Background: Lung cancer represents a heterogeneous group of neoplasms, with the highest frequency and mortality in both sexes combined. In a clinical scenario characterized by the widespread of multidetector-row spiral CT, core-needle biopsy under tomographic guidance is one of the main and safest methods to obtain tissue specimens, even though there are relatively high rates of pneumothorax (0–60% incidence) and pulmonary hemorrhage (4–27% occurrence rates). The aim of this retrospective study is to assess the diagnostic accuracy of CT-guided core-needle biopsy in the diagnosis of primary lung malignancies and to compare our results with evidence from the literature. Materials and Methods: Our analysis included 350 thoracic biopsies, performed from 2017 to 2022 with a 64-row CT guidance and 16/18 G needles mounted on a biopsy gun. We included in the final cohort all samples with evidence of primary lung malignancies, precursor lesions, and atypia, as well as inconclusive and negative diagnoses. Results: There was sensitivity of 90.07% (95% CI 86.05–93.25%), accuracy of 98.87% (95% CI 98.12–99.69%), positive predictive value of 100%, and negative value of 98.74% (95% CI 98.23–99.10%). Specificity settled at 100% (93.84–100%). The AUC was 0.952 (95% CI 0.924–0.972). Only three patients experienced major complications after the procedure. Among minor complications, longer distances from the pleura, the presence of emphysema, and the lower dimensions of the lesions were correlated with the development of pneumothorax after the procedure, while longer distances from the pleura and the lower dimensions of the lesions were correlated with intra-alveolar hemorrhage. Immunohistochemistry analysis was performed in 51% of true positive cases, showing TTF-1, CK7, and p40 expression, respectively, in 26%, 24%, and 10% of analyzed samples. Conclusions: The CT-guided thoracic core-needle biopsy is an extremely accurate and safe diagnostic procedure for the histological diagnosis of lung cancer, a first-level interventional radiology exam for peripheral and subpleural lesions of the lung, which is also able to provide adequate samples for advanced pathologic assays  to assess molecular activity and genetic sequencing. Primary malignancies of the lung represent a heterogeneous group of neoplasms with the highest mortality and frequency in men and women combined , with agThis retrospective study conformed to the principles of the Declaration of Helsinki for medical research, according to the local diagnostic-therapeutic-assistance path (DTAP) for the management of lung nodules. From January 2017 to January 2022, 490 patients underwent at least one core-needle thoracic biopsy. Among these, 410 were admitted to the interventional radiology (IR) division with the pre-eminent diagnostic suspicion of primary malignancy of the lung. Patients were eligible for study inclusion if they met the following criteria: (i) execution of the biopsy procedure, even in cases of partial technical success and/or intra-procedural complications, either minor or major ; (ii) presence of solitary nodules of the lung and target masses not exceeding 50 mm in size (measurement of the long axis of each lesion), because these lesions likely demonstrate necrosis, with a consequent impairment of diagnostic accuracy and a higher rate of false negatives ; (iii) dThe results of biopsy sampling were evaluated in relation to the definitive surgical specimen, when available, or the clinical-radiological follow-up: this post-procedure assessment constitutes the double end point of our study. The risk for patients of being affected by lung cancer was defined by anamnestic and clinical data, by pre-procedure imaging , and by the discussion about the indication for the procedure for single clinical cases in the multidisciplinary team (lung cancer unit) with fellow pulmonologists, thoracic surgeons, nuclear medicine physicians, radiotherapists, oncologists, and pathologists.As aforementioned, all biopsy procedures were performed under CT guidance. Procedural CT scan was performed with a 64-row MDCT system . The technical parameters were a rotation time of 500 ms; a tube voltage of 120 kV; a tube current (effective mA) of 150–400, depending on the patient’s size, with modulated exposure to reduce the dose (Sure exposure: standard); a field of view of 40 cm; and a reconstruction thickness of 2 mm with a reconstruction interval of 2 mm; the CT acquisition has always been volumetric to allow for any multiplanar reconstructions to be performed. CT scans were limited to the lesion area with a margin of a few cm to limit patient exposure; only the final scan was performed involving a greater portion of the lung to better evaluate post-procedure complications.For each patient, the fitness for the procedure was assessed and relative and absolute contraindications were excluded, especially of coagulative nature in compliance with CIRSE and SIR guidelines: in particular, complete blood count and coagulation profile were available for each patient, with platelet count > 50,000/μL and international normalized ratio (INR) ≤ 1.5 as necessarily required values for performing the procedure. Moreover, we considered an activated partial thromboplastin time (aPTT) value ≤1.5 as the mandatory cut-off for patients under endovenous fractionated heparin (LMWH). P2Y12 inhibitors and direct oral anticoagulants (DOACs) were, respectively, withheld 5 days and 2–3 days prior to the biopsy, while LMWH was suspended a dose before the procedure ,20,21. IA localizing radiopaque grid was applied to the skin of each patient, following the evaluation of prior exams and immediate pre-procedure scans, in order to accurately identify and plan the access site. Local anesthetic  was then administered at the designated site. The biopsy technique used was preferably the coaxial technique, with a 17 G introducer needle and an 18 G cutting needle mounted on a full-core needle biopsy gun; in a minority of cases of large superficial or mediastinal masses, 15 G introducer needles and 16 G cutting needles were used . This tySensitivity, specificity, positive and negative predictive value (PPV and NPV), and diagnostic accuracy were calculated and compared by keeping surgical pathology specimen and/or the clinical-radiological follow-up as the reference standards. Predictive values and diagnostic accuracy were dependent on the disease prevalence. These results were reported as mean ±95% confidence interval (95% CI), while data concerning the characteristics of the population were calculated as mean. Therefore, a “true positive” was defined as a CNB specimen leading to final diagnosis of primary lung malignancy, confirmed by a surgical specimen or by the subsequent clinical/radiological follow-up. A “true negative” was defined as a negative CNB specimen or with no evidence of malignant cells, with a non-malignant final diagnosis. We considered as “false negative” each biopsy specimen with no evidence of malignancy, with a final diagnosis of lung cancer obtained by surgical biopsy. A receiver operating characteristic (ROC) curve was drawn using the DeLong technique and the area under ROC curve (AUC) was calculated in order to evaluate the accuracy of CNB in the detection of malignancy, using the final diagnosis as a reference standard.A stepwise backward logistic regression analysis, using 0.05 and 0.10 as inclusion and exclusion criteria, respectively, was used to identify the predictors of concordance between CNB findings and final diagnosis. The variables included in the initial model were the age of the patients, the distance of the lesions from the pleura, the maximum diameter of the lesions, and the number of samples collected with CNB.Similar stepwise backward logistic regression analyses were also conducted to identify the predictors of four complications after CNB . The variables included in the initial model were the following: the age of the patients, the presence of emphysema, the presence of fibrosis, the distance of the lesions from the pleura, the maximum diameter of the lesions, and the number of samples collected with CNB.SPSS for Mac  and MedCalc  were used for the statistical analysis.A total of 350 patients were finally enrolled, including 132 women (37.7%) and 218 men (62.3%). The mean age at the procedure is 72 years. A total of 199 procedures involving the right lung were performed ; among these, 124 (62.3%) involved the upper lobe (RUL), 13 (6.5%) the middle lobe (ML), 59 (29.7%) the lower lobe, while only 3 (1.5%) biopsies were executed on the pleura of the right lung.Instead, 149 procedures involving the left lung were completed ; among these, 90 (60.4%) were performed on the upper lobe (LUL), 8 (5.4%) on the lingula (LIN), 48 (32.2%) on the lower lobe (LLL), and 3 (2%) were performed on the pleura of the left lung.Only 2 biopsies targeted the mediastinum .The biopsied lesions had diameters ranging from 9 to 50 mm (mean diameter 40 mm). Among these, 270 (77.1%) were solid density nodular formations, while 70 (20%) and 10 (2.9%) were, respectively, part-solid and ground-glass abnormalities. The morphology of the target lesions was thus distinguished between “rounded” and “non-rounded”: 158 abnormalities  were classified as rounded, while 192 (54.9%) were described as non-rounded. We also reported the margins of the target lesions: 256 (73.1%) showed irregular margins, 38 (10.9%) had lobulated margins, 35 (10%) demonstrated smooth margins, while 21 (6%) showed ill-defined margins .Relationships between the lesions and adjacent anatomical structures were assessed, and 80 (22.9%) showed pleural attachment: between these, 8 (10%) showed relationships with peripheral bronchial branches, 3 (3.75%) were in contact with hilar and peribroncovascular structures, while 1 (1.25%) demonstrated encasement of the subpleural adipose tissue. Two hundred seventy  lesions had a peripheral location in the lung parenchyma, however, having no relationship with the anatomical structures placed in proximity.A total of 21 nodules subjected to core-needle biopsy  had calcifications, while 14  were cavitary .After CNB, out of 350 patients, the majority showed only minor complications, respectively, i.e., 146 (41.7%) pneumothorax, 101 (28.9%) intra-alveolar hemorrhage, and 26 (7.4%) hemoptysis. Three patients experienced major complications after the procedure, two of those with hemoptysis had a cardiopulmonary arrest, recovered with the intervention of the anestesiologists, while one of the patients with intra-alveolar hemorrhage had a hemothorax and, therefore, was addressed to thoracic surgeons for drainage.We investigated the prognosticators of pneumothorax, hemorrhage, hemopthysis, and cardiopulmonary arrest after CNB using a stepwise backward logistic regression analysis by including in the initial model all the most plausible predictors .p = 0.0120), the presence of emphysema , and the lesion’s maximum diameter  predicted 60.6% of the variance of the outcome variable .For pneumothorax, collectively, the distance from the pleura  and the lesion’s maximum diameter  together predicted 69.7% of the variance of the outcome variable .For intra-alveolar hemorrhage, the distance from the pleura . The most common histotype was represented by adenocarcinoma, found in 182 biopsy samples , followed by 45 diagnoses of squamous cell carcinoma (12.9%) and 16 cases of neuroendocrine tumor , of which 6  were identified as small cell carcinomas (former microcytomas). In 10 cases (2.9%), a more generic diagnosis of poorly differentiated carcinoma or non-small cell lung cancer  was made, due to the inability to better define the histotype of the pathology specimen. In six cases (1.7%), the presence mesenchymal neoplasm was found.In 20 cases (5.7%), the histological outcome was uncertain or inconclusive. In this category, we included all the cases that, despite the absence of neoplastic cells, reported cellular atypia, dysplastic/metaplastic elements, as well as the presence of atypical alveolar hyperplasia, which is a known precancerous condition, whose evolutionary potential in adenocarcinoma, however, has not yet been fully defined. Among this group, 12 patients (60% of the cohort) underwent surgical biopsy (either VATS or open) and were all diagnosed with definitive primary lung neoplasm. A total of 71 samples  were negative for neoplasm, precursor lesions, or atypia: 21 (29.6%) patients, therefore, underwent diagnostic completion by surgical biopsy and 16 (22.5% of the examined cohort) received a definitive diagnosis of lung cancer .p < 0.001) , 58 true negatives , 29 false negatives , and 0 false positives (FP). The adequacy of the sample was reported by the pathologist as “suboptimal” in 6 out of 29 cases of false negatives (20.7%), since the amount of tissue was defined as not adequate for yielding a definitive pathological diagnosis, thus requiring further invasive procedures. In 134 out of 263 positive histological samples (51%), somatic genetic mutations and molecular expression were successfully detected using alternatively immunohistochemistry (IHC), polymerase chain reaction (PCR), and fluorescence in situ hybridization (FISH). Among this cohort, 35 samples (26.1%) demonstrated TTF-1 positivity, followed by 32 cases 23.9%) showing CK7 expression. P40 expression—which is highly specific for squamous cell differentiation [.9% showi< 0.001) .p = 0.0644) predicted 92% of the variance of the outcome variable with border-line levels of significance .We also investigated the prognosticators of concordance between CNB results and final diagnosis using a stepwise backward logistic regression analysis by including in the initial model: age of the patients, the distance of the lesions from the pleura, the maximum diameter of the lesions, and the number of samples collected with CNB. The number of samples , and high social costs. In the last two decades, technical implementations in diagnostic imaging, along with the continuous development of materials and techniques in biopsies and extravascular interventional radiology broadly speaking, have contributed to ease early diagnosis and to perform minimally invasive procedures with high diagnostic power. In this perspective, our study confirms the encouraging results about the diagnostic power of core-needle biopsy: the overall values of sensitivity and specificity are in line with what has already been reported in the literature ,14,24 anThe peripheral and subpleural localization of all the lesions reaffirms and limits the indication to the procedure to the pulmonary cortex, for which it represents the first-choice biopsy procedure, due to a diagnostic performance, in this site, by far superior to bronchoscopy sampling methods and by a minimally invasive path ,28.The results concerning an accurate histological typing, along with the ability to characterize the degree of cell differentiation and the patterns of growth and invasiveness in most positive samples does confirm the high diagnostic power of the method in cases of adequacy of the sample . AnotherAlthough CNB has been constantly substituting more invasive approaches for histological diagnoses for the last decade , also taThe limitations of our study are represented by its retrospective nature, by its monocentricity, and by the loss of patients during the follow-up . A prospective controlled and multicentric study would allow the enrollment of a larger population, limiting the loss of patients after the first diagnosis and allowing a more accurate assessment of the diagnostic performance of the procedure. Moreover, it would provide a more detailed comparison among the great variety of different intra-procedural imaging protocols  about image quality and radiation safety, as well as technical outcomes for lesions of different size and density and overall diagnostic power. A prospective study may also provide further assessment concerning expected outcomes between the only core-needle biopsy versus combined FNAB-CNB procedure. In this regard, it is already known that a combined fine-needle aspiration and core-needle biopsy approach would further increase the diagnostic accuracy, providing cytomorphological information to be integrated with the evaluation of tumor architecture evaluable by the microhistological sample ,32,33.Our study confirms the evidence of the literature: CT-guided core-needle biopsy of the chest is an extremely accurate diagnostic procedure for the histological diagnosis of lung cancer, a first-level interventional radiology exam for peripheral and subpleural lesions, which is able to provide adequate material for immunohistochemistry. In the era of target therapies and cancer immunotherapy, it assumes even greater importance in the patient’s diagnostic-therapeutic process. Despite its slightly simple feasibility, further studies are, however, needed in order to implement the procedure, by comparing different radiation dose protocols and by deeply assessing differences between biopsy methods.


We indicated that every examine received all examinations after 12 hours of fasting. Well-trained technicians performed abdominal ultrasonography. Although univariate analysis revealed that the presence of fatty liver was related to hyperglycemia 10 years later, multiple logistic regression analysis did not support this finding. In the multiple logistic regression analysis fasting plasma glucose levels at the baseline and age were significantly related to hyperglycemia . Fatty liver was not an independent risk factor for hyperglycemia in our follow-up study 10 years after the first diagnosis. The high fasting plasma glucose levels were a risk factor for diabetes, even in the normal range.We examined whether fatty liver, as diagnosed with abdominal ultrasonography, is an independent risk factor for diabetes mellitus during 10 years of follow-up. A total of 840 subjects (467 men and 373 women) were followed for the entire 10 years. The criteria for being non-diabetic were having no history of diabetes, having a fasting plasma glucose level of less than 110 mg/dl and a serum hemoglobin A Type 2 diabetes mellitus is mainly associated with obesity; however, it has also been shown to be associated with a fatty liver.Recently, the prevalence of diabetes mellitus and related deaths have increased in Japan. The 1997 Ministry of Health and Welfare investigation estimated that there were about 13,700,000 patients with diabetes in Japan, of which only about 6,900,000 had been diagnosed.2 and its incidence has increased recently in Japan,3 especially in those between the ages of 40 and 50 years.4 Although the etiology of fatty liver and nonalcoholic steatohepatitis (NASH) are not completely known, studies indicate that steatohepatitis and fatty liver are related to obesity,3,5-19 dyslipidemia,5,8,9,12-14,16-18,20 type 2 diabetes mellitus,8-11,13,17,20,21 leptin,5,15 and insulin resistance.16-19,20-24 Most of these studies were case-control and cross-sectional studies. A cohort study suggested that serum γ-glutamyltransferase (γ-GTP) level was an independent risk factor for non-insulin dependent diabetes mellitus (NIDDM).25 To our knowledge, however, no cohort studies have examined the association between a fatty liver, as diagnosed on ultrasonography, and diabetes risk. Therefore, we examined whether the diagnosis of fatty liver, based on ultrasonographic results, is a risk factor for diabetes over a 10-year follow-up period.A fatty liver or steatohepatitis is the most common liver diseaseA total of 2653 subjects (1491 men and 1162 women) voluntarily visited Yamanashi Kouseiren Medical Center for general check-ups from April 1, 1991 through March 31, 1992.All the subjects lived in Yamanashi Prefecture, a rural area located about 100 km west of Tokyo. The subjects included agricultural workers, white-collar workers, and business people. All the study participants filled in a self-administered questionnaire about their smoking habits , alcohol consumption , and present and past medical histories and family medical history. The questionnaires were checked by 2 public health nurses in the center.Five well-trained technicians performed abdominal ultrasonographic examinations. These technicians had no information about the present illness, or laboratory test results of the patients. A 3.5-MHz mechanical sector-type probe  was used. All ultrasonographic images were recorded on videotape, and images of any abnormal abdominal findings were also recorded on instant film for later reviews by technicians and physicians. After the examination was complete, both the technician who conducted the examination and another technician reexamined the videotape to check for abnormal findings. Furthermore, a physician checked any abnormal findings and conducted follow-up examinations.26 These criteria include the presence of diffusely increased parenchymal echogenicity (bright liver), which is associated with an unusually fine liver texture, the increased attenuation of the ultrasound beam, and the decreased visualization of hepatic and portal veins. Subjects without any of these findings were classified as not having fatty liver.The ultrasonographic diagnostic criteria for fatty liver were made according to the modified criteria of Kurtz et al.Case records of all examinees were entered into a computer database . All the records were available and complete.2) was calculated and served as an index for overall obesity. Serum levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-GTP, fasting plasma glucose (FPG), and hemoglobin A1c (HbA1c) were examined using an auto-analyzer. We indicated that every examine receiving all examinations was after 12 hours of fasting.Anthropometric data (body weight and height) were measured simultaneously . Body mass index (BMI)  criteria.27 The 75-g oral glucose tolerance test was not included in our routine health examination.Subjects were divided into 2 groups according to followed criteria: the normal was defined as FPG level <110 mg/dl and HbA1c levels and no history of diabetes. Among these subjects, 840  underwent a follow-up examination between April 1, 2000, and March 31, 2001  had normal FPG and HbA31, 2001 . Many ofP < 0.05 significance level was selected for all analyses. All statistical analyses were performed using the Statistical Analysis System version 6.12 .Data are expressed as mean ± standard deviation (SD). The following statistical tests were applied as appropriate: Mantel-Haenszel estimates of odds ratios (OR) with 95% confidence intervals (CI); unpaired Student’s t test; chi-squared test with Fisher’s exact test; and multiple logistic regression analysis. A 2-tailed 1c levels at baseline . Among the subjects with normal values, we compared body constitution and laboratory results of the 840 subjects who underwent follow up examinations 10 years later  (group A) with the 1465 subjects who did not undergo follow-up examinations 10 years later (group B). The prevalence of fatty liver was not significantly different between these 2 groups . Among women, values for FPG , TC , and TG levels  were significantly lower in group A than in group B, respectively , AST (P = 0.002 and P = 0.019), ALT (P = 0.001 and P < 0.001), TG (P = 0.001 and P = 0.037), and FPG (P = 0.005 and P = 0.009). Significantly lower levels of HDL-C were seen in the non-fatty liver group than the fatty liver group for both men (P = 0.001) and women (P < 0.001). Among men, γ-GTP (P = 0.016), TC (P < 0.001), and HbA1c (P = 0.005) levels were significantly higher in the fatty liver group than in the non-fatty liver group. There were no significant differences for men or women in the alcohol drinking habits and the family history of diabetes between the 2 groups. Similarly, there were no significant differences in the amount of alcohol consumption for drinkers in both groups (data not shown). There were no significant differences in the frequency of the medical check-ups, or the ratio of BMI changes during the ten years between the 2 groups.The body constitution and serum analysis at baseline, frequency of medical check-ups, alcohol drinking habits, and a family history of diabetes in subjects with fatty liver and non-fatty liver are shown in 1c at baseline, BMI changes, frequency of examinations, alcohol drinking habits, and family history of diabetes  after adjusting for sex, age, BMI, FPG, and HbAdiabetes . SimilarMen who did not drink alcohol or who drank alcohol less than 40 g/week were looked at to examine the relationship between non-alcoholic fatty liver and diabetes. There are 20 cases of hyperglycemia in the group of 136 non-diabetic men. There was a significant association between the fatty liver group and hyperglycemia . However, no significant association was seen in multiple logistic regression analysis .Among non-obese males (BMI of 24.2 or less at both baseline and the end of follow-up), FPG levels at baseline were related to hyperglycemia 10 years later  as shown by multiple logistic regression analysis.8-11,13,17,20,21 although these studies were case-control or cross sectional studies. However, using multiple logistic regression analysis adjusting for age, BMI, FPG levels, and HbA1c levels at baseline, BMI changes, drinking habits, parental diabetes, and frequency of check-ups, no association was observed. Thus it does not appear that the presence of fatty liver is an independent risk factor for hyperglycemia.Our study shows that fatty liver is associated with hyperglycemia among apparently healthy people followed over a 10-year period . These results are in agreement with previous studies,28 In terms of obesity and fatty liver, previous studies have shown that fatty liver occurred more frequently in obese subjects than in normal-weight subjects.3,5-19 The BMI levels were significantly higher in the fatty liver group than in the non-fatty liver group in our study. Although there was not difference in age between fatty liver group and non-fatty liver group, Nomura4 showed that the prevalence of fatty liver was higher in 40s than 30s of age. We think that these factors lead to the diminution of the association of fatty liver and hyperglycemia over time.Obesity, aging, lack of exercise, genetic factors, and stress are known as risk factors of type 2 diabetes mellitus.Our study should be interpreted carefully, however, because of the limitations in the study design. First, our population sample consisted of people who voluntarily decided to have the examinations. They may be more concerned with their health than people who have not received physical check-ups. We do not know how many people have diabetes or fatty liver in our area because no investigation of these people was performed. From this reason, we guessed that the prevalence of hyperglycemia in our study was less than that of the general population in our prefecture. Second, the number of subjects in group A represented about one third of subjects. The members of this group may be particularly concerned with their health or have other health problems. There were no significant differences between groups A and B in terms of the prevalence of fatty liver. However, among women, FPG, TC, and TG levels were significantly lower in the group A than in group B. It is thought that some of the women in group B in this study were diagnosed with diabetes and went to other clinics, so they did not receive a follow-up examination 10 years later. This may be one of the reasons that the prevalence of fatty liver among women in this study was low. The results of multiple regression analysis showed the same results among men and women. Finally, the men and women who were diagnosed with fatty liver had consultations with doctors and nurses. Therefore, there is a high possibility that they changed their eating and exercise habits, which could have influenced the prevalence of diabetes. Thus, the relation between fatty liver and diabetes in our study may be underestimated.16-19,22-24 reported that there were associated with insulin and hepatic insulin resistance even in the absence of diabetes in subjects with steatohepatitis, fatty liver, and NASH. Perry et al25 performed a cohort study and reported that raised γ-GTP levels are an independent risk factor for NIDDM. Given the results of previous studies, we suspected that fatty liver leads to future diabetes. Our results showed that fatty liver is associated with diabetes, but is not an independent risk factor for diabetes.Previous studies29 A previous study in which ultrasonographic findings were compared with histologic results also indicated that the overall sensitivity and specificity of ultrasonographic examinations for the diagnosis of fatty liver are approximately 80% to 95% and 90% to 95%, respectively.30 Many names have been applied to the same condition. Ludwig et al11 shows the terminology for steatohepatitis and a classification of NASH.In terms of the diagnosis of fatty liver, a liver biopsy is necessary to precisely diagnose as fatty liver and determine the types of fatty liver diseases. Invasive procedures were not allowed in the present study. Abdominal ultrasonograms are noninvasive and an easy method for examining liver conditions and other organs. A previous study indicated that ultrasonographic detection and quantitative hepatic fat accumulation are similar with computed tomography and liver biopsy.The results of this study show that FPG levels at baseline were related to hyperglycemia after 10 years, even when FPG levels were in the normal range. FPG levels were also associated with diabetes among men with normal weight and no diabetes. Men who had high FPG levels, even with normal weight, should be careful to maintain a lifestyle to prevent diabetes. We cannot explain about women in detail because the number of women in our study who suffered from diabetes was small.It is not clear what kinds of people with fatty liver and steatohepatitis are at high risk for diabetes in the future. Further investigations including genetic factors are required.


The database is available at 10.17632/kj443jc4yc.1. Acoustic therapies were monitored one week after, three weeks after, five weeks after, and eight weeks after the acoustic therapy. This study was previously approved by the local Ethical Committee (CONBIOETICA19CEI00820130520), it was registered as a clinical trial (ISRCTN14553550) in BioMed Central (Springer Nature), the protocol was published in 2016, it attracted L’Oréal-UNESCO Organization as a sponsor, and six journal publications have resulted from the analysis of this database.The present database provides demographic (age and sex), clinical (hearing loss and acoustic properties of tinnitus), psychometric  and electroencephalographic information of 89 tinnitus sufferers who were semi-randomly treated for eight weeks with one of five acoustic therapies. These were (1) placebo (relaxing music), (2) tinnitus retraining therapy, (3) auditory discrimination therapy, (4) enriched acoustic environment, and (5) binaural beats therapy. Fourteen healthy volunteers who were exposed to relaxing music and followed the same experimental procedure as tinnitus sufferers were additionally included in the study (  In fact, around 70% of tinnitus cases are preceded by a mental disorder. Patients with highly distressing tinnitus can additionally have cardiovascular, endocrine or metabolic diseases2.Tinnitus is a multifactorial and heterogeneous condition highly associated with hearing loss (HL), age, sex, marital status, education, and even, employment. Furthermore, a large number of tinnitus sufferers (around 65%) eventually present sleep disorders, emotional and cognitive distress  or any other mental condition3 based on a survey conducted by the web platform Tinnitus Hub, where 5017 tinnitus sufferers participated, seven of the 25 most widely used treatment were sound based therapies. From the most to the least applied therapies, these were: 1st self sound stimulation, 6th masker, 11th Tinnitus Retraining Therapy (TRT), 18th notched music, 19th soundcure, 20th acoustic neuromodulation, and 21st neuromonics. As can be seen, almost one third of the current available treatments for tinnitus depends on sound effect on body functioning. It is well-established that sound brings about physiological, cognitive and psychological changes4. However, it is still unknown how sound-based treatment alleviate or palliate tinnitus, and what is the appropriate therapy for each clinical case due to its heterogeneous nature.Tinnitus is a heterogeneous affection with no standard effective treatment. A recent study5, authors presented a review of computational methods to analyse EEG signals for evaluating the sound effects of acoustic therapies at a cortical level. Over the past two years, the acoustic therapies that have been assessed are (1) neuromodulation, (2) auditory residual inhibition, (3) binaural beats therapy (BBT), and (4) auditive discrimination therapy (ADT). In the first case6, neuromodulation therapy was applied for 75 days, and EEG monitoring was undertaken every two weeks. It was found that the level of EEG connectivity diminished considerably. In the second case, auditory residual inhibition did not reduce significantly the tinnitus loudness, and this finding was supported by EEG evidence since band power in alpha and gamma increased in magnitude7. Similarly, alpha band power in auditory areas increased during auditory residual inhibition in the study conducted in8. In the third case, BBT reduced stress (23% of patients) and tinnitus perception (15% of patients), and it slightly reduced EEG synchronicity over the right frontal lobe9. In the last case, the level of EEG synchronicity due to auditory processing decreased due to the attentional redirection achieved by ADT10.To measure the sound effects of acoustic therapies on tinnitus, electroencephalographic (EEG) monitoring has been proposed. In12. ADT intends to redirect the patient attention towards the therapy by presenting a composed sound of standard and deviant pulses in a random way, and thus reducing tinnitus perception13. EAE intends to prevent HL, and subsequent plastic tonotopic cortical map changes after acoustic trauma. EAE is based on a sequence of random frequency tones with amplitude proportional to the HL reported on the patient audiometry14. BBT consists of two pure tones presented on each ear, having a difference in frequency according to the target oscillatory EEG band. The use of this therapy has reported reduction of stress levels by reducing activation of areas in the sympathetic system15, what in turn reduce tinnitus perception. In addition to the 89 tinnitus sufferers, 14 healthy volunteers were recruited, exposed to relaxing music (same as control group), and followed the same experimental procedure, as tinnitus sufferers.As can be seen from previous studies, EEG analysis is a helpful tool to evaluate the sound effects of acoustic therapies, in addition to psychoacoustic and clinical assessments. For this reason, the present database provides demographic, clinical, psychometric, and EEG information of 89 tinnitus sufferers who were randomly treated for eight weeks with one of five acoustic therapies. These were (1) relaxing music (placebo), (2) tinnitus retraining therapy (TRT), (3) ADT, (4) enriched acoustic environment (EAE), and (5) BBT. TRT seeks to reduce tinnitus by reducing the loudness perception of the unreal soundemographic information refers to residence place, gender, age (higher than 18-year-old), and nationality. Second, clinical history includes HL level, and frequency, laterality, and intensity of tinnitus perception. Finally, psychometric and EEG monitoring of the acoustic therapies is included, as well. It is important to note that the initial cohort was of 108 participants, 103 of them were included in the study, and 71 of them completed the experimental procedure. See Fig. In total, the database contains four types of information sources of 103 participants. See Table Psychometric monitoring was based on the Spanish version of the Hospital Anxiety and Depression Stress (HADS), and the Tinnitus Handicap Inventory (THI), which provided psychoacoustic effect of acoustic therapies. On one hand, HADS questionnaire evaluates anxiety and depression impact of tinnitus16. On the other hand, THI questionnaire measures the degree of tinnitus perception; emotional, physical, and social response to tinnitus; and tinnitus intrusiveness on audition17. Further details concerning the questionnaire-based monitoring of this study protocol can be found in18.EEG information gives an insight into neuroplastic changes (if any) of acoustic therapies. The available EEG datasets make possible to undertake signal analysis in three modes: spontaneous, evoked, and induced EEG activity. In most of previous studies, only spontaneous activity has been analyzed, namely, participants were either at resting state or at listening to their acoustic therapy. However, EEG signals provide more in-depth neural information when they are related to specific motor, emotional, sensory, perceptual and/or cognitive events. This refers to evoked and induced EEG activity. Traditional patterns for evoked and induced EEG activity are event-related potentials and event-related (de-) synchronization, what can be estimated from the present databank. Spontaneous activity analysis helps to evaluate nature of ongoing activity. In contrast, evoke and induced activity analysis allows studying brain responses when individuals perceive the sound, pay attention to the stimulus, make a decision, and act accordingly. In brief, both bottom-up and top-down mechanisms associated with neuroplastic changes due to acoustic rehabilitation can be studied by using the present databank.19, and registered under the trial number: ISRCTN14553550. The database is available at20.The present database was created by following a protocol formerly approved by the Ethical Committee of the National School of Medicine of the Tecnologico de Monterrey, described and published inThe study protocol was conducted as follows. All of the participants were informed about the experimental procedure and signed a consent form, where they authorized the publication of their collected data and the results of their follow-ups. Most of patients were recruited from the National Rehabilitation Institute, and they were additionally notified that their head physician was also following-up the investigation. Head physicians provided clinical histories and demographic information of patients.All the patients who accepted to participate in the study were assigned to one of five groups: 1) TRT, (2) EAE, (3) ADT, (4) BBT and (5) placebo. Patients with no severe HL were randomly assigned to placebo and EAE groups. On the other hand, patients with a well-identified tinnitus pitch were included in TRT or ADT groups. Patients with tinnitus lower that 1 kHz were assigned to BBT. Control group  was asked to use the same relaxing music as placebo group. On average, 17 volunteers were assigned per group 20.All of the participants (both with and without tinnitus) were instructed to use the corresponding acoustic therapy for one hour every day, at any time of the day, and for eight weeks. The therapy was monitored four times along the two months: the first session 1), the third session 2), the fifth (session 3), and the eighth (session 4) week after having initiated the therapy. At each monitoring session, the THI and HADS questionnaires were applied, and an EEG recording was made, as illustrated in Fig. , the fif, the thi21.Audio players were provided for patients. These audio players had a 4 Gb memory, and included a pair of headphones, and a battery charger. The frequency response of headphones was tested to guarantee the proper reproduction of acoustic therapies, and volume limit was adjusted to the patient audiometry. However, some patients preferred to use their own devices. To record the daytime and the daily duration of acoustic therapies, they are currently offered in an online modeg.USBamp amplifier of EEG signals was used. This system is a high-performance and high-accuracy biosignal amplifier with sixteen EEG channels . These channels can be acquired up to 32 700 samples per second within a bandwidth between 0 and 100 Hz. For this study, the amplifier was configured to record the EEG signals at a sampling frequency of 256 Hz. The Cz channel was used to reference the rest of the channels, and left lobe ear worked as ground. The montage of the EEG channels was according to the 10/20 International System and is depicted in Fig. To record EEG activity, a g.USBamp was connected to the computer via OpenViBE platform, where experimental paradigm was implemented. OpenViBE was configured to digitally filter EEG signals by a band-pass, and a notch filters. The band-pass filter was a Butterworth design of 8th order with cut-off frequencies between 0.1 and 100 Hz. The notch filter was similarly a Butterworth design of 4th order at 60 Hz. Before each recording, OpenViBE was used to measure electrode impedance, which was equal to or lower than 5kohms for being acceptable.The Experimental procedure was undertaken in a well-equipped research laboratory with sufficient conditions to attend volunteers, and record EEG data. Laboratory conditions refer to a quiet atmosphere, water and toilet services, washing facilities, quiet air conditioner and parking place. The laboratory had a low background noise around 35 dBA.As was mentioned above, acoustic therapies were applied for eight weeks, and monitored four times. THI and HADS questionnaires were completed in session 2 (S2), session 3 (S3) and session 4 (S4). EEG signals at resting state (baseline) for six minutes were recorded in session 1 (S1) and S4. In addition, three minutes of EEG recording was undertaken in S4 when participants were listening to their corresponding acoustic therapy. Finally, evoked/induced activity was recorded as well in two different modes: passive and active. Passive mode (PM) for 2.5 minutes was recorded in all of the four sessions, and active mode (AM) was recorded from S2 to S4. EEG recording procedure is described in detail below and illustrated in Fig. Baseline was recorded in S1 and S4. The participants were asked to sit down on a comfort chair with their eyes open at looking at a fixed point on a computer screen for three minutes. After this three-min period, they listened a beep sound once, and they had been previously instructed to close their eyes for three minutes. In total, six minutes for baseline were registered.This mode was recorded at S4, when the assigned acoustic therapy had been already applied for eight weeks. For this mode, participants sat down with their eyes close (EC) and listened to their corresponding acoustic therapy for three minutes.PM was the only condition recorded in the four sessions. Participants were stimulated around two minutes with a sequence of 50 auditory stimuli of one second with an inter-stimulus interval of two seconds. Participants were asked to keep their eyes closed during the auditory stimulation. Every auditory stimulus was in line with the acoustic therapy in use.restaurant: (i) human sound (tasting food), (ii) microwave sound, (iii) glass breaking, (iv) door closing, and (v) soda can being opened; (2) park: (i) camera clicking, (ii) turning a book page, (iii) cards shuffling, (iv) human laughing, and (v) human whistling; and (3) construction in progress: (i) human sound (yelling), (ii) police siren, (iii) mobile dialing, (iv) bang and (v) hit. All the stimuli lasted 1 s and were repeated 50 times at a random rate.AM was recorded at S2, S3, and S4, and EC was requested as possible. Three different soundscapes were played, while five associated auditory stimuli were randomly played. In order to identify auditory stimuli, participants pressed a keyboard button. The soundscapes, and their related auditory stimuli to be identified for each monitoring session were: (1) Raw signals are provided in the present database, in two formats: GDF and SET.th, 2021 at Mendeley Data20.This database was published on September 17On one hand, demographic, clinical and psychometric data of participants is provided in an Excel-file. This file must be read from left to right, and the top of the columns as headers. Each row represents a participant. In some cases, the information would not be available, and unavailability was represented as ‘- ’. EEG-files are provided in GDF and SET formats. Both of them can be imported by using the MATLAB open-source toolbox, EEGLAB.Excel-file and EEG-files are provided in the main folder. EEG-files are organized in three levels: (1) group, (2) patient, and (3) recording condition. See Fig. Interactions with and instructions given to participants during the EEG recording were marked with event numbers. In total, 13 events were marked along the GDF-files. Depending on the type of file, the events used in each experimental condition changed. Then, events per file type are defined in Table A person-centred and needs-based approach that is a common practice in rehabilitation audiology was followed in the present study design. That is, each acoustic therapy was adjusted to the HL and acoustic tinnitus characteristics of each participant, what are indeed reported in Fig. On the other hand, only patients with subjective tinnitus were recruited. Tinnitus can be objective, when sound is generated in the body, or subjective, when no specific inner body sound source. To avoid recruiting patients with objective tinnitus, all of those with any history of otitis, cerebellopontine angle tumours, psychiatrist pathologies, demyelinating diseases of the nervous system, or epilepsy were excluded from the study protocol.Finally, it is important to note that an age-matched control group, which followed the same procedure that experimental group, was included. The daily exposure to any kind of sound can lead to habituation not related to tinnitus palliation. Therefore, it was relevant to have a control group to monitor unrelated habituation changes.19, it attracted L’Oréal-UNESCO Organization as a sponsor, and six publications have resulted from the analysis of this database22.The present study was previously approved by the local Ethical Committee (CONBIOETICA19CEI00820130520), it was registered as a clinical trial (ISRCTN14553550) in BioMed Central (Springer Nature), the protocol was published inThe sample tracking system adopted for this study was in four different directions: (1) a clinical support by the head-physician, (2) demographic information collection, (3) psychometric evaluation, and (4) EEG monitoring. Sample age and gender are presented in Fig. In addition, a psychometric evaluation was undertaken during the acoustic treatment at three different stages of the procedure. This evaluation concerned tinnitus perception assessment (based on THI), and stress/anxiety monitoring (based on HADS). THI-evaluation revealed light, mild, moderate, severe or catastrophic impairment due to tinnitus along the acoustic treatment. See Fig. Finally, an EEG-based monitoring throughout the acoustic therapies was carried out. EEG information is a window to understand the nature of tinnitus, and the possible neuroplastic changes provoked by acoustic therapies. EEG signals provided in this database can be analysed in three different modalities: (1) spontaneous, (2) evoked and (3) induced modality. From those modalities, neuro-markers can be estimated from spontaneous activity, and/or codification and retrieval of auditory material masked by tinnitus perception can be analysed from evoked and induced activity .23. IAF is around 10 Hz in healthy adult individuals, and reflects the functionality of the Central Nervous System, the mental health and the cognitive functions24. Several studies have demonstrated that IAF diminished when neuroplastic changes occurred in traumatic lesion, schizophrenia, attention deficit disorder, and post-traumatic stress. From the figure, it can be seen that mean IAF is below 10 Hz, as is expected owing to the neuroplastic changes provoked by refractory and chronic tinnitus. However, this result is not conclusive since control group has an IAF below 10 Hz, as the rest of the groups. This result is not surprising since IAF slowly decreases in elderly individuals, as well25. The main purpose of results in Fig. As a case in point, individual alpha frequency (IAF) was estimated from EEG signals in spontaneous modality (EO and EC condition), and shown in Fig.


Recently, a considerable amount of literature has been concerned with the impact of screen time on physical activity. Furthermore, recent evidence reveals that children under 14 spend an average of 23 hours each week looking at screens, including watching TV and DVDs, playing video games, or using a computer or mobile device. This study aimed to determine the relationship between technology use and physical activity. 277 parents completed an online questionnaire in this cross-sectional investigation. The questionnaire comprised 44 closed-ended questions divided into three sections: demographics, the impact of technology on children, and the Children's Physical Activity Questionnaire (CPAQ). 88 (31.8%) of children reported up to 5 hours of screen time per day, while 189 (68.2%) reported 6 hours or more. According to the CPAQ, 131 (47.3%) children had a low level of physical activity, 96 (34.7%) had a moderate level, and 50 (18.1%) had a high level. There was a strong relationship between parental age and child screen time, with 24.9% of children with screen time greater than 6 hours having parents aged 35–40 years, compared to 28.4% of children with screen time less than 5 hours having parents aged 25–30 years. Inadequate physical activity in children was linked to the number of siblings, ownership of electronic devices, and screen time. Physical activity should be increased through lifestyle changes that the entire family can implement. Recently, there has been an increased interest in using various forms of technology. The use of cell phones and computers has expanded over the previous two decades, increasing reliance on these technologies for day-to-day work . ChildreFurthermore, it was previously observed that electronic devices improve children's learning abilities, communication skills, language ability, analytical capacity, creative thinking, and extraction of both academic and non-academic activities . HoweverThe use of technology can contribute to poor health by increasing disease and reducing physical activity, particularly among children. Children who use technology are more likely to develop obesity, type 2 diabetes mellitus, all-cause mortality, metabolic syndrome, and various medical and psychological disorders –13. CorrThe use of technology in children may directly or indirectly affect the level of physical activity. Cardiorespiratory fitness, obesity, the quality of physical education programs, TV consumption, and parental influence appear to be the major determinants of physical activity in Saudi children and adolescents . PhysicaThis cross-sectional study used an online questionnaire to collect data on technology use and physical activity among children between 6 to 12 years living in the eastern region of Saudi Arabia. The questionnaire was developed based on modified questionnaires from a prior study . A link ® , Xbox® , or Wii®  or playing internet games, playing on a portable games console and use of Facebook or other social networking sites, e.g., Twitter or Instagram.The first section was designed to collect demographic and education data for the parents, the child, and information regarding the family. The second section represented the Children's Physical Activity Questionnaire (CPAQ), where parents were asked to rate the type, frequency, and length of physical and sedentary activities, including school and leisure time, over the previous seven days. The first component of the questionnaire analysed seven-day activities outside school time, such as soccer, volleyball, tennis, swimming, basketball, and running. The following subsection assessed leisure activities such as bike riding, home chores, pet play, trampoline, scooter, playground equipment play, walking, or skipping rope. The response options were "yes" or "no", and the total amount of time spent on the activity during the week was stated in hours per week. The last section was the Impact of Technology on Children questionnaire designed for children aged 4 to 12 and included questions about the child's technology use, after-school activities, sleep patterns, behaviour, and emotions. Only questions about the child's technology use were used for this study. This section of the survey contained questions concerning the child's electronic device ownership, including the number and type/s of device/s possessed by the child, the age at which the child first acquired a device, the number of hours per day spent viewing television or DVDs and playing video games such as PS3Following data extraction, data were reviewed, coded, and entered into the statistical software program IBM SPSS version 22 . Two-tailed tests were used for all statistical analyses. A p-value of less than 0.05 was considered statistically significant. For statistical purposes, technology consumption time was dichotomized using the median as a cut-off point: total hours spent on the internet, social media, video games, and portable devices were computed, and individuals were separated into two groups. Children who spent five hours or less on screens (screen-time ≤5 h) were classified as low screen-time users, while those who spent six hours or more on screens (screen-time ≥6 h) were classified as high screen-time users. Physical activities were divided into three groups for the CPAQ based on the metabolic equivalent of task (MET): light-intensity (MET 3), moderate-intensity (MET 3 to 6), and vigorous-intensity (MET>6). We performed descriptive statistics (frequency and percent distribution) for all variables, including parents' and children's demographic data, screen time use for different devices, physical activity using CPAQ, and children's electronic device ownership. The Pearson chi-square test was used to examine the distribution of students' screen time consumption, demographic data, and physical activity. A logistic regression model was utilised to determine the most significant determinants of inadequate physical activity among children.Data from 277 children were collected through their parents or caregivers. 88 (31.8%) children reported up to 5 hours of screen time daily, while 189 (68.2%) reported 6 hours or more . Based oThere was a significant association between parents' age and children's screen time, with 24.9% of children with >6 hours of daily screen time having parents aged 35–40 years, and 28.4% of children with daily screen time <5 hours having parents aged 25–30 years P=.021, . Also, 444.4% of children with daily screen time >6 hours were aged 10–12 compared to 29.5% with <5 hours P=.026, . Also, 6versus 69.3% of children who used screens for >6 hours (P=.001).More than half (56.8%) of the children with <5 hours of screen time daily had a high level of physical activity compared to those who used screens for >6 hours . Also, nAmong all included predictors, the number of children in the family, having electronic devices, and high amounts of screen time were the most significant predictors of low physical activity . ChildreOur study found that most children spent more than 6 hours on screen, and almost half had a low level of physical activity on the CPAQ. These findings correspond with research in Saudi Arabia , 26, SpaThe mean age of parents of low-user children was lower than those of children spending more time on screen, which was inconsistent with a previous study in Spain in which children of younger parents were more likely to use technology . SimilarThe current study found no significant relationship between parental educational level, marital status, or monthly income and technology use. This finding contradicts a recent study where children from lower-income households used smartphones and tablets more frequently and for longer periods than those from higher-income households . AnotherLow physical activity is significantly related to children who use screens for 6 hours or more in the current study. These findings confirm prior research that found significant relationships between higher screen time and lower levels of physical activity , 37, indThis study contributes to the evidence by identifying an association between various types of technology use and physical activity in typically developing Saudi children aged 6–12 years old. The instrument was a self-reporting questionnaire, and some parts of the questionnaire were very long, which may have influenced the responses of parents and the overall analysis. Furthermore, according to the findings, future studies should use longitudinal and experimental designs, and utilize both subjective and objective measures of screen use.The current research was conducted to determine the link between technology use and physical activity in typically developing Saudi children aged 6–12 years. According to our findings, about half of the children had a low level of physical activity. The second key finding was a strong association between the number of children in the family and screen time, with nearly half of children with more than 6 hours of screen time having 2–3 siblings. This study also discovered that youngsters who use screens for 6 hours or more have lower physical activity levels. The study found that the number of siblings, ownership of electronic devices, and screen time were the most important predictors of low physical activity.Therefore, it is crucial for parents to set limits and boundaries with their children regarding the amount of time they spend each day using technology. At the same time, increasing physical exercise through lifestyle changes involving all the family and scheduling a time each day for outdoor activity, playtime, and minimize screen time is suggested. An implication of this study is that health care providers may regularly screen children and assess them for physical health requirements and provide interdisciplinary care integrated with the community. As a result, health promotion measures aimed at reducing the number of inactive Saudi children should be a top public health goal.


Rapamycin could improve the developmental competences of the post-maturation oocytes during in vitro aging, yet its effects on the IVM process of oocytes from an aged population were not clear. In this study, the immature oocytes from aged mice or older women underwent IVM with or without 10 nM rapamycin, followed by parthenogenetic activation or insemination and embryo culture. The developmental competence and quality of IVM oocytes in both groups were compared. The results showed that in aged mice, the maturation rate, activation rate, and cleavage rate of IVM oocytes were significantly elevated in the rapamycin group. Additionally, oocytes cultured with rapamycin presented decreased ROS levels, reduced chromosome aberration, and attenuated levels of γ-H2AX. During IVM of oocytes from older women, the GVBD rate, 24 h maturation rate, and 48 h maturation rate were increased in the rapamycin group, compared with those in the control group, although without significant differences. After intracytoplasmic sperm injection (ICSI) and further culture of human oocytes, the high-quality embryo rate in the rapamycin group was significantly elevated. Overall, rapamycin improved IVM outcomes of oocytes from aged mice and older women. The specific mechanism of the positive effects of rapamycin on IVM outcomes might be reducing ROS levels, mitigating DNA damage, and promoting developmental potential.Women over age 35 suffer from the inadequate number and poor quality of oocytes during assisted reproductive treatment, and making full use of the oocytes by  Delayed childbearing is an increasingly common phenomenon worldwide. The mean age of mothers at first birth has been on the rise over the last decades , leadingin vitro maturation (IVM) of immature oocytes during conventional controlled ovarian hyperstimulation (COH) cycles could partly increase the available embryos for women of all ages, especially for those with lower ovarian reserve [in vitro showed lower developmental potential than those derived from oocytes matured within an ovary [Rescue- reserve –11. Nevean ovary , 13, thuStreptomyces hygroscopicus, was discovered in 1975 and applied to immunosuppressive and antifungal therapy [in vitro aging [Rapamycin, a macrolide metabolite produced by  therapy , 15. Pre therapy –19. In o therapy . In latero aging , 22, yetTherefore, the current study aimed to estimate the impact of rapamycin on the quality and developmental competence of IVM oocytes from aged mice, confirm its protective effect on DNA integrity, and preliminarily verify the positive effect specifically in women over age 35.P = 0.035). Following parthenogenetic activation (PA), the activation rates, cleavage rates, and blastocyst formation rates in the rapamycin group were also increased to some extent, compared with those in the control group , as shown in On average, the number of immature oocytes retrieved per mouse (aged 40~48 weeks) was 18.3 ± 1.5. After IVM, the maturation rates of oocytes in the rapamycin group were significantly higher than those in the control group . No significant difference in the abnormal rates of spindle morphology was observed between the two groups . Moreover, the levels of mitochondrial membrane potential (MMP) in the oocytes were also evaluated. The MMP levels slightly increased in oocytes of rapamycin group, compared with those of control group (2.0 ± 0.1 vs. 1.8 ± 0.3), yet without statistical significance (P = 0.485).The quality of IVM oocytes was assessed from three aspects: spindle structure, chromosome arrangement, and mitochondrial activity. As shown in P < 0.001). Additionally, the DNA damage levels were assessed by examining γ-H2AX intensity in oocytes. The results showed that γ-H2AX levels were reduced significantly in the oocytes of rapamycin group .As shown in P = 0.088). The maturation rate of oocytes in the control group was 50.0% at 24 h and reached 65.6% at 48 h, and in the rapamycin group, the maturation rate was 59.7% at 24 h (P = 0.295) and 80.6% at 48 h (P = 0.075).As shown in in vitro were collected for further insemination and continued culture. The results indicated that there was no significant difference in the normal fertilization rate (two pronuclei formation) between the rapamycin group and the control group , but the high-quality embryo (HQE) rate in the rapamycin group was significantly increased .In order to assess the developmental competence of the IVM oocytes, oocytes matured In the current study, IVM of oocytes from aged mice and humans was performed and the effects of rapamycin on the developmental competences and qualities of IVM oocytes were investigated. The results showed that rapamycin increased the maturation rate, PA rate of IVM oocytes, and cleavage rate of the PA embryos in aged mice. Simultaneously, rapamycin also improved the chromosome arrangement, reduced ROS levels, and rescued DNA damage in the IVM oocytes. Moreover, the developmental competences of IVM oocytes from women over age 35 were also improved by rapamycin, with significantly more HQE obtained.Combined with our previous experimental data in young mice obtained under the same experimental conditions , we founBy adding 10 nM rapamycin to the IVM medium, we observed the ameliorative effects in aged mouse oocytes including the increase in maturation rate, activation rate, and cleavage rate; and the decrease of abnormal chromosome arrangement, ROS levels, DNA damage levels, which were in accordance with our results detected in young mice . We, thein vitro after maturation. In 2014, Lee et al. performed IVM in porcine cumulus-oocyte complexes (COCs) for 44 h and continued culture for 24 h or 48 h to induce oocyte aging, and different concentrations of rapamycin were added during the aging process. The results showed that 10 μM rapamycin significantly improved the developmental competence and spindle morphology of oocytes aging for 24 h, decreased ROS levels, up-regulated the expressions of a variety of development-related genes, and significantly increased the blastocyst formation rate and improved blastocyst quality after PA [in vitro oocyte aging, the subsequent activation rate, cytosolic calcium level, and ROS level of oocytes were decreased, the blastocyst formation rate was increased, and the spindle morphology and chromosome arrangement were significantly improved, compared with the control group [However, it is undeniable that in the current study regarding IVM oocytes from older women, the addition of rapamycin still increased the HQE rate from 12.8% to 35.3%, with a statistical significance. Good embryo quality, according to previous studies, was markedly related to higher implantation rate, clinical pregnancy rate, and live birth rate –33. Simiafter PA . Similarol group . Overallin vitro in aged populations. Based on these results, we believe that rapamycin has considerable application prospects in improving oocyte quality (both in vitro and in vivo) and assisted reproductive outcomes in older women.More importantly, studies on rapamycin for aging-related diseases and prolonging lifespan have been increasing in recent years, and the anti-aging effect of rapamycin on various organs including ovaries has been demonstrated in mice –37. DuriOverall, our results from mice to humans provided a basis and reference for clinical practice. As for the safety of rapamycin treatment, our previous study has proved that the addition of rapamycin did not cause extra aneuploidy and could provide embryos with normal karyotypes. Considering that rapamycin has been approved by the FDA for preventing organ rejection and treating cancers , its safIn conclusion, our study preliminarily proved the effects of 10 nM rapamycin for improving IVM outcomes in oocytes from aged mice and older women. The specific mechanism might be reducing ROS levels, mitigating DNA damage, and promoting developmental potential. Further studies will be focused on the expanded sample size validation of rapamycin effects, safety assessments, and long-term impact follow-up to provide evidence for precise clinical translation and better improve IVM outcomes.2 in humidified air. Following IVM, MII oocytes were recognized with the extrusion of the first polar body (PB1), and the maturation rates of the control group and rapamycin group were recorded and compared.For the animal experiment, ICR mice aged 40~48 weeks were purchased from Beijing Vital River Laboratory Animal Technology Co., Ltd. Totally, 18 aged female mice were sacrificed by cervical dislocation and 241 oocytes were obtained. All the experiments were repeated three independent times. Specifically, the bilateral ovaries were isolated, transferred into M2 medium  containing IBMX , and punctured with sterile needles to release immature oocytes. After being washed five times in M2 medium, the denuded GV oocytes were moved to the IVM medium , with or without 10 nM rapamycin , and then cultured for 16 h at 37°C under 5% COThe procedures of PA were as previously described . OocytesThe immunofluorescence staining of mouse oocytes was performed as previously described . Briefly2, and 5% O2) under time-lapse monitoring. The dynamical parameters of oocyte nuclear maturation, including the time of GVBD and PB1 extrusion, were recorded. Subsequently, the matured oocytes were inseminated by ICSI, using the sperm of the patients’ husband. The fertilized oocytes from both groups were further cultured in G1-plus medium. After 16–18 h, fertilization status was checked and the presence of two pronuclei was identified as normal fertilization. The zygotes were then cultured to the cleavage stage. Embryo quality was evaluated on day 2 or day 3. HQE were defined as normally fertilized embryos with symmetrical blastomeres (no less than six) and fragmentation less than 20%, according to the Cummin’s criteria [Couples undergoing ICSI owing to male-factor infertility from June 2021 to May 2022 in our center were registered, and women aged 35 and over were selected. The specific inclusion and exclusion criteria were as previously described . The inccriteria , 42.t-test. Categorical data were expressed as number (frequency) and analyzed with Chi-Square test. Wald P-values were two-sided; P < 0.05 was considered to be statistically significant.SPSS software 22.0  and Graphpad Prism 8.0  were used to analyze and visualize the data. Continuous data were presented as mean ± SEM and analyzed with Student’s


This study aimed to review the literature related to the intrusion of maxillary posterior teeth in subjects needing pre-prosthetic restoration or orthodontic treatment due to anterior open bite, and to report a thin alveolar biotype case needing a pre-prosthetic intrusion of maxillary teeth by introducing a novel, personalized method of intrusion measurement. An electronic search was conducted between February 2022 and March 2022 in the following databases: PubMed, Scopus, Embase, Web of Science, and Lilacs; the terms “tooth movement techniques”, “orthodontic anchorage procedures”, “tooth intrusion”, “intrusion”, “molar”, “premolar”, and “human” were surveyed. Eighteen articles were included in this review; the mean amount of intrusion ranged from between 2.1 ± 0.9 mm and 4.57 ± 0.98 mm (being mostly 2–3 mm). The intrusion force varied between 100 and 500 g; 10 articles reported miniscrews (MS), 7 reported zygomatic plates (ZP), and 1 publication reported both anchorage types. The average treatment time was 6.9 months for MS and 7.9 months for ZP. Levelling the occlusal plane by intrusion of the upper posterior teeth can be achieved by skeletal anchorage. The stability of the obtained results, shortening treatment time, and controlling treatment outcome are the main goals for a complex surgical and orthodontic treatment approach. Levelling the occlusal plane remains one of the major concerns in dentistry, especially in adult patients, due to the complex and multidisciplinary approach, as well as the skeletal component of the condition. Intrusion of the maxillary posterior teeth needs to be performed for open bite correction , or for Occlusal interferences and functional disturbances may result in difficulties during prosthetic reconstruction . LevelliTemporary anchorage devices (TADs) represent an orthodontic treatment option, which is minimally invasive and aids in molar intrusion without needing the patient’s compliance . MiniscrIn adult patients, one of the most challenging malocclusions to correct with orthodontic treatment is anterior open bite , as thisIn performing an intrusive movement, the relationship between the maxillary posterior root apices to the inferior wall of the sinus should be considered, since the cortical bone layer of the maxillary sinus wall could represent a barrier to the intrusion . Cone-beTo the best of our knowledge, a review related to the pre-prosthetic and orthodontic intrusion need of the maxillary posterior teeth has not yet been published. The aim of this study was to review the literature related to the intrusion of maxillary posterior teeth in subjects needing pre-prosthetic restoration or orthodontic treatment due to anterior open bite, and to report a thin alveolar biotype case needing pre-prosthetic intrusion of maxillary premolars and molars in order to develop a customized maxillary plane to propose a novel, personalized method of measuring intrusion. The clinical significance arises from the belief that the new palatal plane is simple to construct, assists in aligning the maxilla parallel to a specified reference line, and can also be performed in segmental CBCT images.This review was performed following the recommendations of the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) Statement” .A structured electronic search was conducted between February 2022 and March 2022 in the following databases: PubMed, Scopus, Embase, Web of Science, and Lilacs. Additionally, MeSH and Emtree terms were used, where applicable. Finally, a handsearching of relevant studies was performed.The research strategy was constructed on the PICO framework , as follows: P—patients with extrusion of upper posterior teeth; I—intrusion; C—no intervention; O—the amount of intrusion . The terms “tooth movement techniques”, “orthodontic anchorage procedures”, “tooth intrusion”, “intrusion”, “molar”, “premolar”, and “human” were surveyed. The retrieved publications were imported into and organized in the Rayyan online software . This soThe following inclusion criteria were pursued: human subjects requiring maxillary posterior tooth intrusion (molar or premolar), due to pre-prosthetic reasons to anterior open bite malocclusion; intrusion performed by skeletal anchorage (miniscrews or zygomatic plate); no previous orthodontic treatment; no orthognathic surgery; no tooth extractions; no active periodontal disease; no associated pathologies; publications with available full text in English language. The following exclusion criteria were considered: patients with systemic diseases; metabolic bone disorders; surgical assisted maxillary posterior teeth intrusion; photobiomodulation or other intrusion aiding techniques; intrusion followed by distalisation with the same anchorage device; mandibular molar intrusion; orthodontic treatments which involved tooth extractions, distalisation, mesialisation or rapid palatal expansion; orthognathic surgery; case reports; literature reviews, abstracts, and animal studies.A total of 1522 records were identified, consisting of 191 from PubMed, 483 from Scopus, 140 from Embase, 363 from Web of Science, and 345 from Lilacs. After screening the duplicates, 333 records were excluded by automation tools. The titles, keywords, and abstracts of the remaining 1189 records were read, and 1091 records were excluded for not being related to the topic, or for not respecting the inclusion and exclusion criteria, as well as for being background articles, books, case reports, reviews, or animal studies. Ninety-eight records were sought for retrieval. Ninety-six articles were identified for eligibility, which met the inclusion criteria, and were checked for eligibility by full-text analysis. After careful reading and assessing the publications, a final number of 18 articles were selected and included in this review. The PRISMA diagram is shown in Data were extracted using a standardized form, which included the following information: (1) authors’ names and publication year; (2) country; (3) aim of intrusion, (4) sample size, age range, and gender; (5) anchorage type; (6) intrusion measurement method; (7) intrusion range; (8) intrusion force; (9) treatment time; (10) outcomes; (11) side effects; and (12) conclusions.Eighteen publications were evaluated in this review. In terms of publishing country, three of them were from Brazil, Egypt, and Turkey, respectively; two were from China and the USA, respectively, while there was one from China and Australia, Hungary, Iran, Korea, and Taiwan, respectively. Thirteen studies aimed at intruding upper first molars due to anterior open bite, whilst in the other studies the objective was the correction of the overeruption of the first molar, and just one study clearly stated the pre-prosthetic reason for intrusion. The vast majority of research that targeted correcting intrusion for open bite included participants aged between 18 and 30 years, whereas in the studies which aimed at intruding molars for overeruption, ages ranged between 20 and 46 years. The mean age, among the studies that reported it (15 studies) was 26.475 years. Regardless of the intrusion goal, there was a gender difference, with females being more prevalent. Ten studies used miniscrews (MS) as the anchorage type, seven used a zygomatic plate (ZP), and one publication used a combination of MS and ZP. In some of the publications, the reported method of intrusion technique was nickel-titanium (NiTi) coil springs ,39,40. OThe mean amount of intrusion was similar across studies, with a range of between 2.1 ± 0.9 mm and 4.57 ± 0.98 mm, being mostly situated between 2–3 mm. The intrusion force varied between 100 and 500 g and, although most of the studies (n = 8) reported a force between 100 to 200 g, one study reported 300 g , and fouThe intrusion amount was measured in lateral cephalograms (LC) in eight studies, lateral cephalograms (LC) and panoramic radiographs (PR) in two studies, lateral cephalograms (LC), panoramic radiographs (PR) and periapical radiographs in one study, CBCT scans in four studies, only panoramic radiographs (PR) in one study, parallel periapical radiographs in one study, and dental cast models also in one study. Eight of the eighteen papers measured the distance between U6 to PP, while the others used mixed methods or custom measurement techniques. The treatment time was reported in 16 studies, ranging from 3 to 12 months, with a mean value of 7.56 months.Thirteen studies reported side effects, while the other five mentioned no issues during or associated with the intrusion. One paper reported soft tissue overgrowth, seven articles described external apical root resorption (EARR) of various degrees, and three studies reported mini-screw loosening. Relapse appeared to be an issue in one study, different degrees of post-surgical discomfort and tongue irritation was mentioned in two studies while three studies reported coronal tilting and other unwanted movements, accompanying the intrusion process. All the articles state the fact that TADs are an efficient treatment option for obtaining a correction of either anterior open bite or levelling of the occlusal plane, with minor side effects if any, and, more importantly, reducing the need for much more invasive and complex interventions, such as orthognathic surgery.The risk of bias was assessed according to the Newcastle–Ottawa Quality Assessment Scale for case-control studies to evaluate the methodological quality of the selected publications  Table 2Table 2. A 28-year-old woman, seeking replacement of missing lower first molars, with second mandibular premolars shifted distally and rotated to the edentulous space, came to our practice. Prosthetic treatment of the edentulous spaces was limited by overeruption of upper first molars and premolars, as well as by the rotated teeth. The occlusal plane was irregular, with extrusion of the upper first molars and premolars into the edentulous spaces and a lower midline shift of 2 mm towards the right side . She hadThe initial radiographs are shown in The main treatment objectives included obtaining a functional occlusion, intruding the maxillary first molars and premolars, levelling the occlusal plane, creating space for prosthetic replacement of the lower molars, achieving functional arch relationships, and enhancing masticatory efficiency. The treatment plan involved orthodontic intrusion of the overerupted upper teeth, followed by fixed appliance therapy. On the right hemiarch, one miniscrew on the buccal side and two on the palatal side were placed, whereas on the left hemiarch, a zygomatic plate was placed on the buccal area, along with two miniscrews on the palatal area. 12 mm (Ø 1.6 mm) Jeil Dual Top JA Screw–Palatal, between tooth 1.3 and 1.412 mm (Ø 1.6 mm) Jeil Dual Top JA Screw–Buccal, between tooth 1.4 and 1.512 mm (Ø 1.6 mm) Jeil Dual Top JA Screw–Buccal, between tooth 1.6 and 1.712 mm (Ø 1.6 mm) Jeil Dual Top JA Screw–Palatal, distal of tooth 1.7In the first quadrant, four mini screw implants, temporary anchorage devices (TAD) were inserted, as follows: All the TADs were inserted under local anesthesia  1:200,000, 2 × 1.7 mL). The preoperative planning aimed for bicortical anchorage , using a rotation speed of 30 rpm and a 30 N/cm insertion torque. No prior preparation of the insertion site was required. In the second quadrant, two mini screw implants were inserted in the palatal region (12 mm (Ø 1.6 mm) Jeil Dual Top JA Screw), the first one between tooth 2.3 and 2.4 and the second distal to tooth 2.7, using the same protocol as for the first quadrant. The only difference consisted of the use of a surgical guide for the two screws in the second quadrant . A printIn addition, due to reduced bone volume compared to the first quadrant and reduced interproximal space, an orthodontic anchor plate was chosen for the buccal area, which was customized on the 3D model. For this region, the same type of local nerve block was used. An incision was placed at the mucogingival junction starting from tooth 2.7 to tooth 2.3, followed by the elevation of the mucoperiosteal flap, with the exposure of the zygomaticomaxillary buttress . The plaTo calculate the amount of performed molar intrusion, the difference of the linear distance from the mesiobuccal cusp of the maxillary first molar to a custom palatal plane (CPP) was measured on CBCT images before and after intrusion mechanics. The CPP was defined by the following three points: ANS, and the lowest points of the pterygoid hamulus on the left and right sides. The measurements were performed by one maxillofacial surgeon and one orthodontist, twice, and mean values were considered .The measurement method is shown in The left zygomatic plate and miniscrews were placed initially, and intrusion mechanics began with the aid of an elastic chain on this side after two weeks of soft tissue healing. Subsequently, at approximately 1.5 months after the left maxillary arch, the right hemiarch was implanted and miniscrews were inserted. No associated symptoms were described by the patient, and no signs of tissue irritation were found. No loose miniscrews or other accidents occurred. Elastomeric chains were changed every four weeks. Approximately 3.59 mm of intrusion was achieved on the right buccal side and 2.21 mm on the right palatal side in six months, 2.26 mm on the left buccal side, and 1.86 mm on the left palatal side in nine months. After intrusion, ligature stainless steel wires were used to keep the intruded teeth in place. Subsequently, upper and lower teeth were included in a full arch appliance, with a 0.022 MBT prescription. The main aim of the treatment objectives, namely the intrusion of the upper posterior teeth, has been achieved. The orthodontic treatment is ongoing in order to solve additional objectives, such as midline correction and space distribution for prosthetic treatment .We initially searched for intrusion aims, such as pre-prosthetic molar or premolar intrusion, as well as an orthodontic intrusion for open bite correction. We only found a few papers linked to the pre-prosthetic intrusion goal, most of which were case reports, hence, they were not included in this review. Nonetheless, a few articles on the subject were found. There are a few reviews related to intrusion for open bite correction, but none of them focused on both orthodontic and pre-prosthetic aspects. Furthermore, non-orthodontic cases of overerupted molars are rare, and the number of included subjects is small.Sherwood et al., reported just four cases, treated for anterior open bite . The larAdults with overerupted molars because of antagonist loss are still a common clinical finding. Occlusal plane rehabilitation should use a multidisciplinary approach. Molar intrusion is required to provide adequate space for prosthetic rehabilitation. If possible, the implant location should be chosen based on the availability of sufficient cortical bone . Due to The recommended loading force of the anchorage devices has been suggested to vary between 50–500 g, reported as 50 g ,47, 100–Out of the 18 reviewed articles, 10 reported MS, 7 reported ZP, and 1 used both anchorage types. The average treatment time was 7.1 months for those using MS, and 7.9 months for the ones that had ZP, which follows the results presented in our case. This might lead to the conclusion that the intrusion using MS could be quicker. One must keep in mind, though, that ZPs are frequently used for the more severe cases, where the requirement for intrusion is increased, leading to the fact that efficiency cannot be evaluated solely based on the type of TAD. Additionally, it might be assumed that ZPs are used when broader movements are needed. However, within the findings of the present review, the average intrusion was similar between the two groups (2.6 mm for the ZPs and 2.7 mm for the MSs). The mean amount of intrusion reported in the selected articles was quite similar, being mostly between 2–3 mm. Everdi N et al., when intruding upper first molars with the aid of zygomatic plates and NiTi coil springs, reported an average intrusion of 2.6 mm, but the authors included patients with extractions. However, they found buccal tipping of the maxillary molars, as well as inflammation at the TAD site . VariousThe intrusion time ranged from 3  to 12 moMolar intrusion has grown more successful and efficient because of skeletal anchoring, yet it is still considered a challenging orthodontic technique . It is aThe relationship between arch bracketing and the intrusion mechanism has been intensely studied. It has been shown that when the arch is not braced, true posterior segment intrusion ensues . HoweverThere are also some important risks and complications of TAD placement, as follows: root trauma, anchorage failure, sinus perforation, nerve injury, soft tissue irritation, relapse , contactTrue molar intrusion as described by de Oliveira et al., with no modifications of the anteroposterior orientation of molars, mesial tipping of posterior teeth, or no changes in the palatal plane angle , has beeSince the approach of posterior teeth intrusion may offer predictable results without relying largely on patient compliance, orthodontic correction of the occlusal plane using a skeletal anchorage should be regarded as state-of-the-art. Nevertheless, due to a high degree of relapse, the intrusion must be maintained by retention procedures. Gonzales et al., have shown that, due to a high degree of recurrence, the stability of open bite treatment with molar intrusion employing skeletal anchoring in adult patients might be regarded as relatively unstable .A dual assessment of the risk of bias was conducted by two authors (O.A. and A.M) to identify potential sources of bias, which is critical for future research quality. Although there was a moderate risk of bias in the selected studies, mainly due to the lack of controls, the flaws were not severe enough to invalidate the findings. The absence of untreated control groups, a short follow-up time, a small sample size, and the lack of intrusion force measurement in some articles were all found to be shortcomings in the reviewed publications. There is still little valid scientific research available to assess actual molar intrusion . Among the limitations of this study might be the reduced number of cases included in the selected articles, the lack of controls, and the variability of used skeletal anchorage, intrusion force, and intrusion mechanism. Additionally, some authors did not report the intrusion amount, intrusion force, intrusion mechanism, or side effects. A major concern is the lack of an untreated control group, although some authors compared the intervention group to another treated group, but with different force amounts. Due to the heterogeneity of the publications, a meta-analysis could not be performed. A strong point of the present study, besides the thorough literature analysis regarding TADs, is the definition of a custom plane that can be used for exact measurements, to evaluate tooth intrusion. The classical PP can be affected by several patient- and device-specific factors, rendering the pre- and post-operative measurements ineffective. Measuring the distance from certain tooth landmarks to the CPP will always yield useful and relevant findings, since this plane is defined by anatomical landmarks that can not suffer changes throughout tooth ingression. Our future recommendations are as follows: a fundamental goal is to define a customized reference plane to ensure optimal reproducibility of pre-and post-surgical measurements. The CBCT scans must be performed under the same conditions, on the same equipment, and, if feasible, by the same operator to improve data consistency and reliability. Optimal anchorage and force management must be aimed, thus, reducing tooth movement (intrusion) time and limiting side effects.According to the findings of this study, there is evidence that levelling the occlusal plane by the intrusion of the upper posterior teeth can be achieved by skeletal anchorage.In the presented case it was possible to obtain a well-controlled intrusion of the maxillary molars and premolars without unwanted side effects. Stability of the obtained results, shortened treatment time, and controlling treatment outcome are the main goals for a complex treatment approach, which draws on both surgical and orthodontic practices. The manuscript’s strengths rely on a thorough analysis of the existing literature and the definition of a CPP , which aims to reduce the inaccuracy of true tooth intrusion evaluation.To achieve the highest possible long-term outcomes, dental practitioners should be up to date on the latest technologies to be used as alternatives for specialized treatment planning and patient monitoring.