Pain assessment and management are important in postoperative circumstances as overdosing of opioids can induce respiratory depression and critical consequences. We aimed this study to check the reliability of commonly used pain scales in a postoperative setting among Korean adults. We also intended to determine cut-off points of pain scores between mild and moderate pain and between moderate and severe pain by which can help to decide to use pain medication.A total of 180 adult patients undergoing elective non-cardiac surgery were included. Postoperative pain intensity was rated with a visual analog scale (VAS), numeric rating scale (NRS), faces pain scale revised (FPS-R), and verbal rating scale (VRS). The VRS rated pain according to four grades: none, mild, moderate, and severe. Pain assessments were performed twice: when the patients were alert enough to communicate after arrival at the postoperative care unit (PACU) and 30 min after arrival at the PACU. The levels of agreement among the scores were evaluated using intraclass correlation coefficients (ICCs). The cut-off points were determined by receiver operating characteristic curves.The ICCs among the VAS, NRS, and FPS-R were consistently high (0.839–0.945). The pain categories were as follow: mild ≦ 5.3 / moderate 5.4 ~ 7.1 /severe ≧ 7.2 in VAS, mild ≦ 5 / moderate 6 ~ 7 / severe ≧ 8 in NRS, mild ≦ 4 / moderate 6 / severe 8 and 10 in FPS-R. The cut-off points for analgesics request were VAS ≧ 5.5, NRS ≧ 6, FPS-R ≧ 6, and VRS ≧ 2 (moderate or severe pain).During the immediate postoperative period, VAS, NRS, and FPS-R were well correlated. The boundary between mild and moderate pain was around five on 10-point scales, and it corresponded to the cut-off point of analgesic request. Healthcare providers should consider VRS and other patient-specific signs to avoid undertreatment of pain or overdosing of pain medication. Up to 80% of patients experience acute postoperative pain, and the severity is greater than moderate in 75% of these patients . PostopePain assessment is necessary for the proper management of pain. There are several tools to assess the strength of pain validated intrapatient and inter-rater reliability. Visual analog scale (VAS), numeric rating scale (NRS), faces pain scale-revised (FPS-R), and face, legs, activity, cry, and consolability scale (FLACC) are scales that are commonly used in hospitals. The choice of tool is based on whether the patient can report his or her pain and varies according to developmental status, cognitive status, level of consciousness, education level, and cultural and language differences .A specific value usually expresses these scales, and it cannot describe the tolerability of the pain to the individual patient. For example, when a patient responds to his or her pain as VAS 5.0 or NRS 5, we do not know if the patient perceives the pain as mild, moderate, or severe. There have been several studies that worked on categorizing the pain score or determining cut-off points focused on chronic pain such as cancer pain or musculoskeletal pain –11. HoweThis prospective study was approved by the institutional review board of Ewha Womans University Medical Center, Seoul, Korea (EUMC 2016–01–019-001). We enrolled a total of 180 patients, each of whom provided written informed consent between April and October in 2018. Adult patients who were older than 19 years and were undergoing elective non-cardiac surgery were included. We excluded patients who had difficulty communicating, vision or hearing problems, those unable to move their arms after surgery, patients with previous histories of chronic pain and intake of pain medication, and those with cognitive disorders.We collected four pain scores: VAS, NRS, FPS-R, and a verbal rating scale (VRS). For VAS, we offered a 10 cm line with a movable pointer so the patient could move the pointer to indicate his or her perceived pain severity on the line from no pain (0 cm) to the worst pain (10 cm). For NRS, the patients were asked to choose a fixed number, which represented their pain from 0 (no pain) to 10 (the worst pain). For FPS-R, we offered a sheet of paper on which there were six figures of faces of gradually changing facial expressions from a comforting face with no pain to a crying face indicating the worst pain. The patients were asked to choose one of the face figures that represented their pain best, and we recorded a corresponding score to the face: six even numbers from 0 for the comforting face to 10 for the crying face. For the VRS, we asked the patients to express their pain in the words of intensity: none, mild, moderate, severe . The data were collected in the following order: VAS, NRS, FPS-R, and VRS.Before arriving at an operating room, we educated the patients about how we would assess the four kinds of pain scores. An assigned anesthesiologist performed anesthesia, and the pain score assessments were performed by one investigator (M Lee) in the PACU. The pain score assessments were performed twice. The first pain assessment was when the patients opened their eyes spontaneously or responded well to physicians’ verbal commands to say their name after arriving at the PACU. The second pain assessment was performed 30 min after arriving at the PACU. During the stay at the PACU, analgesics were given on the patient’s request rather than the certain pain score, and every analgesia was given under the anesthesiologist’s confirmation to prevent respiratory depression or re-sedation. The choice of analgesic was the discretion of the assigned anesthesiologist, and the options were fentanyl 0.5 μg/kg or ketorolac tromethamine 30 mg.We hypothesized all the agreement levels between the three pain scores  from the intraclass correlation coefficients (ICC) would be higher than 0.7. At the value of α = 0.05 and the power = 0.8, the sample size was calculated as 169 using the ICC Sample Size package for R. Considering potential attrition, we determined the target sample size to be 180.Agreement levels between the VAS and NRS, VAS and FPS-R, and NRS and FPS-R were analyzed by ICC applying a two-way random effects model using a consistency definition. Clinical significance of the ICC was as follows: less than 0.40 indicated poor agreement, between 0.40 and 0.59 was fair, between 0.60 and 0.74 was good, and more than 0.75 was considered excellent .To determine the cut-off points of the scores, receiver operating characteristic (ROC) curve analyses were used. The ROC curve is a widely used method when figuring out a diagnostic test’s accuracy and a cut-off point of the test for a disease. This analysis draws a plot of sensitivity (true positive rate) by 1-specificity  at every test value by dichotomizing patients into having the disease or not. Then we can determine the test value where the sensitivity and specificity are highest as the cut-off point, which means that that value can classify whether the patient has disease best , 14.d) to the top-left corner from points on the ROC curve were calculated, and the point with the lowest distance was chosen for the cut-off point [Three ROC curves for each of the VAS, NRS, and FPS-R by VRS were drawn: for the borders of between none (VRS = 0) and mild pain (VRS = 1), between mild pain (VRS = 1) and moderate pain (VRS = 2), and between moderate pain (VRS = 2) and severe pain (VRS = 3). The distance to the corner determined the cut-off points. The distances .The result was considered significant when the A total of one hundred and eighty patients completed the two sets of pain scores. One hundred and eighty-five patients were assessed for eligibility, and five patients declined to participate. There was no dropout of patients or missing data during the collecting of data. Demographic data and surgery-related data are shown in Table The distribution of the pain scores is presented in Table The levels of agreement among the VAS, NRS, and FPS-R are shown in Table p-values were less than 0.001.The ROC curves to determine the cut-off points were drawn, and the cut-off points between none and mild pain, mild and moderate pain, and moderate and severe pain were determined Fig. . and thep-values were less than 0.001  minimums from anywhere from a few days to a maximum of a few years after the surgery , 23. SecROC analysis is an effective and one of the most commonly used methods to analyze the effectiveness of a diagnostic test and to find the optimal cut-off point , 14. We Racial and ethnic differences in pain or treatment have been consistently reported –32. SeveWe observed a wide range of pain scores within one pain intensity. For example, mild pain ratings ranged from 0 to 8 on the NRS and 0 to 7.8 on the VAS. It shows that pain assessments could be superficial and incomplete when they are performed using only pain scores. Healthcare providers are prone to write pain scores less than 3 or 4 as mild pain. However, some patients may perceive their pain to be moderately intense, and these patients may need a pain-reducing drug. Vice versa, even when pain scores are as high as 7 or 8, some patients might think their pain is mild and tolerable. Therefore, doctors or nurses should approach pain in multiple ways to determine whether their patients’ pain is tolerable or needs intervention. Considering we found that the cut-off point between mild and moderate pain was around 5.5, we have to be cautious when we give opioids to the patients with NRS ratings of 4 or 5. The immediate postoperative period is unique due to the residual effects of anesthesia drugs. Providers should be attentive following drug administration. Therefore, from the fact that the AUC of the ROC curve for the analgesic request was the biggest in VRS (0.723), pain assessment using VRS would be useful before an administration of analgesics.This study has several limitations. First, we did not study the patients’ preferences. Second, we included a heterogeneous group of patients undergoing various surgeries. Prediction of postoperative pain intensity is affected by various factors such as age, surgery type, preexisting pain, and anxiety –35. HoweDuring the immediate postoperative period, any pain scale among the VAS, NRS, or FPS-R can be used. We recommend combining these scales with the VRS and other patient-specific signs to avoid under- or overdosing of pain medication, particularly for opioids. We suggest a simple, applicable category of pain in the immediate postoperative situation: an NRS score of 5 or lower is mild pain, an NRS score of 6 to 7 is moderate pain, and an NRS score of 8 to 10 indicates severe pain.


A healthy diet should nourish the brain with essential nutrients, including bioactive compounds, for normal brain functioning and to protect it from the negative effects of inflammation and oxidative stress. In this review, a concise summation of the protective effects of selected fruits, namely, berries, grapes, and citrus fruits, against neurological disorder is presented. The focus is on the neuroprotective potential of these fruits against neurodegenerative and mental disorders. The fruits selection was based on the vast reported pharmacological studies on their neuroprotection efficacies. Hence, the respective knowledge and limitations are discussed based on the biological and pharmacological evidence compiled from the previously reported laboratory, epidemiology, and intervention trials. Cognition is a cluster of brain functions which involves memory, speech, language, reasoning, judgement, planning, learning, compassion, and other thinking abilities. A decline in cognitive abilities is a common aspect of the normal aging process. However, in some instances, severe cognitive impairment occurs as a result of neurological disorders, including various forms of dementia . The gloThe second most prevalent neurodegenerative disorder is Parkinson's disease (PD). Meta-analysis of worldwide data revealed a rising incidence of PD, with more cases observed in North America, Europe, and Australia, compared with Asian countries . HoweverIn addition to neurodegenerative diseases, mental illness also contributed significantly to the 37.6% global growth in the healthcare burden of brain disorders from 1990 to 2010 , adults Although depression is less common among the community-dwelling elderly in Malaysia (7.6%), a critical rate of depression cases has been reported among adults in elder care centres (67%), which is about twice as high as the figure reported for the United Kingdom , 13. In β, interferon beta-1α, and glatiramer acetate are widely used to reduce the exacerbation of multiple sclerosis (MS) chromen-2-one (auraptene) is a coumarin derivative, which has been reported to possess various pharmacological properties including neuroprotective effects  on the mIn addition to the impact on the quality of life for the sufferers, families, and caregivers, mental health disorders, as a health category, are one of the heaviest burdens on the world's economy. In 2010, the total European cost of mental healthcare was estimated as €798 billion , and a tCitrus spp., grapes, nuts, and berries, in neuronal and brain disorders (However, current studies are insufficient to provide more definitive information which relates to optimal servings of these foods or to recommended doses of active phytoconstituents for neuroprotective actions in humans or to interactions with other foods which may act synergistically or antagonistically with prophylactic metabolites. Animal and in vitro studies have shed light on the possible metabolism-based therapies for the mental illnesses, as well as aging, ischemia, trauma, and mitochondrial cytopathies. However, the clinical investigation on the consumption of the selected fruits, which are efficacious as neuroprotective agents, is important. Evidence from larger clinical cohorts and longer trial periods under well-defined controlled conditions is necessary for a more precise estimation of the neuroprotective effects of functional foods, including isorders . In addiDue to the complexity between the nutritional effects of the foods and human health, the present study recommends that the consumption of fruits and nuts based on the guidelines of US Food and Drug Administration  on a dai


Clostridium butyricum (C. butyricum) immunity and intestinal epithelial barrier function at the intestinal mucosal level, by using Salmonella enteritidis (S. enteritidis) to infect specific-pathogen-free (SPF) chickens and intestinal epithelial cells (IEC). We found that C. butyricum could decrease cytokine levels  via the TLR4-, MyD88-, and NF-κB-dependent pathways in intestinal tissues and intestinal epithelial cells. Additionally, C. butyricum could attenuate bacteria-induced intestinal damage and increase the expression level of muc-2 and ZO-1 in the intestine and intestinal epithelial cells. Furthermore, C. butyricum altered the intestinal microbial composition, increased the diversity of the bacterial communities in the cecum of Salmonella-infected chickens. In conclusion, C. butyricum effectively attenuated inflammation and epithelial barrier damage, altered the intestinal microbial composition, increased the diversity of the bacterial communities in the intestine of Salmonella-infected chickens. The result suggests that C. butyricum might be an effective and safe therapy for the treatment of Salmonella infection.This study was aimed to investigate the effects of  Salmonella is a common bacterial entero-pathogen and one of the leading causes of serious illness in humans and animals, such as enteritis and diarrhea  and toxins. Impaired epithelial barrier function may predispose to various intestinal disorders, such as inflammation  chicken model with an emphasis on the response at the intestinal mucosal level.In this study, we aimed to explore the mechanism by which All procedures were approved by the Animal Care and Use Committee of Shandong Agricultural University (SDAUA-2016-016), and all husbandry practices and euthanasia were performed with full consideration of animal welfare.Clostridium butyricum (AQQF01000149) was obtained from Dalian Sanyi Animal Medicine Company (China). The strain was cultured anaerobically with Reinforced Clostridial Medium (RCM) broth at 37°C for 48 h. According to the plate count method as described by 6 colony forming units (CFU)/mL.S. enteritidis was obtained from the Avian Disease Centre of Shandong Agricultural University, and it was selected for the challenge study due to the invasive characteristic previously described , followed by dilution with PBS to a final cell count of 106 colony forming units (CFU)/mL according to the LD50.A virulent atrichia strain of escribed . The S. Salmonella by taking cloacal swabs. Thereafter, a total of 60 health chickens were randomly assigned to three groups (n = 20/group): (S. enteritidis (106 CFU/mL) on day 8 ; and (C. butyricum (106 CFU/mL) once every day from day 1 through day 14 and challenged with 0.2 mL S. enteritidis (106 CFU/mL) on day 8 [C. butyricum + S. enteritidis treatment (EXP)]. At the age of 14 days (6 dpi), all birds were euthanized via cervical dislocation. The tissues of duodenum, jejunum, ileum, and cecum were collected and stored in liquid nitrogen for mRNA and histological analysis. The cecal contents were collected and stored at −80°C for microbial composition analysis.Specific-pathogen-free chickens were obtained from Jinan SPAFAS Poultry Company . SPF chickens refer to animals that do not have specific microorganisms or parasites, but may carry non-specific microorganisms and parasites, also known as third-class animals . Chicken/group):  orally a/group):  orally aC)]; and  orally aOne inch of the cecum of chickens was removed, fixed in 4% paraformaldehyde and prepared for histological studies as described by n = 6/group) were sequenced on an Illumina MiSeq platform provided by Personalbio . Paired-end reads from the original DNA fragments were merged using FLASH. Clustering was performed using the UPARSE pipeline, and sequences were assigned to operational taxonomic units at 97% similarity  according to the manufacturer’s instructions. The V4 hypervariable region of the 16S rRNA gene was amplified by PCR using 515F and 806R primers. Eighteen samples , followed by cDNA synthesis via the Transcriptor First-Strand cDNA Synthesis Kit  using 2 μg RNA template. Real-time PCR was performed using SYBR Green I Master mix (Roche). Two microliters of cDNA, 5 μl SYBR Green buffer 2 × (Roche) and 2.5 pmol of each primer were combined for a total reaction volume of 10 μl. The thermocycler protocol consisted of a 5 min pre-incubation at 95°C for 20 s, 60°C for 30 s and 72°C for 20 s, and melt curves were added. The β-actin reference gene was chosen for the relative expression of targeted genes. mRNA relative expression was calculated using the 2–△△Ct method. The primers used in this study are listed in Total RNA was extracted from duodenal, jejunal, ileal, and cecal tissues using Trizol reagent  according to the manufacturer’s instructions. Briefly, 50–100 mg tissue samples were ground to powder with liquid nitrogen and transferred to a tube with 1 ml of Trizol; after centrifuged at 4°C, 0.2 ml chloroform was added to the supernatant; after centrifuged at 4°C, the supernatant containing the intact RNA was transferred to a new tube, RNA was then precipitated with equal volume of isopropyl alcohol, and washed with 80% ethanol. The RNA was solubilized in RNase free water. RNA quantity and quality were evaluated using a NanoDropg for 3 min. To separate mucus and IECs, a centrifugation step of 10 min was performed at 400 × g. Mucus covering the cell pellet was discarded. The remaining cell pellet was subsequently washed several times until the suspension was clear, and finally, 1 × 107 cells were cultured in six-well plates and incubated at 37°C with 5% CO2. After incubation for 48 h, IECs were treated under three different conditions as follows: (NC) DMEM alone; (PC) S. enteritidis (106 CFU) infection only; and (EXP) pre-incubation with C. butyricum (106 CFU) for 2 h prior to exposure to S. enteritidis. At 2 and 6 h after S. enteritidis challenge, a portion of the cells were then collected and treated with lysis buffer to extract total RNA for real-time PCR.Specific-pathogen-free eggs were purchased from Jinan SPAFAS Poultry Company (China). Chicken intestinal epithelial cells (IECs) were prepared from 19-day-old SPF chicken embryos as described previously  with somP < 0.05 was considered significant.Statistical evaluations were performed using a one-way ANOVA followed by a Duncan multiple range test or a Fisher least significant difference test using SPSS 16.0 . Data were visualized using GraphPad Prism 5 software . S. enteritidis in the PC group showed surface damage and disruption to villi. Cecal tissue of chickens pre-treated with C. butyricum in the EXP group showed less severe surface damage to villi than did cecal tissue of chickens in the PC group. These observations demonstrate that pretreatment of C. butyricum resulted in a reduction of bacteria-induced intestinal damage  (P < 0.05), but there was no significant difference between the NC and EXP groups (P > 0.05); in the jejunum, the gene expression level of IL-1β was significantly elevated in the PC group compared to the EXP group (P < 0.05), but there was no significant difference between the NC and EXP groups and the same change between NC and PC groups (P > 0.05); in the ileum, no significant difference of IL-1β was found among NC, PC, and EXP groups (P > 0.05); in the cecum, the gene expression level of IL-1β was significantly elevated in the PC group compared to the NC group (P < 0.05), but no significant difference was found between the NC and EXP groups and the same change between PC and EXP groups (P > 0.05) (P < 0.05), but no significant difference was found between the NC and EXP groups (P > 0.05); of note, no significant difference of IL-8 in duodenum, ileum, and cecum was found among NC, PC and EXP groups (P > 0.05) , but there was no significant difference between the NC and EXP groups (P > 0.05) (P < 0.05), but there was no significant difference between the PC and EXP groups (P > 0.05). Regarding the expression levels of IL-1β and TNF-α, no significant difference was found among the NC, PC, and EXP groups (P > 0.05) (P < 0.05), but there was no significant difference between the NC and EXP groups (P > 0.05) (P < 0.05), but there was no significant difference between the NC and EXP groups, and the same change between PC and EXP groups (P > 0.05)  were also evaluated. The results showed that at 6 days post-infection, no significant differences were found in IFN-γ and TNF-α among NC, PC, and EXP groups in intestinal tissue  ( > 0.05) . The gen > 0.05) . The gen > 0.05) . Further > 0.05) . The exp > 0.05) . After 6 > 0.05) . The gen > 0.05) .P < 0.05), but there was no significant difference between the NC and EXP groups, and the same change between PC and NC groups (P > 0.05). Of note, C. butyricum effectively attenuated the S. enteritidis-induced changes to muc2 expression in the jejunum. There were no significant differences in muc2 expression in the duodenum, ileum, or cecum among any of the groups (P > 0.05)   . Further > 0.05) .C. butyricum on epithelial barrier function in the chicken intestines by detecting the expression level of Zonula occludens-1 (ZO-1) and Occludin via real-time PCR. The results showed that at 6 days post-infection, the expression level of ZO-1 in duodenum and jejunum was significantly decreased in the PC group compared with the EXP group (P < 0.05), but there was no significant difference between the NC and EXP groups, and the same change between PC and NC groups (P > 0.05). There were no significant differences in ZO-1 expression in either the ileum or cecum among any of the groups (P > 0.05) (P > 0.05) (C. butyricum on tight junction (TJ) expression in IECs in vitro. The data show that after 2 h post-infection, the expression levels of ZO-1 and Occludin were not significantly different among NC, PC and EXP groups (P > 0.05) (P < 0.05), and there was no significant difference between the NC and EXP groups (P > 0.05) (P > 0.05)  . Similar > 0.05) . We also > 0.05) ; but aft > 0.05) . The exp > 0.05) .P < 0.05), but there was no significant difference between the NC and EXP groups and the same change between PC and NC groups regarding the gene expressions of MyD88 (P > 0.05), which indicates a direct effect of C. butyricum. There were no significant differences in TLR4 and MyD88 expression in the duodenum, ileum, or cecum among any of the groups (P > 0.05). The expression level of NF-κB in duodenum was significantly elevated in the PC group compared with the EXP and NC groups (P < 0.05), but there was no significant difference between the NC and EXP groups (P > 0.05)  , but there was no significant difference between the NC and EXP groups and the same change between PC and NC groups (P > 0.05)  . We furt > 0.05) ; but aft > 0.05) .C. butyricum on the microbiota in chicken cecum using Illumina sequencing of the 16S rRNA V4 region. Firmicutes, Tenericutes, and proteobacteria were the three most abundant bacterial phyla in all samples, and C. butyricum increased the proportion of Tenericutes in the EXP chickens compared to the NC and PC groups  production in intestines and the expression level of the pro-inflammatory cytokine  in intestinal epithelial cells of chickens after Salmonella infection. The protective action of C. butyricum was similar to that of other probiotics  of intestinal, inhibit pathogenic bacteria, and thus adjust the bacterial community structure. Our study aligns with another study that showed a diet supplemented with Enterococcus faecalis could shift microbial diversity in the porcine gut and inhibit pathogens (Dietary supplementation of chickens . In thisathogens .Clostridium butyricum effectively attenuated inflammation and epithelial barrier damage, altered the intestinal microbial composition by increasing the diversity of the bacterial community, and promoted immune function in the intestines of Salmonella-infected chicken. C. butyricum might be an effective and safe therapy for Salmonella infection.Salmonella and Clostridium butyricum counts during the course of the experiments to further verify that the organism of the bacteria colonized the gut.In future work, we will supplement the detection of The datasets generated for this study are available on request to the corresponding author.The animal study was reviewed and approved by The Animal Care and Use Committee of Shandong Agricultural University.HL, SS, and XZ conceived and designed the study. XZ, JY, ZJ, JW, and LW performed the experiments and analyzed the data. HL, SS, and XZ wrote and revised the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Co-infections have a key role in virus transmission in wild reservoir hosts. We investigated the simultaneous presence of astroviruses, coronaviruses, and paramyxoviruses in bats from Madagascar, Mayotte, Mozambique, and Reunion Island. A total of 871 samples from 28 bat species representing 8 families were tested by polymerase chain reactions (PCRs) targeting the RNA-dependent RNA-polymerase genes. Overall, 2.4% of bats tested positive for the presence of at least two viruses, only on Madagascar and in Mozambique. Significant variation in the proportion of co-infections was detected among bat species, and some combinations of co-infection were more common than others. Our findings support that co-infections of the three targeted viruses occur in bats in the western Indian Ocean region, although further studies are needed to assess their epidemiological consequences.The online version contains supplementary material available at 10.1186/s12985-021-01673-2. Co-infection (sometimes written as coinfection) can be defined as the simultaneous infection by at least two genetically different infectious agents in the same host –5. It caIn previous studies, we have investigated the presence of either AstVs, CoVs or PMVs in bats in the western Indian Ocean (WIO) region –23. HereBiological material was collected on Madagascar, in Mozambique, on Mayotte, and on Reunion Island as part of previous investigations on infectious agents circulation in bats . The liphangorn package in R, version 2.6.3 [PCR products of expected size were submitted for direct Sanger sequencing . Nucleotide sequences were aligned to generate consensus sequences, and were edited manually using ChromasLite 2.6.5 . The 33 partial AstV sequences and 13 partial PMV sequences generated in this study were deposited in GenBank respectively under the accession numbers MZ614404 to MZ614436 and MZ614437 to MZ614449. Genetic diversity was explored with pairwise distance values obtained from on 2.6.3 . Sequencon 2.6.3 , 29. Theon 2.6.3 , with a 2 = 0.3, df = 1, P > 0.5). Significant differences in AstV detection were observed between roost types , between species  and between males (20.9% ± 3.8%) and females (11.6% ± 3.0%) . AstV prevalence was significantly higher in bats species roosting in caves (27.5% ± 3.9%) than in buildings (2.5% ± 2.0%). On Madagascar, a high detection rate was found in species of the genus Miniopterus as compared to the other taxa , and especially in Miniopterus manavi (88.9% ± 14.5%), Miniopterus gleni (86.7% ± 17.2%), and Miniopterus sororculus (71.4% ± 33.5%). The highest AstV detection rate in Mozambique was observed in Triaenops afer (68.6% ± 12.7%).One hundred and forty-two samples tested positive for AstV  . Significant differences were detected between males (5.4% ± 2.1%) and females (1.9% ± 1.3%) , and between roost sites . Bats living in caves were more frequently positive (5.7% ± 2.0%) than those living in buildings (1.7% ± 1.6%). The proportion of positive bats was also significantly different between species on Madagascar , particularly in Triaenops menamena (42.4% ± 16.9%). In Mozambique, differences between species were not statistically significant .A total of 32 samples tested positive for PMV (3.7% ± 1.3%)  and no difference between males and females  . However, a significant variation was detected among bat species . In Mozambique, the highest prevalence was detected in the cave roosting Rhinolophus lobatus (66.7% ± 30.8%). No difference was observed among the species that tested positive on Madagascar .The detection of CoV was conducted as part of a previous study . BrieflyThe overall proportion of positive bats detected for either AstVs or PMVs was consistent with previous studies performed in the WIO region, and in other tropical regions –34. Inte2 = 7.0, df = 1, P < 0.01) , and no significant variation was observed between males and females . Globally, co-infections involving AstV-CoV (1.4% ± 0.8%) and AstV-PMV (1.1% ± 0.7%) were more frequently detected than CoV-PMV (0.1% ± 0.3%) and AstV-CoV-PMV (0.3% ± 0.4%)   suggesting a potential positive association between these two viruses. Co-infections involving AstVs, CoVs or PMVs were reported in other tropical bat species. For example, a study of Hipposideros cervinus on Borneo reported 4.1% of AstV-CoV coinfected bats with a positive association between these two viruses [Twenty-one of the 871 samples tested positive for more than one virus (2.4% ± 1.0%). These co-infections were detected only in Mozambique (5.0% ± 2.7%) and on Madagascar (1.7% ± 1.1%), with significant variation among these locations (χ01) Fig. . In bothTriaenops menamena (15.2% ± 24.7%), Miniopterus gleni (13.3% ± 14.8%), and Paratriaenops furculus (3.2% ± 0.2%), without significant difference between species  , Nycteris thebaica (7.1% ± 13.5%), Hipposideros caffer (5.1% ± 5.6%), and Miniopterus mossambicus (4.8% ± 9.1%) , also without significant difference between species  and on Madagascar (Triaenops and Paratriaenops). In Mozambique, the proportion of co-infections was significantly higher in Triaenops afer than in all other tested species . Also, as compared to other species that tested positive for co-infection, different combinations of co-infections (i.e. different associations between viruses) were detected in species of the genus Triaenops. Indeed, Triaenops menamena on Madagascar presented two types of co-infections: AstV-PMV and CoV-PMV, whereas Triaenops afer in Mozambique harbored three types: AstV-CoV, AstV-PMV, and AstV-CoV-PMV; while other species, including Paratriaenops furculus, only presented one co-infection type , or with sequences obtained in bats from the same family . However, some sequences were included in more diversified groups including different bat families (e.g. two sequences obtained from Paratriaenops furculus on Madagascar that clustered with sequences detected in Miniopterus griveaudi and Chaerephon leucogaster on Madagascar).Genetic diversity was less important for PMV sequences, with pairwise differences up to 29%. All our sequences were genetically related to PMVs previously described on Madagascar , 19 or iWe report co-infections in bats on Madagascar and in Mozambique, ranging from 3.2% to 15.7% of the positive samples, and depending on the tested bat species. Although our cross-sectional sampling precludes detailed interpretation of the biological drivers of such variation, our results nevertheless highlight that interactions between infectious agents in bats may exist with potential consequences on their epidemiology. AstVs, CoVs, and PMVs are emerging viruses that represent a major challenge for human and animal health. Further knowledge on virus interaction in wildlife, based on long-term longitudinal sampling is needed to fully assess the epidemiological consequences of co-infections [Additional file 1. List and origin of samples, day roost sites, and result of the molecular screening.Additional file 2. Number of tested and positive samples, per location, bat family, species, samples types, and collection year.Additional file 3. Number of tested and positive samples for co-infections, per country, bat family, bat species, sample type, and collection year.Additional file 4. Astrovirus nucleotide sequence similarity obtained with BLASTn.Additional file 5. Paramyxovirus nucleotide sequence similarity obtained with BLASTn


Therefore, we aimed to assess the knowledge of COVID-19, sleep problem and identify sociodemographic factors associated with sleep problems among healthcare workers in a Nigerian neuropsychiatric hospital.a cross-sectional study was conducted among 200 healthcare workers in a neuropsychiatric hospital using self-administered questionnaires to assess knowledge of COVID-19, sleep problem, social support, and sociodemographic factors that affect sleep. Chi-square test and Spearman's correlation were applied to assess the association between sociodemographic factors and sleep problems.about 23.9% of the healthcare workers reported having a sleep problem. However, there was no association of sleep problems with any sociodemographic factors except age (r=0.26) and social support (r=-0.18).the study offered insight into the occurrence of sleep problems among healthcare workers and suggested a guide for planning interventions targeted at improving the psychological well-being of healthcare workers in the face of current global pandemics. Sleep is a naturally re-occurring physiological phenomenon that is essential for rest, repair, learning, and development . When itSleep problems may thus be worse among health workers in low and middle-income countries like Nigeria, who are overlaboured by work schedule . PreviouStudy design and location: the study design was a cross-sectional descriptive one. It was conducted at the federal neuropsychiatric hospital (FNPH) in Benin-City, Edo State, South-south Nigeria. The hospital is a 270-bed facility which provides in-patient and out-patient care, as well as emergency services to mentally ill persons primarily across the region  of Nigeria. The location operates at two sites: the old site is centrally located in the city; and the new (permanent) site, located on the outskirt of the city. The sample size was calculated using single population proportion formula 21. Data was collected over one-month period between May 2020 to June 2020 using self-administered questionnaires to assess knowledge of COVID-19, sleep problem, social support, and sociodemographic factors that affect sleep.Eligibility criteria: healthcare workers who were bonafide staff of the hospital, aged 18 years and above, have worked in the hospital for a minimum of one year prior to the outbreak of COVID-19 in Nigeria, reported no history of mental illness and willing to participate were included in the study. Healthcare workers who did not meet any of the above criteria were excluded from the study.Study population: the study population consisted of the staff with close contact with patients working in the health facility, consultant psychiatrists, resident doctors in psychiatry, medical officers, psychiatric nurses, pharmacists/technicians, laboratory scientists/technicians, clinical psychologists, social workers, occupational therapists, health attendants, and others.Sampling technique: the staff of the hospital who were present in the course of questionnaire distribution were randomly sampled. All the consenting personnel listed above that were available during the study period were recruited.Socio-demographic data collection sheet: specifically designed to inquire about the sociodemographic characteristics of the staff, such as gender, age, marital status, education level, profession, and religion.Knowledge about COVID-19: seven questions were self-designed to capture the knowledge about nature, cause, risk, treatment, fatality, prevention, and prognosis of the coronavirus disease.Sleep problems: this was enquired as a single question: “do you have difficulty falling asleep, staying asleep or waking up early” and a Likert option of responses were provided, such as never, sometimes, half the time, frequently and always; to enable scoring. Higher scores are indicative of greater sleep problems.The Oslo 3-item Social Support Scale (OSS-3): the OSS-3 provides a brief measure of social support [ support . It cove support . Its str support . The higEthical consideration: approval for the study was obtained from the Research and Ethics Committee of Federal Neuropsychiatric Hospital, Benin City, Nigeria, and written informed consent from the participants to qualify for recruitment. The ethical approval obtained was PH/A. 864/vol. XV/129. the study questionnaires were administered within one month to the study population after obtaining consent.Statistical analysis: data collected were analyzed using the statistical package for social sciences (SPSS) version 22. Descriptive statistics were used, such as frequencies and median. A normality test was performed, which revealed that the sleep problem score was not normally distributed, hence a non-parametric test was adopted in bivariate analysis. Chi-square test was used to test the association between sleep problem and categorical variables  while Spearman´s correlation was applied between sleep problem and continuous variables . All the variables except profession were dichotomized for easier comparison with previous studies and to enable enough participants for analysis e.g. the educational status was categorized into at most secondary level of education and at least tertiary education. The profession was categorized into doctors, nurses, and others . The level of significance was set at a p-value of less than 0.05.Concerning their knowledge about COVID-19, This hospital-based cross-sectional study examined the knowledge of COVID-19 and sleep problems among a selected sample of healthcare workers in a neuropsychiatric hospital in the South-south region of Nigeria. This survey outcome can help with making health recommendations and formulating right precautionary measures, which will invariably boost the psychological and physical health of the healthcare workers during and after the pandemic . The heaet al. [et al. [Our study also indicated that 23.9% of the respondents had a sleep problem. This rate is consistent with several studies that have reported the prevalence of sleep problems among healthcare workers, in the range of 10-30% ,15. Howeet al. , where tet al. . It was  [et al. , where t [et al. . The finet al. [et al. [et al. [Another important finding in this study was that increasing age was also significantly associated with sleep problems. This is in tandem with the findings of Patterson et al. , where tet al. . However [et al.  where th [et al. , in an IMost of the health workers in this study were well aware of the etiology of COVID-19 disease, treatment and recovery of individuals with COVID-19. The study also showed that approximately 24% of the healthcare workers reported having sleep problem during the pandemic. It is therefore recommended that during pandemics, preventive interventions are put in place for the overall mental and psychological being of healthcare workers.Healthcare workers do experience poor sleep quality with relevant consequences on their health;Poor sleep quality among healthcare workers is prevalent and this has increased during the COVID-19 pandemic;Several variables such as educational level or work in an isolation unit appear to play a crucial role in moderating sleep disturbance.Sleep disturbance was prevalent among the healthcare workers and sociodemographic variables increasing age and lower level of social support were associated with sleep problem among the study population.


All participants have shown a significant decrease pre–post-lockdown in both health and performance perception, especially in women, individual athletes, medalists, and student-athletes. Strong limitations of training, attention, and motivation as well as a moderate negative emotional state during lockdown were reported, in women, individual athletes, medalists, and student-athletes. Even with an improved emotional state and energy level in the post-lockdown period, moderate-to-high stress scores were reported by women and medalists. Our findings highlight the importance of paying attention to the physical and psychological health of elite athletes on three profiles: team athletes , student-athletes , and women athletes .Spain is one of the many countries highly affected by the COVID-19 crisis, establishing very restrictive measures with a complete lockdown for more than 3 months. This situation forced the complete closure of sport practice and national or international competitions, leading to a negative impact on physical and psychological health of high-performance athletes. Therefore, the objectives of this study were (a) to determine the effects of the COVID-19 health crisis on Spanish high-performance athletes in terms of sports practice, life quality, and emotional state and (b) to identify the profile with the greatest difficulties during and after the lockdown. A sample of 130 high-performance athletes aged between 18 and 34 years (67 women and 63 men) participated in this study . Measures included socio-demographic data through a 5-dimension  In early 2020, a new viral outbreak began to spread internationally. On January 30, 2020, according to the International Health Regulations  aged between 18 and 34 years. The 85.4% of the sample were considered top or elite athletes according to the Spanish government. The 29.2% had been in the elite for 0–3 years, 46.9% for 3–10 years, and 23.8% for more than 10 years of their sporting life. The 83.1% of the participants had achieved a gold, silver, or bronze medal in their sport discipline at least once during their time competing internationally in the elite. In total, 54.6% of the athletes belonged to individual sports, while 45.4% belonged to team sports. Finally, 86.9% of the sample were considered student-athletes. All of them gave their consent for their responses to be treated anonymously, and the University’s Research Ethics Committee approved the study, which was conducted in accordance with the Declaration of Helsinki.ad hoc survey was created in order to collect relevant data according to the objectives of this study. This survey was composed by items related to (a) gender, (b) best sporting result obtained , (c) sporting discipline practiced , (d) student-athlete, and (e) high-performance sporting expertise.An International Physical Activity Questionnaire  health perception, (2) performance perception (ranging both between 0 = bad and 4 = excellent), (3) degree of limitation in training , (4-6) Limitations of training, attention and motivation due to negative emotional causes , and finally, (7-8) Positive-negative emotional state and (9) energy levels . Cronbach’s alpha coefficient reported values of reliability between 0.78 and 0.96. This instrument provided a profile of the health status of participants and is one of the most widely used generic scales in both descriptive and evaluative studies.An adapted questionnaire based on the original ionnaire  translate  and then adding the 12 items together. The direct score obtained indicates that a higher score corresponds to a higher level of perceived stress. Cronbach’s alpha coefficient reported the values of reliability between 0.78 and 0.82. The PSS was completed concerning the post-lockdown period.A shortened version of the Spanish version of the ale PSS;  designedProfile of Mood States (POMS) in its original reduced version . In total, 130 elite athletes  completed the whole online survey agreeing to participate in the present study. Through human resources contact, coaches from multiple sports disciplines were encouraged to discuss with their athletes the importance of conducting this type of study and to raise awareness of the difficulties that elite athletes have experienced both physically and psychologically, during this unusual and uncertain period. During 5 weeks, the project team was in contact with the supervisor for the athlete recruitment in order to receive information about the process. Responses to the online questionnaire by the athletes were provided in a single session and without any interruption until all the tests were completed. The completion of the online survey was performed in a controlled manner and in the presence of the respective coaches. The athletes answered the IPAQ questionnaire according to pre- and post-lockdown periods, except for resting days and hours with three time-point questions: (a) PRE (before the lockdown); (b) DURING (during the lockdown period); and (c) POST (after the lockdown). For the questionnaire related to health status and limitations, only two points (pre vs. post or during vs. post) were taken into consideration. The remaining questionnaires (perceived stress and mood states) were only related to the post-lockdown period. Athletes who agreed to participate were informed of the confidential and voluntary nature of the study as well as the absence of any reward for participation. When answering the questionnaire, all of them had accumulated 99 days of lockdown. Finally, in appreciation of their collaboration, a final report was sent with the main findings of the study.After obtaining the approval of the Ethics Committee of the University, the online tool was designed through the t-test was applied. Additionally, paired Wilcoxon signed-rank test was used to assess changes within pre vs. during or during vs. post and pre vs. post COVID-19 lockdown when available. Chi-square test was used for categorical variables. Wilcoxon’s effect size (ES) was calculated for non-normal variables; otherwise, Cohen’s D was used. Differences at p < 0.05 level were considered statistically significant. All statistical analyses and plots were performed using the packages nortest , yielding non-normal results for all variables except Stress score. Median and interquartile ranges were used for non-normal continuous variables, and mean (± standard deviation) was used for Stress score variable. The N and percentages were used for descriptive variables as well. Comparisons for each variable type were assessed based on the following categorical variables: gender, best result achieved, modality, student-athlete, and high-performance expertise. Wilcoxon’s rank-sum test was used for continuous variables if non-normally distributed; otherwise, a  nortest  and rsta nortest . Correla package .The descriptive data from all the variables are shown in p < 0.001). Attending to the categorical variables, men increased from 2 to 6 days of rest during the lockdown, and then returned at 2–3 days in the post-lockdown period. Team sports use more resting days in each pre–during–post stage compared to individual sports (p < 0.01). Student-athletes increased resting days during lockdown to a lower extent compared to non-athletes, regained their pre-lockdown habits later on (p < 0.01). From a general perspective, sportsmen and women belonging to team sports and with lower competitive level retained 1 day more for resting in the post-lockdown period compared to pre-lockdown.A paired Wilcoxon signed-rank test revealed significant differences in days of resting in pre vs. during and during vs. post for all of the groups analyzed (p = 0.008), in individual sports (p = 0.003), and in athletes with medium-broad expertise in elite (p = 0.032), significantly decreasing their daily and weekly training hours between pre- and post-lockdown.Concerning hours of training and moderate physical activity, changes were observed in medalist athletes (podium) (p < 0.001). The aforementioned samples considerably increased the hours of rest per day during lockdown, where the intervals of 3–5 h and +5 h per day were greatly increased. In the post-lockdown period, the resting hours were generally somewhat higher than those shown in the pre-lockdown period.Significant differences for hours of resting pre vs. during, during vs. post and pre vs. post, were reported for the whole sample and by subcategories, especially for both genders, medalist athletes, both individual and team sports, student-athletes, and athletes with 3–10 years of experience in the elite . Both genders, male , and female , showed a significant decrease in the performance perception pre–post-lockdown  and performance perception  pre–post-lockdown .The degree of limitation in training was compared during and post-lockdown for all the categorical variables. A paired Wilcoxon signed-rank test indicated that these differences were significant (χ2(2) = 36.847, p < 0.001], attention  as well as motivation  due to negative emotional causes, and the lockdown status. A higher number of participants reported limitations during lockdown period but not after.A chi-squared test found that there was a statistically significant association between the limitations of training [p < 0.001, moderate ES, being more pronounced in men); both modalities ; best result ; student-athletes , and short and medium high performance (HP) sporting expertise .Concerning the negative emotional state, p < 0.01, small ES); student-athletes ; and athletes with (medium) 3–10 years of experience in the elite   .p < 0.05 and p < 0.001, small ES, for female and male, respectively); individual and team athletes ; medalists ; student-athletes ; and short sporting experience   .t-test revealed significant differences between genders for stress scores  and in medalists, with higher scores compared to non-medalists . When combining both variables, women still show significantly higher levels, but only within those competitors with the best result (podium) . In addition, women showed higher scores compared to men in team sports (p = 0.008), student-athletes (p = 0.004), and medium sporting expertise (3–10 years) (p = 0.002) (A = 0.002) .p = 0.01, large ES). In general terms, as sporting expertise increases, the differences between medalists and non-medalists equalize and become non-significant after 3–10 years of experience in the elite  and fatigue (p = 0.003) with higher scores for women, and vigor with higher scores for men (p = 0.008). Those with better results have a slightly more negative profile, showing higher levels of tension (p = 0.02) and hostility (p = 0.04) than non-medalists. They generally score a little higher on the negative dimensions of the profile and lower on vigor compared to non-medalists. No significant differences were found for any factor regarding other categorical variables . It also meant the delay and/or cancelation of sporting events all over the world, with the postponement of the Olympic Games for the first time in its history, being an example of the magnitude of this crisis worldwide. A large number of retrospective studies were carried out during the lockdown period, trying to understand the problems athletes were facing and how they could affect their physical and mental health. To complement these studies and the problems that have become evident, it is necessary to know what consequences have been produced on the lives months of athletes after exceptional circumstances. For this purpose, the present results extend previous knowledge on the consequences of the COVID-19 pandemic by providing new evidence on the physical status, quality of life, and mental health of Spanish top-level athletes who, after a long lockdown period, had to return to their sporting lives in a new context.Attending to physical health, the major increase in the resting time that Spanish athletes dedicated during the lockdown period seems to be a relevant aspect to be taken into account. According to previous studies with elite athletes , a signiIt should also be noted the rest days of team sports athletes, which were longer compared to individual sports athletes during the lockdown period, coinciding with the study by Also, noteworthy are the results in student-athletes, characterized by pursuing academic studies at the same time as their sporting careers and are framed within the so-called dual career , where aIn any case, they duplicated the practice of physical activity compared to non-athlete university students. Apparently, despite the loss of physical activity, the student-athletes followed the recommendations to exercise at home during the lockdown, but similar to the results of the present research, the sedentary activities could be related to increasing the time dedicated to studies, with the aim of synchronizing the learning processes in their future profession.On the contrary, these statements would disagree with the results reported by “activity must be resumed slowly and by listening to the athlete, as there is still uncertainty as to whether we will return to the old habits of the old ‘normality,’ or whether the pandemic will give rise to a new stage with new lifestyles that will define the future” (p. 54).Related to progressively returning to sport, it is observed that there are differences between the hours that athletes dedicated to training before the lockdown and in the post-lockdown. The athletes with the highest competitive level, in individual sports and with medium and broad experience in the elite, significantly reduced their daily and weekly training hours after the lockdown by returning to training. For this reason, the main responsible for the athletes’ return to training and competitions should have specific knowledge of the different profiles and how the COVID-19 health emergency situation may have influenced their lives. Along the same lines, The health perception of athletes in the post-lockdown period after the difficulties experienced during the lockdown period, is a factor that has been taken into account through two summary components: physical and psychological . AccordiAlthough the health and performance perception in athletes after the lockdown period has not yet been extensively studied, a study carried out during lockdown with more than 13,000 youth athletes , states Considering the competitive level of athletes, those with higher level  reported a significant decrease in the health and performance perception compared to pre-lockdown. It could be interpreted that these athletes were those who had Olympic qualification as one of their next objectives. Therefore, after 4 years of preparation, the postponement was an added stressor. In this line, studies affirm that this situation could cause a loss of concentration, motivation, and the desire to continue preparing for the Olympics with the same energy as before, affecting, among other variables, their health and performance perception . It shouThe health of athletes was possibly also influenced by emotional problems experienced during the lockdown period, the reduced time dedicated to training, and the training performance with less attention and motivation compared to pre-lockdown. Social distancing seems to be one of the main reasons for the appearance of such problems . StudiesThis perceived loss of social connection and support  could inFocusing on the post-lockdown period, differences between the limitations experienced in training during lockdown (high degree) and the post-lockdown (low degree) were observed for both genders, also reported by medalists, individual sports, student-athletes, and those with more experience in the elite. It seems clear then the importance of maintaining adequate levels of physical activity in professional athletes, as in addition to positive physiological effects, sports practice enhances psychological well-being. Moreover, strategies should be incorporated to reduce stress and anxiety about returning to competition, respecting each individual’s own time, avoiding injuries and frustrations to quickly reach the competitive level they showed prior to lockdown . RegardiThese negative emotional values decreased significantly in the post-lockdown period, especially in men, medalists, student-athletes, both modalities , and athletes with 0–3 years of experience. This correlates with a decrease in training limitations, and an inverse correlation in the positive emotional state and energy level, both increasing significantly in the post-lockdown period. This is possibly linked to being able to get back to socializing, training again with the opportunity to compete in a short-term period, resuming studies and leading a regular life after months of lockdown.Furthermore, it is important to highlight those fluctuations in stress and modifications in exercise routines, especially when drastic, could result in sports injuries or illnesses . AccordiThe so-called Coronavirus experience  is underAs discussed above, and now related to the emotional state, student-athletes should be particularly considered since their behavior is different compared to other athletes not combining academic and sporting life. Significant differences were reported in the negative emotional state, with student-athletes showing a worse baseline level during lockdown, suggesting a worse post-lockdown emotional state, but actually the results showed a significant drop afterward, correlating with the increase in positivity and energy. These results could mean that the student athletes took advantage of the lockdown period, to spend more time than usual on their studies instead of training, whereas, after return to training, they experienced a better emotional state, as they can continue their normal academic activity as well as training and competition, feeling more competent and controlling the situation. In fact, non-student-athletes showed an inverse behavior, being affected by the situation to a greater extent, maintaining their emotional state unchanged in the post-lockdown period.As highlighted by other studies , COVID-1Student-athletes have reported higher values of negative emotional state during the lockdown, similarly to The results on stress and mood of athletes in the post-lockdown period showed significant differences between genders and best sporting results. Women showed higher levels of depression and fatigue, as well as higher levels of stress, especially those sportswomen with better results. On the other hand, men had higher values for vigor. Once again, the present study shows that women experienced more negative consequences of lockdown, possibly affecting their mental health and, therefore, their personal life and sporting performance in the period of post-lockdown. According to Carrying out a cross-sectional study to find out the situation of athletes at different times of the health crisis could find limitations in the results obtained, because the responses were obtained in the post-confinement period. A longitudinal study could have been presented for the most appropriate in this case, but the uncertainty in the duration of the periods lived, as well as the difficulties that the athletes were facing, were the reason for carrying out the study once the confinement had passed and efforts were being made to regain normalcy, even with a large number of limitations.In addition, other limitations to consider would be the inclusion of the questionnaires used in the present study in a single survey, which could mean that it was too long for the athletes to answer, as well as the inability to take the data in person due to mobility limitations that characterized the post-confinement stage in Spain.This study shows how the health crisis caused by COVID-19 altered the sporting practice, life quality, and emotional state of Spanish elite athletes during the lockdown and in the subsequent post-lockdown period. Concerning the sporting practice, even with the advice of coaches during the lockdown, there were modifications due to the restrictions and the closure of sports facilities. After returning to the new situation, sporting activity did not return to normal levels immediately, since training was carried out in a progressive and scheduled manner by professionals, well aware that training had to be adapted to the circumstances. The health and performance perception were other altered factors in the athletes, especially in student-athletes and women groups. In addition, athletes with a higher competitive level suffering greater uncertainty due to the postponement of competition had an important decrease in both perceptions that should be considered. Furthermore, the health of athletes was also influenced by emotional problems, leading them to perform their training sessions with less attention and motivation compared to before the health crisis. However, the post-confinement period led to a decrease in the negative emotional state of the athletes, while at the same time increasing their positive emotional state and energy level in order to face their tasks. On the other hand, the stress level remained moderately high, due to the workload to be recovered, especially concerning the competitive and academic field for student-athletes.We highlight the identification of profiles of different athletes to be considered, due to the consequences and difficulties caused by the health crisis on their lives. First, Spanish women athletes could be a group to be specifically approached that might indicate the prevalence of implicit gender inequalities in sport, becoming even more evident in a global crisis situation. Our findings could be related to less support received from organizations, as well as to other gender-related difficulties  that should be further studied. Considering the physical and emotional health of female athletes, it appears to have been impaired, potentially affecting their lives and sports performance. During the last two Olympic Games, Spanish women have won more medals . Therefore, it would be necessary to increase the research, in order to know the real impact of the pandemic on the elite sport of women in Spain, as well as the current and future consequences of the pandemic. Second, Spanish athletes who practiced team sports had more limitations when training both during and in post-lockdown periods, mainly due to the social distance, something that should clearly be considered. Third, student-athletes, who found the lockdown an opportunity to focus more time on their academic careers, leading to an increase in more sedentary activities, with possible implications for their sports performance on the one hand, but advances for their lives outside of sport as well.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the San Antonio Catholic University (UCAM), Murcia, Spain. The patients/participants provided their written informed consent to participate in this study.EC, CLdS, and MT participated in the design of the researchproject. EC, LMMA, CLdS, and MT participated in the surveydesign and adjustments. ASP, AL, and JAGR participated in thesubject recruiting and data collection process. LMMA and GSparticipated in the data analysis and results. EC, LMMA, GS, andADA participated in the preparation of the original manuscript. EC, LMMA, GS, YR, CLdS, and MT participated in the revised version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The aim of this study was to analyze athlete-specific psychological strain among Olympic athletes following the postponement of the Tokyo 2020 Olympic games due to the COVID-19 pandemic.A survey that comprised three sub-sections , Patient Health Questionnaire—Depression Module (PHQ-8) and Participant characteristic) concerning mental health, performance issues and concerns about the postponement of the Tokyo Olympics, was distributed online and sent to 102 Olympic athletes.A total of 85 participants from 11 Olympic sports were enrolled. Results indicated that most athletes showed psychological strain related to concerns regarding the postponement of the Tokyo Olympics. Depression severity was positively associated with maladaptive avoidance coping patterns, negative effects in training, worries and fear. Depression severity was also negatively associated with motivation and adaptive factors such as chances and opportunities that can be drawn from the pandemic.The present sample of Olympic athletes reported suffering from psychological uncertainty associated with the postponement of the Olympic games. Sports federations should therefore, provide ongoing wellbeing support to athletes and offer them, for example, sports psychological support in order to be able to better deal with pandemic-related uncertainties and changes. The International Society of Sport Psychology suggested that the postponement of the 2020 Tokyo Olympic games represents a significant career disruption that could involve a loss of identity, motivation and meaning  with emoThe emotional response of Olympic and Paralympic athletes to the decision to postpone the Olympic games in Tokyo is likely to be varied . After yWhile the severe acute respiratory syndrome coronavirus 2 (hereafter referred as COVID-19) continues to spread worldwide, the impact on mental health symptoms and disorders in both the general population and within elite sports is gaining increased attention –8. XiongThis study aimed to explore and describe mental health symptoms and athlete-specific psychological strain among Olympic athletes during this pandemic phase, and to understand whether sports psychology, medical and/or coaching support were available for athletes during this phase. We hypothesized that the postponement of the Olympic Games would have a negative impact on athlete wellbeing, as evidenced by elevated levels of psychological strain and depressive symptoms.The present study was part of a research project examining dispositional and emotional features associated with athletes’ mental health symptoms due to the COVID-19 pandemic. An online questionnaire was distributed by international sports federations with the request to send it to athletes who had already qualified or were still in the qualification process for the Olympic Games in Tokyo 2020. The survey was send to 102 athletes from which 86 (84%) completed the survey. One participant did not agree to the privacy policy statement and was excluded.The online survey was open from July until September 2020.Athletes who had already qualified or were still in the qualification process for the Olympic Games in Tokyo 2020Age 18 years and olderComplete surveyAgreement to the privacy policy statementInclusion criteria:Athletes who had not qualified or were not involved in the qualification process for the Olympic Games in Tokyo 2020Age under 18 yearsIncomplete surveyNo agreement to the privacy policy statementExclusion criteria:Participants provided informed consent before participating voluntarily in the study. The study was approved by the Ethics Committee of the University of Witten/Herdecke (No. 171/2020). The study team used the Declaration of Helsinki ethical principles for medical research involving human subjects as standards.The Survey comprised three sub-sections, including participant demographics, questions related to the COVID-19 pandemic and 41 questions about athletes’ feelings towards their sporting activity.The APSQ is a 10-item mental health questionnaire with 3 subscales assessing self-regulation, performance and external coping in athletes. The 4-item performance subscale and 3 additional single items from APSQ  were used to provide a brief, targeted self-report of athletic distress and maladaptive avoidance coping patterns  . Items wn = 11) of the athletes scored the commonly used threshold of ≥ 10 for the PHQ-8. Scores above this cutpoint suggest that the probability for a major depression is increased , upon reasonable request.t-tests to explore mean differences between athletes. For these t-tests the five response categories "None of the time", "A little of the time", "Some of the time", "Most of the time" and "All of the time" of single items were combined into dummy variables with the category "rarely" for the first two response categories and with the category "yes" for the last three response categories. Whenever group size (in the t-test) was smaller than 30 nonparametric tests were calculated additionally. Results did not show any differences regarding significance. Effect sizes according to Hedge's g were determined for all differences. All statistical analyses were performed using IBM SPSS 27 , with p-values < 0.05 used as significance threshold. All plots were created using the R package .To investigate associations between depression and athletes’ problems, worries and fears, Pearson correlation analyses were conducted. We conducted M = 26.92, SD = 4.60) participated. Athletes of 11 Olympic sports and 24 countries took part in the study. Most participants were Olympic athletes in judo , field hockey , wrestling  and surfing . For most,  the Olympics 2020 in Tokyo would have represented their first Olympic games. A total of 40% (n = 34) athletes had participated in a previous Olympics, with 13% (n = 11) athletes participating twice or three times. Athletes detailed demographics are shown in the Flow chart diagram in Fig. A total of 85 participants (52 women), aged 18 to 44 years (n = 79) reported agreeing with the decision to postpone the Tokyo Olympic Games . While a majority of athletes  reported experiencing difficulties when the Olympic games were postponed , most  also reported seeing an opportunity to better prepare for the re-scheduled Olympics in 2021  and to work on their weakness . Means and standard deviations from single items concerning feelings about the postponement, training and coping can be found in TableAlmost all participants . The commonly used cut point of ≥ 10 , showing that athletes in team sports report higher PHQ-8 scores than athletes from individual sports.Across the sample, the mean PHQ-8 score was 5.51 . No sex differences were found. PHQ-8 scores correlated strongly with the APSQ performance subscale, r(85) = 0.53, p = 0.001. Figure The mean score reported on the performance subscale of the APSQ was 11.14  and individual sport , we found significant differences in on the performance subscale of the APSQ, t(83) = 3.28, p = 0.002, g = 0.88, 95% CI , showing that athletes in team sports report higher psychological strain than athletes from individual sports.When comparing team sport  reported significantly higher depression scores  compared to athletes having no difficulties , t(83) = − 3.04, p = 0.003, g = − 0.68, 95% CI . Similar results were obtained in relation to athletes finding training more stressful  compared to not , t(83) = − 2.52, p = 0.01, g = − 0.55, 95% CI , athletes feeling less motivated  compared to those not feeling less motivated , t(83) = − 2.53, p = 0.01, g = − 0.55, 95% CI , and athletes feeling irritable, angry or aggressive  compared to those feeling rarely irritable, angry or aggressive , t(83) = − 5.57, p < 0.001, g = − 1.24, 95% CI . Athletes seeing this time as an opportunity to work on their weaknesses reported significantly lower depression scores  compared to athletes not seeing this chance , t(83) = 3.12, p = 0.002, g = 0.79, 95% CI .Athletes who indicated difficulties with the postponement of the Olympics in Tokyo  shifted to the right, which suggests higher scores on the PHQ-8.Figure Regarding density distributions of the single items addressing the chances athletes can draw from the COVID-19 pandemic and the Tokyo 2020 Olympics postponement Fig. , the denThe aim of this paper was to explore and describe mental health symptoms and emotional responses of Olympic athletes in light of the COVID-19 pandemic. It was hypothesized that the postponement of the 2020 Tokyo Olympics would have a negative impact on athletes and their well-being. This exploratory assumption was confirmed in several ways, although we acknowledge that the results need to be interpreted in the context of several limitations, including the relatively small sample size, the low statistical power, and the use of modified outcome measures.Our results demonstrate a significant association between self-reported depression severity and athlete reactions to the postponement of the Tokyo Olympics, including perceived difficulties with training, motivation and self-regulation. These findings are consistent with other COVID-19 research regarding loss of motivation, coping problems and negative emotional response in elite athletes . Our desOur results suggest that athletes reported experiencing a range of problems associated with the postponement of the Tokyo 2020 Olympics. Athletes with higher depression scores reported experienced more impairing problems with the cancellation of the Games, including stress in training, and other motivational and self-regulatory aspects. Moreover, these athletes viewed the cancellation of the Olympic Games less as a chance to improve their performance compared to those screening below the PHQ-8 cut-off.physical health and advise amongst medical services [Very few Olympic athletes reported receiving professional support for their mental health and well-being at the time of responding. This is particularly surprising, since Olympic athletes are the highest performing athletes, who should be able to access and receive the best interdisciplinary support possible . It is uservices , despiteservices , yet theservices . While mservices , 11. Higservices .The impact of the pandemic on elite athletes exposes the weak spots of systems and organizations in relation to mental health support. The whole multidisciplinary entourage  in elite sports should be aware and prepared for mental health issues of their athletes, and national sports federations and stakeholders should create sports environments that promote mental well-being for the athletes and entourage members .In addition to the limitations we already highlighted, this study has several other limitations. Unfortunately, we did not include para-athletes or athletes from developing nations making this sample less representative. Further limitations relate to the cross-sectional study design and the reliance on self-report. Nonetheless, we see value in research on real aspects of behavior as seen in the Olympic sports represented in this study, and in highly selective samples of Olympic athletes (24 different countries and 11 different sports) like ours. It can provide clues to how athletes react to and cope with live changing events and setbacks, not only in the lab but also in real life.The study demonstrated that the present sample of Olympic athletes suffered from the uncertainty associated with the postponement of the Olympic games. Only a small amount of athletes were receiving professional help regarding mental health issues in this difficult times. Sports federations should support the athletes and offer them, for example, sports psychological support in order to be able to better deal with the uncertainties and changes.


Microangiopathic hemolytic anaemia, thrombocytopenia, renal failure, neurologic abnormalities, and fever form the pentad of thrombotic thrombocytopenic purpura (TTP). Early diagnosis is crucial because TTP responds well to plasmapheresis therapy but is associated with substantial mortality if left untreated. A substantial percentage of patients with TTP used to die from systemic microvascular thrombosis in the brain and the heart. However, since plasma exchange therapy became a mainstay in the treatment of TTP, mortality has reduced considerably. Diagnosing TTP can be difficult due to the vast range of symptoms and the absence of clearly defined diagnostic criteria. Hemolytic uremic syndrome and disseminated intravascular coagulation are a close differential of TTP. Here we report two patients with TTP who achieved remission when treated with steroids, plasmapheresis and were free of disease relapse till about two months during follow-up in the outpatient department. Thrombotic thrombocytopenic purpura (TTP) is one of the entities in thrombotic microangiopathy (TMA). Eli Moschcowitz first defined TTP in 1924, and it is characterised by a pentad of symptoms, including microangiopathic haemolytic anaemia, thrombocytopenia, renal failure, neurologic abnormalities, and fever. TTP affects around 4-6 million people per year . Proof oPatient 1oF, haemodynamically stable, and general examination revealed no abnormality, Glasgow coma scale (GCS) was E4M5V3. He was evaluated accordingly, his reports done were: blood urea- 63.9 mg/dL, serum creatinine- 1.97 mg/dL, sodium- 141 mEq/L, potassium- 3.22 mEq/L, chloride- 103.2 mEq/L, hemoglobin- 14.6 g/dL, platelet count- 42000/cumm, tropical fever workup came negative, serology was negative, blood and urine cultures were sterile, Chest X-ray (CXR) was normal, procalcitonin (PCT) was 50 ng/ml, prothrombin time (PT) and activated partial thromboplastin time (aPTT) were normal, direct and indirect Coombs test was negative, urine routine; protein +++, glucose ++, pus cell 3-/HPF, red blood cell (RBC) 25-30/HPF, ultrasound abdomen- right kidney (RK)- 11.7 x 5.8cm, left kidney (LK)- 10.7 x 6.1 cm, raised bilateral echogenicity, cortico-medullary differentiation (CMD) maintained. Liver function test (LFT)- bilirubin (direct/Indirect) 1.17/0.9 mg/dL, aspartate transaminase (AST or SGOT) and alanine transaminase (ALT or SGPT) were normal, HbA1c was 9.2%. MRI Brain showed no significant brain parenchymal abnormality. After sending cultures, the patient was empirically started on intravenous antibiotics: injection piperacillin tazobactam + teicoplanin, injection artesunate with other supportive treatment. On day 1 evening, he became violent with the inability to control by restraint, was sedated and intubated, in view of the prolonged need of sedation and risk of respiratory depression, put on a mechanical ventilator. Lactate dehydrogenase (LDH) was 90 U/L on day 1. Repeat LDH on day 2 was 589 U/L which increased to 987 U/L on day 3. On day 3, renal function test (RFT) showed blood urea 191 mg/dl, creatinine 5.15 mg/dl and since morning his urine output had decreased, so the patient was haemodialysed. Direct and indirect Coombs tests were negative and peripheral smear for schistocytes was reported as negative. In view of fever persisting over 102 - 106oF despite broad-spectrum antibiotics and antimalarial drugs, the elevation of LDH within three days, fall in hemoglobin, deranged RFTs, altered sensorium, and thrombocytopenia with normal coagulation parameters; a diagnosis of thrombotic thrombocytopenic purpura was made. His mean corpuscular volume (MCV) was 78.7 fl and the PLASMIC score was 6 points (high risk) denoting 72% risk of severe ADAMTS13 deficiency (defined as ADAMTS13 activity level <15%). Injection methylprednisolone 1 gm was started post hemodialysis on day 3. On day 4, LDH was 1443 U/L and the first session of plasmapheresis with an exchange of 2.5 litres followed by haemodialysis (HD) was done. The patient dramatically became afebrile after the first session of plasmapheresis, while prior to plasmapheresis he had a fever of 102 - 104oF. A second dose of injection methylprednisolone was given post HD. Improvement in LDH level and platelet count was seen on day 5 and the second session of plasmapheresis with an exchange of 2.5 litres of plasma and the third dose of injection methylprednisolone 1 gm was given. Improvement in LDH and platelet count was seen on day 6 and day 7 and the third and fourth session of plasmapheresis with an exchange of 2.5 litres was done and oral prednisolone 1 mg/kg was started on day 6. By day 8 his sensorium had improved, and he was oriented, he was extubated, and his blood reports were urea- 137 mg/dL, creatinine- 2.08 mg/dL, sodium- 139 mEq/L, potassium- 3.41 mEq/L, chloride- 98 mEq/L, hemoglobin- 11.3 g/dL, platelet count- 208000 per cumm, LDH- 705 U/L. In view of urine output of 2550 mL, plasmapheresis was withheld even though LDH was >500 U/L as his plasmapheresis filter was not reusable and it was decided to wait and see the trend of the platelet count and LDH to decide about the further need for plasmapheresis. His blood pressure started increasing, he needed Injection nitroglycerin infusion and later started on oral antihypertensive drugs. From day 9, serial RFT and platelet count showed improvement and no further plasmapheresis or hemodialysis was needed till discharge. He was shifted to ward on day 11 and after his blood sugar level was also controlled . After it was ascertained that his RFT, platelet count, and LDH were stable he was discharged on day 14 on antihypertensive drugs, mixture insulin and oral hypoglycaemic, and prednisolone 1 mg/kg with a plan to continue the same dose for a total of one month and then taper and omit. His daily lab reports and events are shown in Table A 38-year-old man presented to our hospital with chief complaints of fever for six days and altered sensorium for two days. He was treated elsewhere for the past four days and then shifted to our hospital. On examination he was febrile - 104Patient 2A 27-year-old man presented to our ICU with fever, alteration in sensorium, and decreased urine output. On examination and investigation, he was found to have fever, disorientation, thrombocytopenia, renal dysfunction, and microangiopathic haemolytic anaemia. A diagnosis of TTP was made. His mean corpuscular volume (MCV) was 86 fl and the PLASMIC score was 6 points (high risk) denoting 72% risk of severe ADAMTS13 deficiency (defined as ADAMTS13 activity level <15%). He was initiated on three pulses of injection methylprednisolone followed by oral prednisolone 1 mg/kg for one month and then taper and omit. Alternate day haemodialysis was done till his urine output improved and daily plasmapheresis was done till his platelet count increased above 150000 per cumm. Tropical fever workup investigation was negative, HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) were also negative, blood and urine cultures were sterile, CXR was normal, PCT was 0.42 ng/mL, PT and aPTT were normal, direct and indirect Coombs test was negative. Urine routine showed protein +++, RBC >50/HPF, pus cells 4-5/HPF, urine protein creatinine ratio (UPCR) 2651 mg/g creatinine. Ultrasound abdomen showed RK- 11.7 x 5.8cm, LK- 10.7 x 6.1 cm, raised bilateral echogenicity and CMD maintained. LFT- bilirubin was normal. Serum SGOT (1082 U/L) and SGPT (220 U/L) were raised on admission but later normalized. HbA1c was 6%. His daily lab reports and events are shown in Table In adults, thrombotic thrombocytopenic purpura is idiopathic in around a third of instances, meaning it develops suddenly and without any known underlying cause. Women are more likely to be affected. The median age at the time of diagnosis is around 40 years old , dissemiLaboratory data should be obtained in patients who come with new thrombocytopenia, with or without evidence of renal insufficiency and other aspects of classic TTP, to rule out DIC and evaluate for signs of microangiopathic hemolytic anemia. Increased lactate dehydrogenase and indirect bilirubin, decreased haptoglobin, and increased reticulocyte count, along with a negative direct antiglobulin test, all support the TTP diagnosis. Schistocytes should be looked for in the peripheral smear. The diagnosis of TTP in both cases was made on clinical grounds. According to the newer classification, both the cases fit mostly into primary TMA acquired - TTP due to ADAMTS13  antibodies triggered due to infection, as the elevated procalcitonin levels suggested in both cases.Because plasmapheresis eliminates von Willebrand factor multimers, ADAMTS13 anti-metalloproteinase antibodies . Fresh f3 and the LDH levels fall below 400 U/l, as these are the most sensitive markers for assessing therapeutic response [3 for two days after which plasmapheresis was halted, although LDH levels showed an increasing trend immediately after plasmapheresis was stopped and later showed a downward trend. Thus corticosteroid therapy plays a role in maintaining complete disease remission, in both of our cases following the initial rise in LDH seen after halting plasmapheresis, later on, there was a downward trend in LDH. Outpatient follow-up is essential to monitor remission or detect recurrent chronic form with a mortality rate of roughly 15% [The literature does not provide a treatment time, however, therapy should be continued until the platelet count reaches 100,000/mmresponse . In bothPrimary TTP is triggered by conditions such as pregnancy, infections, cancers, HIV, lupus, surgical stress, chemotherapy, or medications such as clopidogrel and ticlopidine. TTP is a serious condition and a keen eye is to be kept for diagnosing it when conditions which trigger it are present. Plasmapheresis is the cornerstone of therapy and has improved patient outcome considerably, and addition of corticosteroid therapy helps in maintaining complete disease remission when plasmapheresis is stopped and also at follow-up.