent struggles to identify their life goals may also contribute to the overuse of smartphones: The absence of clear goals to pursue and work hard encourages students to use smartphones.Staff also speculated that lack of information about the negative consequences of smartphone addiction or overuse could play a significant role in smartphone addiction among students: does not understand the hazards of using smartphones for a prolonged time.(University student) Lack of awareness of the impacts of smartphone addiction leads to the problem of excessive use of smartphones.The analysis confirmed several factors related to smartphones that can lead to overuse. These include the availability of affordable smartphone devices and interactive applications in the smartphones:Smartphones are cheap and easy to use.are (available) at reasonable prices that enable everyone to have them.(Smartphones) I see those games and applications: they are very attractive.University students also explained that the use of social media applications among Saudi university students could exacerbate smartphones overuse: Social media applications are the biggest reason makes us overuse our smartphones.Moreover, one student explained that smartphone games are particularly addictive for students: There are some games that make you so addicted. So that even if the internet is cut off, you must find a friend who connects you to the Internet.Similarly, university staff noted that the availability of smartphones and interactive applications results in the overuse of smartphones among students: Smartphones are easy to use; attractive and tempting, to the youth. (University students) are now tempted by many advertisements which attract them more and more to use their smartphones.When I spoke with students about the games on the smartphone, they told me that they use the games on a daily basis and for long hours.Students unanimously cited social pressure as one of the social factors responsible for the drastic increase in the usage of smartphones: When a new movie is released, all of my friends start watching it (via smartphone) except me. I started thinking, “no, let me watch it with them”, so as not to be alone and feel old-fashioned.Buying a new smartphone and using it everywhere has become fashionable.The results from university staff regarding social factors slightly diverged from that of students. While university staff largely agreed that social pressure is a huge factor in the overuse of smartphones, they added the additional factor of fear of losing a sense of connection: Mimicking others is one of the factors that lead to addiction. Students copy each other’s behaviour, and (there is) an urge to be admired through ‘likes’ and comments.Fear of being called outdated or traditional forces them (students) to use a smartphone.University staff agreed that students keep using smartphones in order to maintain a constant connection with their friends: Fear of losing online friends pushes students to use their smartphone.The data collected identified four major negative impacts of the overuse of smartphones on students: namely, academic engagement and performance (low academic performance/not paying attention); physical ; mental well-being ; and social (isolation and decreased face-to-face communication). see .Students indicated that the overuse of smartphones can cause low academic productivity or performance and distraction from attention during both lectures and private study: Student academic performance is affected by smartphone use during lectures. It (smartphone) disrupts students’ focus in lectures.In addition to the impact on academic performance, university students admitted that using a smartphone distracts them from their daily tasks or jobs.who are excessive (smartphone) users, may forget their prayers, works, their important task, and other duties in their lives.(Students) Data analysis indicated that university staff focused on the negative impacts of the overuse of smartphones on student productivity; particularly student academic performance. The majority of staff members were concerned that smartphones usage persistently diverts student attention from their studies: It contributes to the distraction of students’ attention…It (a smartphone) negatively affects the quality of students’ homework, as it consumes most of the students’ time and distracts their focus during homework.Students indicated that the overuse of smartphones exerts negative impacts on physical health resulting in body pains, lack of sleep, and inadequate exercise: There are some health concerns about the excessive use of smartphones including problems with vision, spasticity of the hand, and neck pain.I do not sleep well because notifications (from smartphone applications) keep waking me up.My lack of exercise is because all of my time is occupied by using my smartphone.University staff participant responses echoed those of students. The data indicated that overuse of smartphones negatively impacts student’s physical health in terms of body pain, lack of sleep, and inadequate exercise: Using it (smartphone) for a prolonged time will affect eyesight and lead to neck pain, and low exercise.Mostly it (smartphone) negatively impacts sleep and physical activity levels.Students maintained that the overuse of smartphones may be associated with a range of negative emotions including stress, nervousness, tension, and anger. Several observed elevated signs of stress and nervousness amongst students who overuse a smartphone: cause psychological problems such as nervousness.(Smartphones) Some smartphone games make us angry.University staff held similar views to the student participants and agreed that the overuse of smartphones can result in stress, anxiety, and mood swings: Students often feel anxious and stressed out if the phone (smartphone) is taken away from them or the internet servers are disconnected.Students indicated that the overuse of smartphones may negatively impact user’s social interaction, thereby fostering social isolation and reduced interpersonal communication: Smartphones affect students’ social life and isolate them from society.received many criticisms about being isolated and not interacting with others because of using our smartphones all the time.We Everyone around you is on their mobile: there is no conversation between them.The university staff’s responses resonated with those of students. Most of the university staff maintained that the overuse of smartphones may lead to social isolation: It (smartphone) also might lead to social problems causing isolation and not being integrated into society.It (smartphone) disconnects the student from real life and social connections.The participants suggested various strategies for reducing the overuse of smartphones among university students. Some of those proposed included the creation of awareness programs, extracurricular activities, changing students’ daily life routines, and limiting phone usage. These suggestions are discussed below : Students suggested that the university could provide awareness programs and seminars to reduce the use of the smartphone by: … creating awareness programs at the university level such as programs, seminars, or sending text messages about smartphone overuse and addiction can improve students’ knowledge, and eventually decrease smartphone overuse and addiction among them.University staff also maintained that awareness programs, as well as extracurricular activities, could be used to educate university students about smartphone overuse and addiction: When students finish their lectures, they sit in the corridors and do nothing… So the university could provide extracurricular activities like drawing, writing, sports programs… Such programs can reduce phone use and prevent smartphone overuse or addiction.The university can help through awareness campaigns about smartphone addiction.Providing field trips and entertainment journeys are great extracurricular activities to reduce smartphones among students.The majority of students suggested that changing student’s daily routine to reduce free time could decrease smartphone overuse or addiction. They further held that engagement in physical activity, reading, and social activities can limit undue exposure to smartphones: Two weeks after going to the gym, I started sleeping enough. I wake up in the morning and sleep at night, with less smartphone use. My phone usage was reduced to five hours a day from nine hours or ten hours per day.Socializing with people, like attending social events, can reduce phone usage.The majority of university staff agreed that changing daily life routines could prevent the overuse of smartphones among students: Encouraging students to participate in sports instead of spending their time on smartphones and social media can decrease smartphone overuse…Moreover, staff also suggested that social activities such as gatherings with family members or friends can help to reduce the overuse of smartphones among students:Participating in family and friends gatherings can help to decrease smartphone overuse.Students suggested that reducing smartphone application notifications, deleting some smartphone applications, and/or limiting internet connection could reduce smartphone overuse or addiction: Reducing smartphone applications’ notifications or deleting some applications or limiting smartphone use, or even disconnecting the internet can be used to reduce smartphone use.(Student N-9 written response)Installing some apps to count daily phone usage will help in controlling smartphone use…University staff suggested that the overuse of smartphones could be reduced by limiting the usage of smartphones or preventing smartphones from being used in class: Defining a particular daily time period for not using any smartphone can help…We could also limit internet access during lectures…Qualitative methods were applied in order to derive the broadest possible understanding of student experiences of using a smartphone and university staff perceptions of smartphone use among students. The overall findings confirmed that students and staff alike held both positive and negative perceptions about using a smartphone. Potential factors leading to smartphone overuse included personal factors, smartphone, and social factors. Finally, the participants suggested a range of strategies to reduce smartphone usage.communication (Staff N-18), education (Staff N-13), and entertainment (Staff N-18). This aligns with the literature which confirms university students hold predominantly positive attitudes towards smartphones and use them for education , communication, socialization, shopping, and internet searching  at reasonable prices that enable everyone to have them (Student N-15), attractive ads, and engaging Apps such as social media and gaming (I see those games and applications: they are very attractive (Student N-7), social media applications are the biggest reason makes us overuse our smartphones (Student N-1)) contributed to smartphone overuse. These findings are supported by literature indicating that social media and gaming Apps comprise the underlying factors of smartphone addiction among young users  ng users ,69,70,71using it everywhere has become fashionable (Student N-5), Fear of being called outdated (Staff N-1), and mimicking others (Staff N-6)) lead to smartphone overuse. However, staff participants cited the fear of losing online friends as a leading cause of overusing smartphones among students. These findings correspond with the findings of previous studies which concluded that social pressure  keep waking me up (Student N-1)), and physically inactive ). These findings are supported by a number of previous studies which demonstrated that overusing smartphones caused body pain [Participants highlighted the negative impacts of overusing smartphones on the physical health of students including body pains  is taken away from them or the internet servers are disconnected (Staff N-12)) and negative emotions (some smartphone games make us angry (Student N-9)) were also associated with smartphone overuse by the participants. Similarly, the findings from the literature review showed that stress, anxiety [Mental health  anxiety ,84,85, a anxiety ,87 were everyone around you is on the mobile: there is no conversation between them (Student N-4)) and social isolation (It (smartphone) also might lead to social problems causing isolation and not being integrated into society (Staff N-6)). The finding of other studies confirms the negative effects of overusing smartphones on social isolation [The participants also perceived that the overuse of smartphones leads to diminished face-to-face interaction , offering social activities providing field trips and entertainment journeys are great extracurricular activities to reduce smartphones among students (Staff N-2), promoting physical activity encouraging students to participate in sports instead of spending their time on smartphones and social media can decrease smartphone overuse (Staff N-1), and encouraging family and friend activities participating in family and friends gatherings can help to decrease smartphone overuse (Staff N-2). The participants suggested that universities could reduce smartphone overuse in students by developing awareness programs Installing some apps to count daily phone usage… (Student N-13) and limiting internet access during lectures (Staff N-18) were both recommended as effective in preventing smartphone use during lectures.Participants also suggested that reducing smartphone application notifications, deleting certain smartphone applications, and limiting internet connection could act to reduce smartphone overuse or addiction among students. Despite generating invaluable data regarding smartphone addiction and its main drivers, this study has some inevitable limitations. It was not possible for the male researcher to interview the female participants and record their interviews due to the social and cultural mores of the study setting. Thus, the written responses to open-end questions used with female participants may have constrained a more fulsome exploration of the perceptions of both student and staff female participants.Develop policies and guidelines limiting the usage of smartphones during lectures.Establish free and accessible sports facilities in all universities.Develop specific counselling and prevention programmes with regard to smartphone overuse and addiction in universities.Educate students about the proper use of social media.Students and staff held both positive and negative perceptions about using a smartphone. Personal factors (having free time and low self-confidence); smartphone factors , and engaging smartphone Apps); and social factors  appeared the main potential factors leading to smartphone overuse among the participants. The main negative impacts of a smartphone overuse were found to be related to low academic productivity, poor physical health , compromised mental well-being (stress and negative emotions), and decreased socialisation . The participants suggested that awareness campaigns about smartphone overuse, promoting family and social events, encouraging physical activities, and limiting internet use can reduce smartphone usage among university students. Findings for the qualitative data revealed how university students and staff perceive smartphone use in the Saudi Arabian context. Their real-world understanding of the leading factors of smartphone overuse and addiction among university students is of significant interest and value for both understanding smartphone addiction and devising specific real-world prevention interventions. The implications of the study are given below.


Recently several patients, who developed Guillain–Barré syndrome characterized by prominent bifacial weakness after ChAdOx1 nCoV-19 vaccination, were described from different centers. We recently observed a patient who developed a similar syndrome, later in the follow up he showed worsening of the neuropathy two months after the initial presentation. Repeat EMG showed reduced nerve sensory and motor conduction velocities of both upper and lower limbs, and a diagnosis of chronic inflammatory demyelinating polyneuropathy  was made according to established criteria. Our report expands on the possible outcomes in patients who develop Guillain–Barrè syndrome after COVID-19 vaccinations and suggest that close monitoring after the acute phase is needed in these patients to exclude a chronic evolution of the disease, which has important implications for long-term treatment. COVID-19 vaccinations have mostly been associated with adverse events of little clinical significance such as injection site reaction or non-specific systemic symptoms such as fever and muscle aches, which usually resolve within days [Vaccines are the most cost-effective measures available against the COVID-19 pandemic with more than seven billion doses administered worldwide in November 2021 . He developed mild sensory ataxia with wide based gait and postural instability. Repeated nerve conduction study showed marked slowing of sensory and motor conduction velocities of both upper and lower limbs, prolonged distal latency, conduction blocks and absent F response, leading to a diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) according to established criteria . He receLater he was treated with IVIg cycles every six weeks. At last clinical evaluation, six months after presentation, the clinical features were characterized by complete resolution of left facial palsy with persistence of slight weakness in the right upper facial area. Gait ataxia improved but did not resolve completely. Paresthesias on the lower limbs were disabling and thus treatment with pregabalin and alpha lipoic acid was started with benefit. Clinical features and examinations of the patient are summarized in Acute demyelinating polyneuropathy is a rare, but well recognized complication of COVID-19 vaccines. The disease variant with bifacial weakness has recently been recognized to be more common in patients with adenoviral-vectored  vs. mRNA-based  vaccines . In lineA difference of the previously described cases of bifacial palsy, in which the clinical course is reported favorable or stabilized or which have been described in the acute phase, in our patient is available the most prolonged follow-up, that is of 6 months. This pro-longed clinical observation led to diagnose a chronic form of demyelinating polyneuropathy, which was an unexpected clinical evolution. Therefore, our report expands on the possible outcomes in patients who develop Guillain–Barrè syndrome after COVID-19 vaccinations and suggest that close monitoring after the acute phase is needed in these patients to exclude a chronic evolution of the disease, which has important implications for long-term treatment.Our patient presented a clinical onset of GBS with bifacial weakness with paresthesias phenotype; 8 weeks later he presented a clinical deterioration, thus a diagnosis of CIDP was made, supported by neurophysiological findings. The distinction between GBS with fluctuations after start of treatment and CIDP is difficult but it has been recommended that diagnosis of CIDP should be considered when a patient thought to have GBS deteriorates again after 8 weeks from onset or when deterioration occurs 3 times or more .In GBS, acute motor neuropathy may involve facial nerves in various clinical presentations that include unilateral, bilateral facial palsy, bifacial palsy associated with involvement of other cranial nerves and bifacial palsy associated with limb paresthesia, moreover facial involvement is also possible in patients with classical forms of GBS. Interestingly it has been proposed that Bell’s palsy may share similar pathogenic mechanisms with autoimmune neuropathies .The specific clinical phenotype of bifacial weakness with paresthesias is quite uncommon and accounts for about less of 5% of the patients affected with GBS or Miller Fisher spectrum disorders , whereasGBS and CIDP are immune-mediated disorders in which the exact mechanism of the immune response linked to the pathogenesis is still not clear. In GBS, the pathogenic events are associated with the immune response usually to a previous infection, which subsequently leads to a cross-reaction with the production of antibodies directed to epitopes of the myelin sheath or to peripheral nerves and roots, thus causing an autoimmune process. Antecedent infections are reported in about two-thirds of patients with GBS , therefoNeuropathies after vaccination are rare event and CIDP developing in the postvaccination period is distinctly unusual, accounting for about 1.5% of patients , and pooThe optimal management and long-term outcomes of these patients remain to be determined. We treated our patient according to the available recommendation with IVIg administration at earliest convenience , howeverIn recent months, several case reports have shown that some variants of GBS can occur after the administration of the ChAdOx1 nCoV-19 vaccine, and in particular the bifacial weakness and paresthesia appears to be the prevalent form. This case report clearly shows the need for close monitoring of patients developing GBS after COVID-19 vaccination after the acute phase. We highlight that adequate long-term clinical follow-up is essential in these cases, as evolution to a chronic form is possible, despite adequate treatment. While an eventual causal relationship between different types of COVID-19 vaccines and autoimmune neuropathies remains to be determined, neurologists should be aware of this possibility as prompt diagnosis and treatment is crucial to improve outcomes in patients with GBS or CIDP and other potentially serious neurologic disorders.


Undertake a scoping review to determine the effectiveness of community-centred interventions designed to improve the mental health and well-being of adults from ethnic minority groups in the UK.We searched six electronic academic databases for studies published between January 1990 and September 2019: Medline, Embase, PsychINFO, Scopus, CINAHL and Cochrane. For intervention description and data extraction we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist and Template for Intervention Description and Replication guide. Quality was assessed using Cochrane risk of bias tools. Grey literature results were deemed beyond the scope of this review due to the large number of interventions and lack of available outcomes data.Of 4501 studies, 7 met the eligibility criteria of UK-based community interventions targeting mental health in adults from ethnic minority populations: four randomised controlled trials, one pre/post-pilot study, one cross-sectional study and one ethnographic study. Interventions included therapy-style sessions, peer-support groups, educational materials, gym access and a family services programme. Common components included a focus on tackling social isolation, using lay health workers from within the community, signposting and overcoming structural barriers to access. Four studies reported a statistically significant positive effect on mental health outcomes and six were appraised as having a high risk of bias. Study populations were ethnically heterogeneous and targeted people mainly from South Asia. No studies examined interventions targeting men.There is a paucity of high-quality evidence regarding community-centred interventions focused on improving public mental health among ethnic minority groups. Decision makers need scientific evidence to inform effective approaches to mitigating health disparities. Our next steps are to map promising community activities and interventions that are currently being provided to help identify emerging evidence. This scoping review addresses the large evidence gap which exists on the effectiveness of community-centred interventions in improving public mental health of UK ethnic minority populations, who are disproportionately affected by poor mental health.A six-stage scoping review framework, including stakeholder consultation, was applied to summarise the evidence for community-centred interventions.We included all community interventions irrespective of setting and type.Analyses of review data were limited to studies published in peer-reviewed journals and citation tracking of references.We used national definitions for ethnic minority categories but acknowledge challenges in viewing ethnic minority groups as homogeneous in their mental health needs.Poor mental well-being disproportionately affects people from ethnic minority populations in the United Kingdom (UK).14These risks affect mental health through numerous pathways, for example, stigma and the lack of racially, culturally and/or ethnically appropriate healthcare may cause delays in help-seeking, ultimately leading to poorer outcomes.17In the UK, the term Black, Asian and minority ethnic (BAME) is frequently used to refer to individuals who are in a racial or ethnic minority.22Strengthening public mental health involves both the promotion of mental health and well-being and the prevention of mental illness. It has the potential to effectively and sustainably reduce social and racial inequalities in mental health outcomes.26 27Community-centred interventions  have potential to influence the cultural and social factors that protect and promote mental health and well-being. These include social connectedness, access to safe and affordable housing, and power in local decision-making.We undertook a scoping review, an approach for summarising evidence and identifying knowledge gaps in unclear and emerging fields,35A systematic search of six electronic databases between January 1990 and September 2019 was conducted: Medline, Embase, PsycINFO, Scopus, CINAHL and Cochrane. The search strategy  was crea10.1136/bmjopen-2020-041102.supp1Supplementary dataWe excluded evidence from the grey literature as an initial search of primary data from local government, relevant third sector and NHS websites identified numerous activities and possible interventions . Information was provided in formats such as a flyer or a website or Facebook page describing services and activities, but with limited descriptions of the community intervention and outcomes data. Consequently, data synthesis exceeded the methodological approach of a scoping review; a mapping methodology would be more appropriate.36We included studies where participants were working-aged adults (aged 18–64 years adapted from the UK definition of 16–64 years) who were either well or had a common mental disorder, such as anxiety and depression. Common mental disorders were included to reflect the high prevalence of these conditions in the general population; one in six adults in England.Only community-centred interventions were eligible for inclusion. We defined community-centred broadly to include all interventions that were not clinical in nature, that is, did not involve the treatment of patients by health professionals such as cognitive–behavioural therapy and drug therapy. Therapy-style sessions that were delivered by lay health workers were included. There is a wide range of overlapping concepts in community-based and community-centred terms, and these were captured by our broad search strategy.The UK Office of National Statistics 2011 Census ethnicity terms were used .42 Ethni8Two independent reviewers  screened non-duplicate titles and abstracts against eligibility criteria (n=4501). The abstracts that matched criteria  were revData were extracted by two independent reviewers . A data extraction framework was developed to capture key study characteristics: author, year of publication, setting, study design, population demographics, sample size, theory of change, and outcomes and results. Intervention details were extracted using the Template for Intervention Description and Replication guide: rationale, materials, procedures, provider, methods, location, timing, tailoring, modifications and assessment of intervention adherence.44Quality appraisal was performed by two reviewers  using the Cochrane tool for risk of bias for randomised controlled trials (RCTs).48The research question was informed by people’s experiences and stakeholder workshops. This study did not involve the recruitment of patients, and no patients were involved in the design or conduct of the study.We identified a total of 4483 non-duplicate titles and an additional 18 from forward–backward citation searching . Seven oThe interventions were highly heterogeneous in design and focus. They included therapy-style sessions delivered by lay health workers,Interventions were either a single session (n=1) or took place over a minimum of 10 weeks to 8 months (n=6). The duration of the family services programme is unclear. Four studies aimed to improve mental health by expanding social networks and facilitating social support49–51 55Qualitative data commonly found a reduction in social isolation and stress, and improved mood and self-confidence.Mental health outcomes were predominantly measured using standardised screening instruments for common mental disorders and social functioning . Qualita49Following narrative synthesis, we identified three themes with the perspective of informing the delivery of public mental health interventions for ethnic minority communities: addressing social isolation and loneliness, promoting access and use of services, and being delivered by lay health workers.et alChaudhry The intervention was successful in improving mental health outcomes; a significant reduction in depressive symptoms was found at the end of the 10 sessions  and three women reported a reduction in suicidal ideas. These outcomes, and participants’ anecdotal feedback, suggest that a reduction in depressive symptoms is partly attributed to reducing social isolation by bringing the women together. Participants highly valued the provision of free transport by female Urdu speakers to avoid any objections from family and community members. Heterogeneity in the content and attendance of each session makes it difficult to assess the mechanism for improved outcomes. The small sample size and lack of control group further limit the generalisability of these findings.et al.Chaudhry’s pilot study formed the basis of the RCT conducted by Gater The intervention had no significant change in depression in all three arms. Social functioning significantly improved in both the social intervention and combined treatment groups at 3 months  but not at 9 months. Focus groups, held at the end of each session, found that the intervention was too short and that a major barrier to participating was resistance from family members. Participants found it helpful to confide in others and were intending to maintain new friendships. Overall, this study was appraised as low risk and provides evidence in favour of social group interventions for short-term improvements of positive mental health.GrayThirty case records of families were examined, and 22 interviews were conducted with support workers, families themselves, and professionals managing or referring to these services. Support workers were found to have had a positive impact on families by bringing them together; reducing social isolation, bullying and racism; promoting equality of access and pertinent use of services; and liaising successfully with other health and social care services. It was highly valued that projects were culturally sensitive and that support workers were of the same ethnicity. Power dynamics were important as facilitators’ decisions were of potentially significant consequence to the families. This makes the support workers not only essential to delivering the intervention but also integral to achieving a positive outcome for families.et alJacob There was no statistically significant difference between the intervention and control group on the explanatory model of depression at follow-up. The number of women who recovered from depression (defined as GHQ-12 ≤2) at 2 months was significantly associated with receiving the educational leaflet . However, women in the intervention group had significantly lower baseline levels of psychiatric morbidity at entry into the trial, potentially explaining the observed differences between the two groups.et alRabiee Only nine participants participated in three focus groups: two men (one White and one Black) and seven women . Participants valued building their social networks through the scheme and acknowledged the links between their physical and mental well-being. Although the authors suggest a financial barrier inhibiting people joining the gym, no formal data were collected on cost or participant finances. The generalisability of these findings is limited as participants were selected through opportunistic sampling and may over-represent younger adults who are motivated to use the gym.et alAfuwape Those who received the intervention showed significant improvement at 3 months in depressive symptoms  but not in general functioning . The effects beyond 3 months are unknown. There was no difference in costings between the intervention and control group; health and social care utilisation costs were calculated for 3 months. The risk of bias is increased by the small sample size and participants in the non-intervention arm having a significantly greater prevalence of psychiatric history. The generalisability to the wider ethnic minority population is potentially limited due to the exclusion of non-English-speaking participants and the use of screening tools that do not have clear evidence of validity in these populations.et alLovell This intervention had no statistically significant effect on mental health outcomes. The semistructured interviews established that acceptability was enhanced by involving family and the community, having a health professional’s recommendation, and having an empathetic facilitator. This study is limited by its small sample size and by having patients choose their intervention arm, albeit reflecting the realities of engagement and participation when delivering interventions.We found seven studies of community-centred interventions that aimed to improve mental health and well-being among ethnic minority groups in the UK. Although studies varied in design, four key interventional characteristics emerged.First, interventions aimed to address social isolation through building peer-to-peer support and social networks.Second, interventions aimed to overcome structural barriers in accessing care. Addressing practical considerations, such as translating educational materials into different languagesThird, interventions were delivered by lay health workers.65Fourth, interventions had an emphasis on signposting and or facilitating linkages to complementary or additional services.2Of the community interventions we identified, we found more targeted South Asian ethnic groups, which may reflect these groups making up a greater proportion of the UK population. There were no interventions designed for and targeting men, despite men being less likely to seek help for common mental health problems.67A limitation of this study was the omission of grey literature. Preliminary grey literature searching found over 50 community-centred services, which confirms that most relevant interventions reside outside publication in peer-reviewed journals and indicates significant publication bias. We were unable to include these interventions in this review due to a large number of individual activities/ interventions and the lack of available primary data. We consider a mapping methodology to be more appropriate to comprehensively summarise this evidence.68A further limitation is the generalisability of our results that include all ethnic minority populations in the UK; homogeneous recommendations cannot be made to a culturally and ethnically heterogeneous population. Furthermore, we excluded all white ethnic minority groups apart from Irish Travellers and Gypsies. However, the UK has a white ethnic minority European population, such as people from Poland, who may be subject to similar systemic health inequalities and challenges to their mental health and well-being as other ethnic minority groups.2Interventions specifically targeting refugees, asylum seekers and new migrants were also excluded. In the UK, refugees make up approximately 0.2%We recognise that the evidence for ethnic differences in some common mental disorders is complex, variable and indeed equivocal for specific ethnic groups. However, there is a disconnect between the scale of community-centred intervention provisions and published evidence. This may imply a bias in terms of scientific priorities and funding that needs urgent rectification, as current evidence is limited and weak.how successful interventions work to improve mental health and for whom, taking into account intersectionality such as between gender and ethnicity. This requires resources to be appropriately allocated to third sector organisations, which typically provide these interventions, as they are often bound to deliver short-term projects and lack resources for robust evaluations. Evaluations should also include economic analysis; community interventions are potentially an affordable means to improving public mental health.73It is important that future research seeks to understand These findings also suggest the need for more activity on preventing mental illness and promoting well-being; most of the studies focused on people with existing common mental conditions. Health promotion and primary prevention alongside universal approaches are critical components of strong public mental health and sustainable health systems.Lastly, labels such as ‘Asian’ or ‘Black African’ present challenges to mental health research by viewing ethnic minority groups as homogeneous in their mental health needs, despite evidence indicating otherwise.Despite well-documented ethnic disparities in mental health, there is a paucity of high-quality evidence regarding community-centred interventions that focus on improving public mental health among ethnic minority groups. Decision makers need scientific evidence to help commission appropriate services and to inform effective approaches to mitigating these health disparities. Our next steps are to map the promising community activities and interventions that are currently being provided to help identify emerging evidence.