Osteoporosis, characterized by bone mineral density reduction, bone mass loss, increased bone fragility, and propensity to fractures, is a common disease in older individuals and one of the most serious health problems worldwide. The imbalance between osteoblasts and osteoclasts results in the predominance of bone resorption and decreased bone formation. In recent years, it has been found that regular and proper exercise not only helps prevent the occurrence of osteoporosis but also adds benefits to osteoporosis therapy; accordingly, bone homeostasis is closely associated with mechanical stress and the intricate crosstalk between osteoblasts and osteoclasts. In this review, we summarize the mechanisms of exercise on osteoporosis and provide new proposals for the prevention and treatment of osteoporosis. The bone mass reduction in osteoporosis results in skeletal fragility and increases the fracture risk. Approximately 1.5 million new fractures are reported worldwide each year, resulting in a huge economic burden for the affected families and countries  adenosine receptors (P1), P2X ion channels, and P2Y G-protein–coupled receptors , 33. P2X3.1.4Polycystin-1 (PC-1) and polycystin-2 (PC-2) were first identified in renal primary cilia cells. By conjugating transiently, they form mechanosensitive receptor channel complexes, TRPP channels, and act as mechanosensitive channels. It is known that defects in PC-1 and PC-2 result in autosomal dominant polycystic kidney disease. However, the full spectrum of PC1 and PC2 effects has been difficult to establish , 36–39.in vivo , osteoblasts, and osteocytes display noteworthy decreases in bone mineral density as a result of the reduced osteoblast-related bone formation in vivo , 38. In  increased the quantity of PC1/3 in the pituitary gland , indicat3.1.5Piezo proteins (Piezo1 and Piezo2), discovered in 2010, form mechanosensitive cation channels . Piezo cPIEZO1 and PIEZO2 show robust expression in primary articular chondrocytes. GsMTx4, a PIEZO-blocking peptide, reduces chondrocyte death by regulating the Ca2+ signaling pathway after mechanical injury, shedding light on cartilage injury therapy . Moreovein vivo and in vitro  to mature osteoclasts . Zhou etIFN-γ belongs to type-II interferons. The last developmental phases of osteoclasts can fuse to multinucleated osteoclasts through IFN-γ activation. IFN-γ induces the expression of NFATc1 and then the transcription of c-FOS . RANKL iHowever, another study showed that running inhibited bone metabolism and levels of proinflammatory factors in male aged rats . In oldeIn addition to inflammatory cytokines, other factors associated with bone microenvironment, such as osteoprotegerin (OPG), can respond to mechanical stimuli. OPG is a decoy receptor for RANKL, and also influences bone remodeling. A prior study showed that moderate intensity endurance and vibration exercise upregulated OPG expression and downregulated the level of RANKL, thereby delaying osteoclast maturation and activity .Overall, these findings indicate that cytokines, especially inflammatory factors, eventually modify the microenvironment in response to exercise or external mechanical stimuli, which changes cellular functions, influences bone homeostasis, and facilitates bone remodeling.3.2.2Exercise promotes the activity of different types of muscle, especially skeletal muscle and cardiac muscle. Thus, muscles can be considered organs that can release signal factors. These factors, such as irisin, cathepsin B, and lactic acid, are important messengers in the muscle–organ crosstalk. Recently, it has been shown that in response to exercise, many myokines have effects on mitochondrial metabolism and are beneficial for cognitive behavioral therapy . Moreove3.2.2.1Irisin is a myokine that is a transcript of FNDC5 . The levIrisin not only allows for the crosstalk with adipose tissue, but also with bone, which are closely related to muscle in time and space. It has been shown in humans that after exercise, the levels of irisin produced from skeletal muscle and released to serum are increased , 66. ComUnder simulated microgravity, differentiation of osteoblasts can be increased by irisin . MeanwhiThus, it may be a novel pharmacologic modulator for the therapy of fracture and related complications of disuse osteoporosis. Moreover, moderate-intensity treadmill exercise promotes the circulation of irisin, so it is not difficult to deduce that after fracture, moderate-intensity treadmill exercise as soon as the body conditions allow may stimulate bone healing and recovery .3.2.2.2Myostatin (MSTN), also known as growth differentiation factor 8 (GCD-8), belongs to the transforming growth factor-β family. It is also a negative regulator of muscle growth.MSTN is secreted as a precursor protein; then, an N-terminal propeptide and a C-terminal growth factor dimer are generated, and an inactive latent complex is subsequently formed. Under the regulation by bone morphogenetic protein 1/tolloid proteases, the complex liberates mature myostatin , 73.Organisms with MSTN knockout show BMD upregulation. A recent study in ovariectomized rats has demonstrated that after 10-weeks weight-bearing training, MSTN circulation increased, and bone loss was attenuated . In that3.2.2.3In addition to MSTN and irisin, other myokines such as kynurenic acid (Kyna) also show important regulatory function in bone metabolism in osteoporosis . In the Postmenopausal osteoporosis due to decreased estrogen levels and ovariectomized models show the characteristics of reduced estrogen levels . A recenIn summary, myokines, especially irisin and myostatin, can protect bone mass by acting on osteoblasts and osteoclasts, and by regulating the crosstalk in the bone microenvironment.4A patient with osteoporosis has a low bone mass and deteriorated osseous microarchitecture, which results in weakened bone strength and an increased risk of fragility fractures. The Ministry of Health in the UK estimated 137 million women and 21 million men have a high osteoporotic fracture risk globally, and its prevalence is expected to double in the coming 40 years . In a prChoice of exercise types requires careful consideration of risks and benefits of each manner of activity, as well as modern health status and physical fitness intensity. Physical exercise programs appear to have varying impacts on osteoporosis depending on their frequency, duration, and intensity . For patSimilarly, the most recent national guidelines from UK also recommend individuals with osteoporosis to undergo resistance and effective exercise programs to increase bone strength. Moreover, by taking part in physical activities, the risk of falls is reduced with the improvement of bone strength and balance. Vertebral fractures and falls caused pain. To reduce the pain, we should improve posture by undertaking spinal extension exercise .4.1Primary osteoporosis is most common in older population and postmenopausal women. There are two main forms of primary osteoporosis, including postmenopausal osteoporosis (type 1) and senile osteoporosis (type 2) .4.1.1Due to reduced estrogen levels in postmenopausal women, osteoporosis and osteoporotic fractures are common . It has Recent research has demonstrated that effective exercises as indicated intervention strategies can prevent and control postmenopausal osteoporosis . By measAlthough exercise is regarded as an effective method to deter bone loss triggered by estrogen deficiency in postmenopausal women, the optimal training system for peak bone growth has not yet been outlined. A previous study has found that interval training is not better than endurance training regarding OVX mice bone growth . However4.1.2Age-related bone loss is associated with accelerated bone resorption and lower bone formation, resulting in osteoporosis and related fractures. Resembling other types of osteoporosis conditions, age-related bone loss is associated with a systemic bone loss related to trabecular and cortical compartments, osteopenia, osteoporosis, and subsequently high fracture risk . The numDue to widespread aging-induced changes in cellular function, tissues and organs change phenotypically, including those in the bone microenvironment. In elderly people, the production of mesenchymal stem cells (MSCs) and hematopoietic stem cells (HSC) is exhausted, and the regulation of cellular signaling is changed, resulting in the upregulation of pro-adipogenic, pro-osteoclastogenic, and anti-osteogenic factors. These are all systemic and bone-localized cytokines that affect the cellular crosstalk in the bone microenvironment . ImpairePhysical activity is considered an effective support for improving bone health in older people . The numIn conclusion, the beneficial effects of exercise against aging-related osteoporosis have been reported in many studies. However, there are still many unsolved issues, such as improvement of its clinical efficacy and reduction of time spent on exercise by elderly patients.4.2Osteoporosis can occur secondary to other traumatic conditions and metabolic diseases, such as long-term and large-dose drug intake , 102, hy4.2.1Immobilization and weightlessness have important effects on body physiology; because they involve a lack of mechanical loading, they lead to the reduction in skeletal integrity. As a result, disuse is one of the major risk factors for osteoporosis . Disuse Exercise increases osteoblast collagen expression and mechanical strain affects collagen arrangement, which have an effect on new bone formation, thereby strengthening the skeleton. Bed rest or weightlessness, without physical activity, negatively regulates bone by affecting the activities of osteoblasts and osteoclasts . It has In recent years, there has been an increased concern about mechanoresponsive sensitivity in human fracture recovery to help patients’ fast and robust return to normal life. Qian et al. found that, for bedridden patients, increased miR-138-5p levels in bone specimens correlated with a lower degree of bone formation . They foAltogether, physical exercise is an effective therapeutic strategy to help patients with immobilization and improve their quality of life. Improvement of sensitivity to mechanical stimuli is a feasible approach for accelerating patients’ recovery.4.2.2Glucocorticoids are broadly used to suppress inflammation in many immune diseases, such as rheumatic diseases and those arising after organ transplantation . GlucocoEarly studies have found that glucocorticoids regulate differentiated bone cell functions and osteoclastogenesis to regulate the balance between bone resorption and bone formation . GlucocoGlucocorticoid overdose and unsatisfied treatments lead to detrimental side effects on bone as well as on muscle, cartilage, and fat mass. Healthy diet and regular physical exercise might mitigate these conditions . As for In conclusion, exercise has a positive effect on the treatment of glucocorticoid-related osteoporosis, although more studies are needed to investigate the physiological and pathological mechanisms involved.5In summary, mechanically speaking, the exercise-related regulation of osteoporosis is complex and likely involves multiple pathways, including direct and indirect mechanisms. This includes mechanical signaling transduction from receptors on the cell surface, such as PC-1/2 and Piezo1/2, to cytokines in the bone microenvironment, ranging from inflammatory factors to myokines. The changes in biochemical markers of bone turnover and consequently the change in bone mass might be seen as a manifestation of direct or indirect exercise effects, but more studies are needed to further clarify fine regulation.Considering the advantages of exercise in the regulation of osteoporosis, such as low costs, easy performance, and few adverse effects, exercise has a huge potential in the future in osteoporosis treatment and prevention. Hence, exercise has become increasingly appreciated by doctors and researchers Table 1.All authors were involved in conceptualizing the paper. XC led the drafting of the manuscript. SX and HZ reviewed, edited, and approved the final paper. All authors contributed to the article and approved the submitted version.


We describe early-onset diabetes in a 6-month-old patient carrying an LRBA gene mutation. Mutations in this gene cause primary immunodeficiency with autoimmune disorders in infancy. At admission, he was in diabetic ketoacidosis, and treatment with fluid infusion rehydration and then i.v. insulin was required. He was discharged with a hybrid closed-loop system for insulin infusion and prevention of hypoglycemia (Minimed Medtronic 670G). He underwent a next-generation sequencing analysis for monogenic diabetes genes, which showed that he was compound heterozygous for two mutations in the LRBA gene. In the following months, he developed arthritis of hands and feet, chronic diarrhea, and growth failure. He underwent bone marrow transplantation with remission of diarrhea and arthritis, but not of diabetes and growth failure. The blood glucose control has always been at target (last HbA1c 6%) without any severe hypoglycemia. LRBA gene mutations are a very rare cause of autoimmune diabetes. This report describes the clinical course in a very young patient. The hybrid closed-loop system was safe and efficient in the management of blood glucose. This report describes the clinical course of diabetes in a patient with a novel LRBA gene mutation. Lipopolysaccarides-responsive beige-like anchor (LRBA) protein deficiency OMIM #614700) is an autosomal recessive disorder caused by homozygous or heterozygous mutations in the LRBA gene 4700 is a,4,5,6,7.Furthermore, LRBA variations are among the four genetic causes of very early onset autoimmune diabetes . In factMost of these patients have negative pancreatic autoantibodies, suggesting that the autoimmune mechanism that causes diabetes may be different from that seen in type 1 diabetes. It could be that the autoantigens involved in the etiology of diabetes have not yet been identified, or that the autoimmune mechanism that causes pancreatic cell destruction is cell-mediated and not antibody-mediated ,10,11.Here, we describe a patient with early-onset diabetes who, on genetic analysis, turned out to be compound heterozygote for two mutations in the LRBA gene, a mutation inherited from the mother , until now never described, and one from the father , previously described ,13. We fThe patient was born at full term . He was referred to the Metabolic Diseases Unit of Children’s Hospital in Bari at 6 months of life for diabetic chetoacidosis . The patient had been showing inconsolable crying for 2 days. The fever appeared the day before admission (39.2 °C). Polyuria and polydipsia had occurred over the previous few days.w/v of NaCl (30 mL/h) for 2 h and then with 500 mL of 5% glucose solution with 20 mEq of NaCl and 20 mEq of KCl (25 mL/h) and insulin infusion (0.01 IU/kg/h) with further changes on the basis of blood glucose values. Subcutaneous insulin infusion with hybrid closed-loop system (Minimed670 G) was started in day 2 allowing stable blood glucose control.At admission, the patient was in fairly good general condition and presented Kussmaul respiration. The anterior fontanel was slightly depressed. Heart and abdomen were normal, and left hydrocele was detected. Weight was 7.6 kg (10–25 °C), and length was 66 cm (25–50 °C). The patient was promptly treated intravenously with saline solution of 0.90% Electrocardiogram, thyroid and abdominal ultrasound were normal. Biochemistry showed negative anti-GAD and anti-ZnT8 autoantibodies, while insulin and anti IA2 antibodies were positive . The patient was discharged after 11 days, with an insulin requirement of 0.05 IU/kg/h from 8 p.m. to 8am and 0.125 IU/kg/h from 8 a.m. to 8 p.m. and with a bolus from 0.1 to 0.3 insulin units based on the blood glucose value detected at each feeding.One week later, he was admitted to the hospital because of hyperglycemia (522 mg/dL) and fever. A jugular venous access was placed to manage fluids infusion and insulin therapy. Progressive glycemic compensation was reached, and defervescence was observed within 36 h.Some days later, fever relapsed. A blood culture was performed, showing Staphylococcus Aureus and Klebsiella oxytoca infections. He was properly treated with antibiotic therapy with rapid defervescence. After removal of the venous access, a local edema progressively appeared, with overlying hot and hyperemic skin. A thrombosis of the right jugular vein was suspected and confirmed by an echo-color Doppler. A treatment with s.c. eparine (100 IU/kg twice a day) was started, with an improvement of the clinical condition. Seven days later, anemia (hemoglobin 8.2 g/dL) with positive direct Coombs test was found. Blood transfusion was then performed with hemoglobin normalization. Antibodies for toxoplasmosis, rubella, cytomegalovirus, herpes simplex, parvovirus B19, varicella-zoster virus and the anti-neutrophil membrane were negative, while the antinuclear antibodies (ANA) were positive.At 9 months, he presented persistent diarrhea and growth retardation. The serological tests for celiac disease, RAST, fecal occult blood test, coproculture and research for gastrointestinal pathogens resulted negatives. Because of the persistence of diarrhea, at 13 months of age, he underwent an esophagogastroduodenoscopy and colonscopy. The former showed antral edema and hyperemia, nodular hyperplasia of the bulb, hypotrophy of the duodenal folds, and scalloping, suggestive of gastritis with nodular hyperplasia of the bulb. The findings suggested a possible inflammatory bowel disease (IBD). The latter showed that, at the level of the cecum, the colon presented erythematous mucosa, and the vascular reticulum appeared at times distorted without visible erosions. At the level of the proximal sigmoid, nodular hyperplasia of the mucosa was more marked than normal, and at the level of the rectum, there were minute aphthae, suggestive of IBD. The histological examination concluded that the picture was compatible with the diagnosis of celiac disease of grade B2according to Villanacci classification. The patient started Mesalazine (250 mg twice a day) with clinical benefits.In the meanwhile, at 10 months, the patient presented swelling, pain and redness in the joints of the fingers and toes. After proper biochemical and clinical evaluation, polyarticular Juvenile Idiopathic Arthritis was diagnosed, and Prednisone (5 mg twice a day) was initiated.In view of the very early onset of autoimmune diabetes, next-generation sequencing (NGS) analysis for monogenic diabetes genes was performed at 7 months of age. The proband resulted compound heterozygous for two mutations in the LRBA gene NM_001364905.1), a deletion in exon 15 (c.2999del) p.Ser1000Tyrfs*2, never before described in other patients, and a nonsense mutation in exon 23 (c.1963C>T) p.Arg655*, previously described ,13.64905.1, Both mutations were confirmed by Sanger sequencing in the proband and his parents. The mother was heterozygous for the first mutation, and the father for the second one. Of note, both mutations generate, if translated, two truncated proteins affecting the expression of the PH, BEACH and WD40 domains, and probably generate an LRBA deficiency. The patient underwent bone marrow transplant from his sister at the age of 16 months, who was heterozygous and turned to have an autoimmune thyroiditis with normal thyroid function. The transplantation was successful. Arthritis and diarrhea progressively reduced, he presented recurrent episodes of thrombocytopenia, which required immunoglobulins infusion. At last visit, at 24 months of age, the blood glucose control was excellent , and no severe hypoglycemia ever occurred. Growth was still stunted, height was 78 cm (<3° centile), and weight was 11.5 kg (10–25° centile).After obtaining informed consent for genetic analyses, genomic DNA was extracted from EDTA whole blood using a QIAmp DNA Blood Kit .https://www.operapadrepio.it/it/?option=com_k2&view=item&layout=item&id=5323 (accessed on 1 September 2021). DNA libraries were prepared by SureSelectXT-CCP17 , according to the manufacturer’s instruction, and sequenced on NextSeq-500 (Illumina Inc.). Regions of interest were covered >98% at a reading depth> 30x. References-based assembly was performed by Sequencher-v5.4.6 Software  and variants assessed on a genomic scale and interpreted by Alamut Visual version 2.10 Interactive Biosoftware . All identified mutations were validated by Sanger sequencing on a second PCR product.The proband’s DNA was subjected to NGS analysis of the monogenic diabetes genes listed at In this paper, we describe the clinical course of an infant with type 1 diabetes and immune dysregulation due to a LRBA gene mutation. LRBA protein is a member of the BEACH-WD40 protein family. It is involved in the immune response by actively reacting to the presence of lipopolysaccharide (LPS), but its defect appears also to be related to altered autophagic mechanism. This leads to the accumulation of damaged organelles and toxic substances in cells, and to a subsequent increase in the apoptosis mechanism. The increased apoptosis concerning B lymphocytes and cytotoxic T lymphocytes explains the augmented infectious risk of these subjects. Furthermore, it appears that patients affected by LRBA deficiency have a low level of at least two immunoglobulin isotypes  ,15.On the other hand, the bigger apoptosis of T-reg cells results in the reduction in immune tolerance and therefore in autoimmune phenomena, as seen in other autoimmune diseases, such as systemic lupus erythematosus. In particular, LRBA appears to prevent lysosomal degradation of the CTLA-4 receptor. CTLA-4 is a powerful immune suppressor located in T lymphocytes with the task of blocking the co-stimulation of T cells, downregulating autoimmune processes. In fact, CTLA-4 mutations cause a disease called CHAI (CTLA-4 haploinsufficiency with autoimmune infiltration), which has almost overlapping symptoms with LRBA deficiency with autoantibodies, regulatory T (Treg) cell defects, autoimmune infiltration, and enteropathy (LATAIE). Abatacept is a drug mimicking the action of CTLA-4; therefore, it is capable of reducing autoimmune processes in patients with this mutation, and it is today one of the most important therapeutic options . AnotherAll mutations identified so far are associated with LRBA deficiency, which may cause a syndrome with a wide spectrum of clinical manifestations  ,4,5,6,7.Interestingly, both of the proband’s LRBA mutations generate, if translated, two truncated proteins lacking the expression of the PH, BEACH and WD40 domains, and probably generate an LRBA deficiency. All the above domains, located in the C-terminal of LRBA protein, are highly conserved and participate in multiple cellular processes such as signal transduction, vescicular trafficking, and transcriptional regulation and are involved in the maintenance of intracellular stores of CTLA-4 by inhibiting its lysosomal degradation ,12.Our patient had diabetes as the first symptom, but the clinical picture soon became complicated with the onset of sepsis, anemia, and severe neutropenia. After a while, he also began to develop severe persistent diarrhea and growth failure, with the features of chronic IBD, and polyarticular arthritis of the toes and fingers with positive ANA. In all, they were manifestations of an ongoing autoimmune process.Persistent diarrhea and growth retardation have been reported in patients with LRBA deficiency ,20. An aNo etiological treatment is available, but prophylactic antibacterial therapy and immunoglobulin replacement should be given, similarly to all primary immunodeficiencies. Despite all the currently available therapies for immunodeficiency, the control of the autoimmune mechanisms has been achieved only in patients treated with large doses of corticosteroids ,23,24,25Our patient presented a very early onset, 6 months, with several different autoimmune disorders before 1 year of age. Fortunately, we suspected a primary immune deficiency after the first few weeks of disease, and thus, a genetic diagnosis was available when he was 8 months old. This point allowed us to have frequent follow-up visits and, therefore, early diagnosis of all clinical manifestations. A systematic review reported an interquartile range at onset of 0.6–3.5 years, with a diagnostic delay in immunodeficiency of 1.0–9.7 years . Our patThe clinical course of these patients is rarely reported in the literature, especially in such young patients. Diabetes mellitus has been reported in 24% of 109 patients with LRBA deficiency  and in sThe novelty of this case is the identification of a novel frameshift mutation in the LRBA gene and the clinical admission investigation that may be worth reporting and useful for clinicians. Most previously published papers just summarize the clinical findings in their cohort, with scarce data about the timing of the other autoimmune disorders onset and their clinical course. The description of these rare patients provides supportive information for clinicians and researchers.In conclusion, we describe two compound heterozygous LRBA mutations in an infant with early onset diabetes mellitus and autoimmune disorders, in whom treatment with bone marrow transplantation was successful. The patients carried two mutations in LRBA gene. The first, p.Arg655*, was previously reported in homozygosis  and rece


The aim of the study was to investigate the association of insulin resistance (IR) with cardiovascular risk factors and sleep complaints among citizens of Palanga over a 10-year follow-up period. This epidemiological longitudinal cohort study was performed with 835 subjects.All participants were evaluated for sociodemographic, clinical and cardiovascular risk factors, behavioral factors, self-perceived health and biochemical analysis. IR was evaluated using the homeostasis model assessment of IR (HOMA-IR).p = 0.043], snoring frequency  and very loud snoring .All study participants were stratified into two groups, without IR (HOMA-IR ≤ 2.7) and with IR (HOMA-IR > 2.7). The analysis of parameters between the two study groups showed statistically significant relationships between IR, cardiovascular risk factors and sleep complaints within the 10-year period. After adjusting for a 10-year period, sex, age, body mass index, physical activity, education, systolic and diastolic blood pressures, presence of disease, total cholesterol, triglyceride levels, metabolic syndrome (MetS) and diabetes mellitus (DM), IR was statistically significantly more frequent in subjects with increased sleep latency [odds ratio (OR) 1.37, 95% CI 1.01–1.93; The incidence of obesity, MetS, DM, elevated fasting glucose level, triglyceridemia and sleep complaints became more frequent after a 10-year period in subjects with IR. Over a 10-year period, IR was significantly associated with an increase in sleep complaints: sleep latency reflecting difficulty to fall asleep, snoring and very loud snoring. Insulin resistance (IR) is characterized by an impaired glucose metabolic response to a given amount of insulin and is considered to contribute to the development of diabetes mellitus (DM) and to be a major risk factor for cardiovascular diseases . CardiovA group of cardiovascular and metabolic abnormalities, such as abdominal obesity, hypertension, dyslipidaemia, atherosclerosis, and IR predispose individuals to cardiovascular disease and type 2 DM , 7. CompCross-sectional studies have shown that sleep disordered breathing impairs glucose tolerance and/or insulin sensitivity, as measured by HOMA-IR, even after adjusting for body mass index (BMI) and in non-diabetic patients . FurtherTo date, correlations between IR and the risk of sleep disorders and cardiovascular diseases during aging have received little attention in the medical literature; therefore, the topic remains controversial, is not well understood and needs further investigation. In order to understand the contribution of sleep as a whole to public health, it is necessary to integrate the concepts of sleep quality and duration in order to assess their combined and independent influence on health outcomes. This raises the question of how the modifications of cardiovascular risk factors and sleep complains evolve according to the presence of IR during aging. Thus, we aimed to investigate the association of IR with cardiovascular risk factors and sleep complaints over a 10-year follow-up period.A sample of 2,500 citizens of Palanga aged 35–74 years was drawn from the National Population Register in 2002. The citizens of Palanga were chosen for the investigation, because there was close community with minor migration reflecting the population of the western part of Lithuania. The optimal size of the sample, ensuring representativeness of the population of Palanga aged 35–74 years, was calculated as 1,630 ± 33 subjects. From the sample of 2,500 citizens, 160 were not invited to participate in the study because they were not found at the given address. In total, 1602 persons  participated in the survey in 2003. The response rate for the first survey (2003) was calculated as follows:  ×100 = 68.5%. In the period from 2003 to 2013, 158 of the participants in the first survey in 2003 died (9.9%) and 47 (2.9%) had changed their address. When contacted, 20 (1.2%) declined to participate, 11 (0.7%) could not participate as a result of serious health problems, and 435 (27.2%) did not respond to multiple invitations sent to them by post. During the second survey, data from 931 people, 322 males and 609 females, aged 45–84 years, were collected. The first and second surveys were approved by the Bioethics Committee of Lithuania . Informed consent was obtained from all participants during both surveys. However, blood samples were collected from only 850 subjects and 15 (1.8%) subjects, whose blood tests showed severe thyroid dysfunction, were excluded from the analysis. The final longitudinal study cohort consisted of 835 subjects: 300 (35.9%) men and 535 (64.1%) women . The meaAll study participants were evaluated according to socio-demographic characteristics , behavioral factors and self-perceived health using a questionnaire. Fasting blood samples were taken from all participants and biochemical tests were performed to assess glucose, insulin, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglyceride levels. IR was calculated according to the HOMA-IR. MetS was defined according to the Adult Treatment Panel III (ATPIII)  and InteThe questionnaire on general data  was usedArterial blood pressure (mmHg) was measured twice using a quicksilver sphygmomanometer  from the right arm while the person was sitting, with the precision of 2 mm referring to the methodological recommendations . An aver2 (m) using the data from the height and weight measurement. Patients were diagnosed as being overweight when their BMI was 25.0–29.9 kg/m2, and with obesity when their BMI was 30.0 kg/m2over. Waist circumference was measured during the physical examination. Weight and height were measured with participants standing, without shoes or heavy outer garments. Waist circumference was measured in the erect position at the midpoint between the lowest rib and the superior border of the iliac crest.Body height was measured in stocking feet (without shoes) using a medical height rod. Body weight was measured without shoes using a medical scale . BMI was calculated according to the following formula: BMI = body mass (kg)/heightThe Basic Nordic Sleep Questionnaire  was usedn = 850, mU/L, norm 3.0–25.0). IR was calculated according to the HOMA-IR formula: HOMA-IR = [fasting plasma insulin (μIU/ml)] × [fasting plasma glucose (mmol/l)]/22.5); normal ≤ 2.7 . Blood samples were analyzed for concentrations of glucose , total cholesterol , LDL cholesterol , HDL cholesterol , women's, norm 0.9–2.0), and triglycerides  in both 2003 and 2013. The blood obtained in 2013 was centrifuged and the serum was frozen at −70° C. Serum samples of insulin were analyzed in a single batch after completion of this study in 2013  and adjusted for the 10-year period, sex, age, body mass index, physical activity, education, systolic and diastolic blood pressures, presence of disease, total cholesterol, triglycerides, MetS, and DM (Model 2), (Table 3). A logistic regression analysis using an enter method was used to investigate whether IR was related to cardiovascular risk factors (Model 1) and adjusted for the 10-year period, sex, age, and education (Model 2), (Table 4). The dependent variables in all models were all sleep complaints and cardiovascular risk factors in 2013. Statistical analyses were performed using the Statistical Package for the Social Sciences v.22 . The threshold of significance was set at p < 0.05.The clinical and the sociodemographic characteristics were reported using frequencies and percentages for the categorical variables, and means and standard deviations for the continuous variables, and medians (25–75th percentiles) for variables with non-normal distribution. Variable distribution was assessed visually and using the Kolmogorov-Smirnov test. The data characteristics were compared between the groups without and with IR were using Fisher's χAn increase of number of participants with high BMI (≥30) was seen in the IR group compared with the without IR group . Howeverp = 0.003), resulting in more frequent severe drowsiness in the morning (p < 0.001) and during the day (p = 0.002). Daytime sleepiness was also more frequently observed among people with IR. They were also more likely to use sleeping pills (p = 0.034) and, unsurprisingly, were more likely to use alcohol to improve sleep (p = 0.012).Analysis of sleep complaints showed statistically significant changes in the IR group after the 10-years period . In 2013p = 0.027], early waking up in the morning , snoring , very loud snoring , and breathing pauses during sleep .The results of the logistic regression analyses of different sleep complaints are presented in p = 0.043). These complaints are symptoms of disturbed sleep due to insomnia. Other significant changes were observed in complaints characterizing breathing disturbances during sleep. There was a statistically significant relationship between IR and increase in snoring  and very loud snoring , but not between IR and breathing pauses .After adjusting for the 10-year period, sex, age, physical activity, education, systolic and diastolic blood pressures, presence of disease, total cholesterol, triglyceride, MetS and DM (Model 2), IR was statistically significantly more frequent in subjects with increased sleep latency , hypertriglyceridemia , MetS , DM  and obesity .The results from the logistic regression analyses between IR and cardiovascular risk factors are presented in Our results showing an increased number of people with BMI ≥ 30 in the IR group are in parallel with literature data demonstrating the relationship between obesity and the development of DM and cardiovascular diseases , 31. We The literature data about sleep disturbances and IR show that poor sleep has a negative impact on glucose metabolism, obesity, development of DM and arterial hypertension . A crossOur data demonstrating an increase in sleep complaints after the 10-year period in the IR group is in accordance with laboratory and epidemiological data reporting that insufficient sleep has been linked to reduce insulin sensitivity and increased risk of type 2 DM , 32. If Sleep duration may increase triglycerides and HDL levels, both of which are components of MetS. A study of Japanese people discovered that among women, both short and long sleep durations are associated with a high serum triglyceride levels or low HDL cholesterol levels, while in men, the relative risk of a high LDL -cholesterol level was lower . AnotherThe relationship between disturbed sleep and DM is two-sided, as chronic sleep disturbances elevates the risk of developing IR, while diabetes worsens the quality of sleep. Sleep disturbances significantly increase the risk of developing diabetes and cardiovascular diseases , 31. DisInvestigation of the association between sleep duration, obesity, adipokines and IR in 2,848 participants including 593 with inflammatory marker data showing high risk of type 2 DM, showed an independent relationship between long sleep duration and IR . FastingWe have found an interesting result that sleep complaints with disturbed breathing were characteristic of individuals with IR. Loud snoring interrupted by breathing pauses is a serious symptom of sleep apnoea and it is significantly associated with IR. This is confirmed by Bonsignore and colleagues  who demoDisturbed sleep may lead to obesity, IR, and development of DM, as well as to development of cardiovascular risk factors and cardiovascular diseases. Because of this, the use of simple, low-cost methods for the diagnostics of disturbed sleep and the management of sleep complaints may in many cases significantly contribute to the prevention of cardiovascular diseases and DM.The present study has some strengths and limitations to be addressed. The strengths of our study include a reasonable sample size that allowed us to adjust our findings for variables that could potentially contribute significantly to our understanding of IR in relation to cardiovascular risk factors and sleep complaints in humans. Another strength of the current study is the large number of biomarkers measured. A great strength of this epidemiologic longitudinal cohort study was its ability to draw attention to IR, as this condition remains an important public health issue that can accompany a variety of risk factors. The main limitation of the present study is that blood samples of insulin were obtained from only in the second survey in 2013, which prevented us from evaluating the presence of IR at both timepoints.Our results demonstrate that IR is associated with the development of major cardiovascular risk factors and sleep complaints. The incidence of obesity, MetS, DM, elevated fasting glucose level, triglyceridemia and sleep complaints was more frequent after a 10-year period in subjects with IR. After a 10-year period, IR was significantly associated with an increase in sleep complaints, including sleep latency reflecting difficulty in falling asleep, snoring and very loud snoring.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Bioethics Committee of Lithuania . The patients/participants provided their written informed consent to participate in this study.NK: conceptualization and formal analysis. AP, GV, and NM: methodology. NK, AP, GV, and NM: validation. GV and NM: investigation, writing—review and editing, and supervision. AP: data curation. NK and AP: writing—original draft preparation. NM: lead of the project. All authors have read and agreed to the published version of the manuscript.This research was funded by a Grant (No. S-SEN-20-13) from the Research Council of Lithuania.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.


To date, one of the reference therapies for the treatment of mutated BRAF metastatic melanoma is based on the combination of BRAF and MEK inhibitors. Although many trials have compared BRAF and MEK inhibitor combination therapies, there is no evidence of superiority in the use of one of the three combinations over the others. Furthermore, comparative data on safety are scarce. To help clinicians tailor patients’ treatment using the most appropriate BRAF/MEK inhibitor combinations, we performed a meta-analysis of adverse events associated with each treatment combination.I2 = 66%) and Binimetinib . In combined therapies, the rate was 98% for both Vemurafenib + Cobimetinib  and Encorafenib + Binimetinib (95% CI: 0.96–1.00). Grade 3 or higher adverse events were reported in 69% of cases for Binimetinib , 68% for Encorafenib (95% CI: 0.61–0.74), and 72% for Vemurafenib + Cobimetinib . The most common grade 1–2 AEs were pyrexia (43%) and fatigue (28%) for Dabrafenib + Trametinib and diarrhea for both Vemurafenib + Cobimetinib (52%) and Encorafenib + Binimetinib (34%). The most common AEs of grade 3 or higher were pyrexia, rash, and hypertension for Dabrafenib + Trametinib (6%), rash and hypertension for Encorafenib + Binimetinib (6%), and increased AST and ALT for Vemurafenib + Cobimetinib (10%). Conclusions: Our study provides comprehensive data on treatment-related adverse events of BRAFi and MEKi combination therapies, showing related toxicity profiles to offer a helpful tool for clinicians in the choice of therapy.Purpose: This meta-analysis summarizes the incidence of treatment-related adverse events (AE) of BRAFi and MEKi. Methods: A systematic search of Medline/PubMed was conducted to identify suitable articles published in English up to 31 December 2021. The primary outcomes were profiles for all-grade and grade 3 or higher treatment-related AEs, and the analysis of single side effects belonging to both categories. Results: The overall incidence of treatment-related all-grade Aes was 99% for Encorafenib (95% CI: 0.97–1.00) and 97% for Trametinib (95% CI: 0.92–0.99;  In the early 1980s, new discoveries in the fields of molecular biology, cell biology, and immunology led to a better understanding of the mechanisms underlying the neoplastic transformations in cells .These discoveries opened the doors to the targeted therapy, which is based on small selective inhibitory molecules or monoclonal antibodies that make it possible to act on a specific target expressed by cancer cells and not by healthy ones, allowing to significantly reduce toxicity and side effects ,2. The tIn clinical practice, the prominence of this effect is mainly ascribable to melanoma treatment; in fact, in about 40–60% of patients affected by cutaneous melanoma, tumor cells harbor a specific mutation called BRAF-V600E, which results as targetable by BRAF inhibitors which interfere with this signal transduction pathway, causing apoptosis in melanoma cells ,8,9.The rationale behind the use of the combination of BRAF and MEK inhibitors is to prevent the aberrant activation of mutated BRAF in the context of the RAF-MEK-ERK pathway ,11,12,13To overcome said issue, in the reference therapy for BRAF-mutated metastatic melanoma, BRAF inhibitors are used in combination with MEK inhibitors to act simultaneously against two different targets of the same pathway, evading the cancerous cell-intrinsic resistance ,8,9,20. Currently, three different doublets are available in clinical practice , and each one of them is present in at least one phase 3 clinical trial ,21,22,23To help clinicians to better select the right BRAF/MEK inhibitor combinations for the right patients, we performed a meta-analysis with the aim to indirectly compare the different safety profiles of BRAF and MEK inhibitors. With these data, we have also elaborated a tool to facilitate the assignment of drugs to the most frequently encountered clinical scenarios.One database—Medline (PubMed)—was used to search for relevant articles published in English in a peer-reviewed journal, with the last search update on 31 December 2021. Systematic research was set up to identify published studies on BRAF and MEK inhibitor therapies that reported treatment-related adverse events, filtering only English articles obeying this query: “LX-4032 OR PLX4032 OR RG-7204 OR RG7204 OR RO-51-85426 OR RO-5185426 OR RO5185426 OR Vemurafenib OR Zelboraf OR GDC 0973 OR GDC-0973 OR GDC0973 OR RG 7420 OR RG-7420 OR RG7420 OR RO5514041 OR XL 518 OR XL-518 OR XL518 OR Cobimetinib OR Cotellic OR GSK-2118436 OR GSK-2118436A OR GSK2118436 OR GSK2118436A OR Dabrafenib OR Tafinlar OR GSK 1120212 OR GSK-1120212 OR GSK1120212 OR JTP 74057 OR JTP-74057 OR Trametinib OR Mekinist OR LGX-818 OR LGX818 OR NVP-LGX-818-NXA OR NVP-LGX818 OR NVP-LGX818-NXA OR Encorafenib OR Braftovi OR ARRY-162 OR ARRY-438162 OR MEK-162 OR MEK162 OR NVP-MEK162 OR Binimetinib OR Mektovi”.The selection of the studies was conducted based on the following inclusion criteria: (a) studies on BRAF inhibitors and MEK inhibitors, (b) studies with a sample size of 20 patients or higher, and (c) studies reporting data on toxicity related to BRAF and MEK inhibitors. Reviews, case reports, and studies on the evaluation of QoL  were excluded. The retrieved articles were screened and selected by two independent authors (M.B. and L.P.) according to the inclusion and exclusion criteria, and disagreements were settled by a third researcher (M.G.). This process resulted in 91 eligible records  9,14,16,108,109.Quality assessment and risk of bias were evaluated through the ROBINS-I tool . All incAdverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTC-AE) version 4.0.From each included study, the parameters that were taken into consideration were: author, year of publication, study design, country, period of conduction, total number of patients, and number of patients reporting adverse events according to grade. I2 and τ2 statistics. Publication bias was assessed through a funnel plot ..110].p < 0.05) emerged for all considered treatments.Adverse events of any grade (G1–G5) have been registered in a large percentage of patients treated with BRAF and MEK inhibitors . Among BFocusing on BRAF inhibitors , inducedWhen analyzing the data on single G1–G2 adverse events, there is a variability in the incidence of the various side effects considered.As for monotherapy, Vemurafenib is associated with arthralgia in 40% of cases, rash in 34%, and fatigue in 33%, while Dabrafenib causes fatigue in 41% of patients, pyrexia in 32%, and rash in 31%. Significant incidence data above 30% were also observed for Trametinib causing rash in 38% of cases, Encorafenib associated with alopecia in 56%, and Binimetinib causing rash in 64%, diarrhea in 40%, and vomiting in 38%.As for the combination therapy, Vemurafenib plus Cobimetinib causes diarrhea in 52% of cases, Encorafenib plus Binimetinib causes diarrhea in 34%, and finally, Dabrafenib and Trametinib are associated with pyrexia in 43% .When analyzing the data involving single G3–G5 adverse events, regarding monotherapy, the incidence is equal to or less than 5% in most cases, such as: increase in transaminases and asthenia, and decreased ejection fraction, diarrhea, and fatigue.p-value < 0.01) of cases.Higher rates of incidence are instead recorded in the course of therapy with Encorafenib, which induces arthralgia in 13% (95% CI: 0.05–0.27) of patients, Trametinib causes hypertension (95% CI: 0.08–0.16) and skin rash (95% CI: 0.08–0.16) in 11% of cases, and Binimetinib induces anemia in 8%  of cases, skin rash in 8% (95% CI: 0.05–0.11), vomiting in 8% (95% CI: 0.01–0.04), and hypertension in 8% (95% CI: 0.05–0.11) .Grade 5 adverse events were registered in each treatment group. One case of intracranial hemorrhage was registered following treatment with Dabrafenib. Vemurafenib induced a higher number of grade 5 adverse events, the most frequent of which were unknown deaths, general physical health deterioration, cerebral hemorrhage, cerebrovascular accident, pneumonia, and intracranial tumor hemorrhage . Two patAmong BRAF inhibitors, a necessary dose reduction was registered in 33% of patients treated with Vemurafenib (95% CI: 27–40%) and 14% of patients treated with Dabrafenib (95% CI: 10–19%), whilst, when analyzing MEK inhibitors, it was registered in 27% of patients treated with Trametinib (95% CI: 19–38%) and 56% of patients receiving Binimetinib (95% CI: 43–69%). As for the combined therapies, the data show a dose reduction applied to 65% of patients treated with Vemurafenib and Cobimetinib (95% CI: 59–71%), and to 28% of patients treated with Dabrafenib plus Trametinib (95% CI: 21–36%). Treatment was discontinued in 30% of patients treated with Vemurafenib (95% CI: 17–47%) and 10% of patients treated with Dabrafenib (2–34%), whilst among MEK inhibitors, it was interrupted in 31% of patients treated with Trametinib (95% CI: 15–55%) and 37% of patients treated with Binimetinib (95% CI: 9–78%). As for the combined therapies, treatment was discontinued in 24% of patients treated with Dabrafenib plus Trametinib (95% CI: 9–51%) .To evaluate whether side effects have an impact on prognosis, we correlated the reported incidence of side effects and some oncological outcomes. No correlation emerged between the incidence of side effects and the median progression-free survival (r = 0.15), response rate (r = −0.10), and complete response rate (r = −0.09). There was a slight positive correlation, instead, between the incidence of side effects and the median overall survival (r = 0.22). A slight but negative correlation was instead registered between the incidence of side effects and the median duration of response (r = −0.41). Finally, there was a strong, direct, positive correlation between the incidence of side effects and dose reduction (r = 0.68) .This meta-analysis, through the review of toxicity profiles of BRAF and MEK inhibitor therapies, both in monotherapy and in combined regimes, aimed to find the most suitable doublet for the individual patient.BRAF inhibitors are selective inhibitors of BRAF kinase with immunomodulatory action. The toxicity profiles amongst them are similar: rash, joint pain, and fatigue are recorded with overlapping incidence rates, but may present a few exceptions, such as the excessive sensitivity to sunlight caused by Vemurafenib, or hyperkeratosis or dysesthesia seem to occur more frequently, particularly with Encorafenib monotherapy ,114,115.MEK inhibitors, on the other hand, have extrinsic activity against MEK1/2 kinases involved in the MAPK pathway ,118,119.The end purpose is to be able to tailor a therapy, avoiding specific side effects in patients that already suffer from mostly chronic diseases involving the same organs or apparatuses. Following this statement, the significance of single side effects is not considered in absolute value but in relation to the clinical conditions and comorbidities of the patient on the receiving end of the treatment.To obtain this and achieve accurate results with a complete and clear profile of side effect incidence rates, the analysis has been divided into four different fields: two of which focus on any-grade and grade 3 through 5 side effects, and two other fields concentrating specifically on single side effects belonging to both previously mentioned categories. The side effects we chose to analyze singularly are the ones deemed both common and clinically relevant, and they include: anemia, arthralgia, alopecia, asthenia, diarrhea, fatigue, pyrexia, rash, vomiting, headache, transaminase level increases, anorexia, hypertension, and decreased ejection fraction.Although a direct comparison between the three drug combinations is not possible, the incidence rates of any-grade side effects appear to be comparable and higher than 90% for all 3 doublets, whilst a greater divergence is registered when focusing on grades 3 through 5 side effects. Specifically, the results highlight a higher incidence of the latter following treatment with Vemurafenib plus Cobimetinib and Encorafenib plus Binimetinib, where values stand, respectively, at 72% and 68%, whilst the remaining doublet, Dabrafenib plus Trametinib standing at 44%, shows remarkably lower incidence rates. This implies that whilst lower-grade side effects are expected no matter which doublet is chosen for therapy, we can anticipate a significantly decreased rate of high-grade side effects when choosing the Dabrafenib and Trametinib doublet. In regard to the analysis of lower-grade side effects (G1 and G2), the results describe that systemic side effects such as arthralgia, alopecia, asthenia, fatigue, rash, headache, and pyrexia are frequent in all three therapeutic regimens, with small variations: the combination of Vemurafenib and Cobimetinib presents higher incidence rates of arthralgia, fatigue, and skin rash; on the other hand, the onset of headache, pyrexia, and asthenia are more frequently caused by the combination of Dabrafenib and Trametinib. Analyzing specific organ side effects, the main toxicity involves the gastrointestinal system: greater than 20% in all three drug combinations for both diarrhea and vomiting. Specifically, the highest incidence of G1–G2 diarrhea, 52%, is registered in the combination therapy with Vemurafenib and Cobimetinib, while the highest incidence of vomiting, 29%, is observed following the use of Encorafenib and Binimetinib. Intermediate incidence rates ranging from 8% (Encorafenib plus Binimetinib) to 25% (Dabrafenib plus Trametinib) are recorded for anorexia and ranging from around 7% (Encorafenib plus Binimetinib) to approximately 15% (Vemurafenib plus Cobimetinib) for liver toxicity, with increased transaminase levels. Lastly, incidence rates lower than 10% were associated with cardiovascular involvement. These data show that even though there is a comparable toxicity spectrum when considering systemic side effects, a higher variability is registered between the incidence rates of side effects targeting specific organs or apparatuses. This trend is also noticeable when we switch the focus to higher-grade adverse events.Some of the grade 3 through 5 side effects present superimposable incidence rates between the three doublets, and these are anemia (5–6%), asthenia (3%), decreased ejection fraction (2–3%), and headache (1–2%). The key factor, though, on which this analysis shines the light, is the unevenness between the doublets. When considering therapies with Dabrafenib plus Trametinib and Encorafenib plus Binmetinib, arthralgia is registered in 1% of cases, rising to 4% when the treatment considered is Vemurafenib plus Cobimetinib. This consideration can be meaningful in orienting towards the therapeutic choice when patients undergoing this specific oncological treatment suffer from chronic joint issues or concomitant rheumatological pathologies.Hypertension is recorded in 6% of patients treated with Dabrafenib plus Trametinib and with Encorafenib plus Binimetinib, an incidence rate that increases to 8% when considering the Vemurafenib and Cobimetinib doublet. In this case, the first two therapeutic options should be favored. Even if the difference appears to be small, granting a better cardiovascular toxicity profile in a general population commonly affected by these kinds of comorbidities is preferable. On the same line, pyrexia is registered in 2% of cases in the Vemurafenib and Cobimetinib combined therapy, an incidence that increases to 4% when we consider Encorafenib plus Binimetinib and reaches 6% in case of treatment with Dabrafenib plus Trametinib. The difference between these numbers in absolute value can seem small, but when considering the comparison regardless of what the actual number is, what is clear is that Dabrafenib plus Trametinib leads to an essentially tripled incidence rate of pyrexia, a factor that should be kept in mind when choosing the appropriate doublet.When it comes to gastrointestinal side effects, both vomiting and diarrhea present higher incidence rates following therapy with Vemurafenib and Cobimetinib, respectively, 8% and 5%, which decreases for the other doublets: vomiting rates diminish to 2% in both the other doublets, and diarrhea rates decrease to 1% and 3%, respectively, for Dabrafenib plus Trametinib and Encorafenib plus Binimetinib. Therefore, although our data are descriptive in nature, it could be speculated that Dabrafenib and Trametinib, compared to other drug doublets, might induce gastroenteric grade 3–5 side effects in a lower percentage of cases.Vemurafenib plus Cobimetinib is a doublet that also results in a relevant rate of side effects such as skin rash (8%) and hepatotoxicity. In fact, it determines an increase in hepatic cytonecrosis indices (AST and ALT) in 10% of cases, compared to essentially halved rates if we instead consider the therapies with Dabrafenib and Trametinib (4%) and with Encorafenib and Binimetinib (5%). This information is relevant when we consider hepatopathic patients for treatment: the doublets consisting of Dabrafenib plus Trametinib or Encorafenib plus Binimetinib may be preferred over Vemurafenib plus Cobimetinib.Although the combination of Vemurafenib and Cobimetinib is associated with higher incidence rates of diarrhea compared to other doublets, the same result does not emerge when considering vomiting and anorexia. In fact, although the results are clear in stating that the use of Dabrafenib and Trametinib is associated with a higher incidence rate of anorexia, the same cannot be stated for vomiting, where the data are conflicting. A higher incidence rate of grade 1–2 vomiting is related to the use of Encorafenib and Binimetinib, whilst when it comes to grades 3 or higher toxicity, the V-C doublet emerges. Comparing the results obtained on the incidence profiles of the single most frequent side effects following the prescription of BRAF and MEK inhibitors, it is observed that the combination therapy with Vemurafenib and Cobimetinib is associated with a higher rate of diarrhea, arthralgia, and skin rash for any considered grade. This combination is also correlated to an onset of liver toxicity with a transaminase level increase, and cardiovascular toxicity, resulting in higher incidence rates of hypertension and decreased ejection fraction when compared to the other doublets, even though, focusing especially on the grade 3 or higher decrease in ejection fraction, higher incidence rates were reported in the Dabrafenib and Trametinib therapy regimen. In conclusion, based on the results of this meta-analysis, it appears that some doublets may be more suitable than others in certain patient categories in virtue of a lower rate of specific side effects. This study shows that when the chosen combination is Vemurafenib and Cobimetinib, there is a higher incidence of hepatotoxicity; consequently, the use of other doublets presenting the lowest rates of hepatotoxicity could be preferred, in this case the Encorafenib and Binimetinib one. The data are relevant, especially in the absence of a direct comparison, when we consider treatment in patients with underlying liver cirrhosis or rare genetic liver dysfunctions. The same type of reasoning can be applied to cardiovascular diseases. Considering the high incidence of arterial hypertension, heart failure, and atrial and ventricular arrhythmias in the general population, the lower incidence of side effects that could affect the heart should guide the choice of which doublet to prescribe. The lowest incidence rate for increased blood pressure and decreased ejection fraction was recorded in relation to Encorafenib and Binimetinib, potentially becoming the preferred doublet in this specific subset of patients. Considering the progressive trend towards a longer life expectancy, and therefore an increase in numbers of the elderly population, it is crucial to consider side effects such as arthralgia in specific contexts, such as patients suffering from aging-linked arthrosis, chronic arthropathies, and above all, rheumatological diseases that afflict bones and cartilage, such as rheumatoid arthritis. This study shows that treatment with Vemurafenib and Cobimetinib is related to a higher incidence of any-grade arthralgia; therefore, one could move towards the use of the other two doublets, reporting lower and almost overlapping incidence rates.Furthermore, it was found that combination therapy with Vemurafenib and Cobimetinib shows a higher incidence of any-grade skin rash. In this case, resorting to the use of Dabrafenib and Trametinib or Encorafenib and Binimetinib would represent the better option for patients suffering from dermatological diseases. Finally, the main hematological side effect studied was anemia. In this regard, the data are conflicting: Vemurafenib and Cobimetinib, when combined, would determine a higher incidence of grade 3 or higher anemia, whilst a higher incidence of grade 1–2 anemia is associated with the use of Dabrafenib and Trametinib.The toxicity profile review performed, in addition and relation to patients’ clinical conditions and comorbidities, can prove useful in selecting the best doublet. This analysis, however, presents some limitations. Firstly, even though the amount of gathered data was high and this work turned out to be solid, a direct comparison between drugs was not possible. Furthermore, the non-inclusion of data belonging to either quality of life reports (QoL) or patient-reported outcome measures (PROM) represents another limitation. Nevertheless, the results of this meta-analysis can represent a valuable basis for future studies aimed to identify the optimal doublet to use in a specific clinical context and to define differential toxicity based on cancer type, line of therapy, and baseline biomarkers .The goal of this meta-analysis was to provide a useful tool to guide the clinician towards the best therapeutic option among the different combinations of BRAF and MEK inhibitors used in melanoma treatment . In virt


Dissociative symptoms have been recently related to bipolar disorder (BD) symptomatology. Moreover, the disease burden carries on a share of perceived self-stigma that amplifies the BD impairment. Internalized stigma and dissociative symptoms often seem overlapping, leading toward common outcomes, with reduced treatment seeking and poor adherence. We hypothesize a potential relationship between dissociation and self-stigma in patients suffering from BD.In this cross-sectional study we enrolled a total of 120 adult clinically stable BD outpatients. All participants completed the Internalized Stigma of Mental Illness (ISMI), Dissociative Experiences Scale-II (DES-II), and Manchester Short Assessment of Quality of Life (MANSA).n = 66, 55%; BD-II n = 54, 45%) onset were 46.14 (±4.23), and 27.45 (±10.35) years, with mean disease duration of 18.56 (±13.08) years. Most participants were female  and 40 (33%) of them experienced lifetime abuse, with an average of 1.05 (±0.78) suicide attempts. DES scores  correlated with ISMI total-score, with significant association with spikes in Alienation  (p < 0.001) and Stereotype  (p < 0.001). Linear regression analysis has shown a significant association between DES total score and alienation (p < 0.001), stereotype (p < 0.001) and MANSA total-score (p < 0.001).Average age and age at BD (BD-I For the first time, our data suggests that self-stigma is associated to dissociative symptoms, reducing overall quality of life in BD. The early identification of at-risk patients with previous lifetime abuse and high perceived stigma could lead the way for an ever more precise tailoring of treatment management. Bipolar disorder (BD) is a severe psychiatric disorder characterized by shifts of emotions, energy and thought, as well as changes in concentration and sleep need, with impairment in the ability to carry out day-to-day tasks, which mainly occur during biphasic mood episodes of mania or hypomania and depression, and are expressed as recurrent episodes of changes in energy levels and behavior, with a negative impact on patients' overall quality of life , 2.The lifetime prevalence is around 1% worldwide, and, usually, the onset is in the late second or early third decade of life . The chrFrequently, not recognizing the mood shift and poor insight can delay treatment initiation and a worsening of the clinical course , 8. IndeMoreover, several studies highlight that patients suffering from affective disorders present dissociation as a preferred coping strategy , 14, andIn recent years, some advances have been made regarding the knowledge concerning stigma in BD, and, according to our current understanding, there are mainly three kinds of stigma. The most well-studied concept is the internalized or self-stigma, which explains the subjective appreciation of negative experiences and perceptions of the patients themselves, leading to identity transformation and stereotype endorsement . The secWe hypothesize a potential relationship between internalized stigma and dissociative phenomena in patients affected by BD, potentially leading to a peculiar negative clinical course and a worsening quality of life. Therefore, the present work aimed to assess the correlation between self-stigma, dissociative symptoms, and quality of life in a clinical sample of patients suffering from BD with a cross-sectional study design, and to test if the dissociative symptomatology may be related to a specific subthreshold of internalized stigma and/or to quality of life.This study was designed as a naturalistic and uncontrolled cross-sectional observational study at the outpatients' Psychiatry unit of the University Hospital Mater Domini of Catanzaro  and was conducted between May 2020 and January 2022. All consecutive potentially candidate patients were screened for eligibility and invited to participate in the study, where applicable. Participants were screened and diagnosed by a clinical interview conducted by experienced clinicians through the Structured Clinical Interview for DSM-5 (SCID-5 CV) . The intWe included all patients fulfilling the following inclusion criteria: (1) aged between 18 and 70 years and able to read and understand the informed consent form; (2) capability to answer self-report questionnaires; (3) diagnosed with BD type-I (BD-I) or type-II (BD-II) according to the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) ; (4) cliAccording to the Ethical Committee, participants were provided with a complete description of the study aims and methods and gave written informed consent to participate in the study before any procedure took place. The study protocol was submitted and approved by the Ethical Committee of University Hospital Mater Domini at Catanzaro (n. 307/2020), and the study procedures were carried out in accordance with the ethical principles set out in the revised version of the Helsinki Declaration .ad hoc schedule. In detail, we used a semi-structured interview collecting data on age, sex, civil status, years of education, current occupation, family history of psychiatric diseases, psychiatric and general medical comorbidity, onset, and longitudinal course of the disorder , number of previous suicidal attempts and psychiatric hospitalizations, and current prescribed treatments.We collected patients' demographics and clinical  information through an Then, all participants were evaluated by means of the following Italian versions of assessment scales:• The Clinical Global Impression for Bipolar Patients (CGI-BP)  is a mod• The Internalized Stigma of Mental Illness (ISMI) scale  is a 29-• The Dissociative Experiences Scale II (DES-II) , and its• The Manchester Short Assessment of Quality of Life (MANSA) has been developed as a brief, handy and innovative instrument for assessing the quality of life, focusing on satisfaction with life as a whole and with life domains . It inclp ≤ 0.05. Statistical analyses were performed by using the Statistical Package for Social Sciences Version 26 .Descriptive statistics were calculated for socio-demographic and clinical characteristics and other relevant assessment instruments. As appropriate, data are presented as means and standard deviations (SD) or frequencies and percentages (%). A Spearman's correlation analysis was performed to test the correlation between psychometric scale and clinical and sociodemographic variables. A linear regression model was used to describes the relationship between the DES total score as dependent variable, and ISMI subscales and MANSA total score as independent variables. Odds ratios (OR) with 95% confidence intervals were assessed for observed associations. All tolerance values in the regression analyses were >0.1 and all variance inflation factors were <10, expressing that the assumption of multicollinearity was not violated. The level of statistical significance was set at a nominal value of n = 10) or to sign the informed consent (n = 6), or other reasons (n = 2). Therefore, the final sample was made up of 120 patients, of whom 66 (55%) suffering from BD-I and 54 (45%) from BD-II. The average age  was 46.1 (±14.23) years, and the majority of participants were female , single , graduated , employed , with positive family history for both psychiatric  and general medical  disease, and 33.3% (n = 40) of them experienced lifetime abuse  and anxious features , with also frequent mixed  and psychotic  symptoms. Seasonality was also very common , as well as suicidality , with an average of 1.05 (±0.78) suicide attempts  at BD onset was 27.45 (±10.35), while the average disease duration was 18.56 (±13.08) years. We recorded a mean of 5.43 (±5.10) depressive, 3.92 (±2.90) maniac, and 3.11 (±3.06) hypomanic episodes, then the average number of affective episodes was 10.47 (±9.91) among patients. Most included patients presented aggressive behaviors  score was higher than the settled cut-off of 30 points , with spikes shown especially in Alienation , Stereotype  and Social distancing  items. As for the MANSA scale, participants scored an average total of 49.1 (±10.9) out of 93 total points, while ISMI mean score was 60.4 (±9.6) out of a tool range between 29 and 116 .t = 4.329; p < 0.001), Stereotype  and MANSA total score   .This study found a strong relationship between internalized stigma and dissociative phenomena in patients suffering from BD, which may lead to a peculiar negative clinical course and a worsening quality of life. To the best of our knowledge, this is the first time internalized stigma was explored concerning its role in dissociation symptoms in BD, with consequences on quality of life. Further, as shown by Spearman's correlation analysis, internalized stigma is correlated to several clinical variables predictive of poor clinical outcomes in BD. ISMI total score correlates to a higher number of total episodes, hospitalization, psychotic features, and previous substance abuse, highlighting its impact on those factors predictive of a higher psychopathological burden. Such results are easily explained due to the impact of stigma on the life of psychiatric patients, especially those suffering from BD , 37. A gUsually, one of the most explored findings resulting from studies using ISMI is the relationship between internalized stigma and more severe psychopathology, lower self-esteem, reduced treatment adherence, and greater symptom severity –42. PiloFurther, previous research indicates alienation as a maladaptive coping strategy in psychiatric patients facing traumatic experiences , 52. ThiConsequently, both self-stigma and dissociative symptoms represent two elements of greater severity of BD that potentially worsen its clinical outcome lowering treatment adherence and deteriorating the prognosis , 55. PreMoreover, results presented in our study should be interpreted in the light of both some limitations and strengths. Indeed, although the clinical sample involved was recruited in a naturalistic setting, adequate to describe the general population and similar to several analogous studies , 61, 62,Recently, dissociative symptoms have been studied concerning their impact on BD clinical course and treatment response, while perceived stigma is already well-known to interfere with clinical outcomes. However, the relationship between dissociative symptoms, self-stigma and quality of life in patients suffering from BD is still far from being fully understood and has been explored in this study.Although burdened by several limitations and by a cross-sectional study design which avoids a generalization, our findings correlate self-stigma reported by patients affected by BD to experienced dissociative symptoms, resulting in a reduced overall quality of life. Therefore, the study of this network may represent an area of clinical research interest for the future, with the goal of reaching a more patients' focused clinical practice to anticipate a precise diagnosis, manage personalized treatment, and improve prognosis.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Committee of University Hospital Mater Domini at Catanzaro  (n. 307/2020), and the study procedures were carried out in accordance to the ethical principles set out in the revised version of the Helsinki Declaration. The patients/participants provided their written informed consent to participate in this study.LS: conceptualization and formal analysis. RdF and LS: methodology and writing the original draft preparation. RdF, MD'A, and LS: investigation and data curation. RdF, GM, EC, AT, PD, and LS: writing and review and editing. All authors read and approved the final 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.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 authors report on a boy with dyslexia and attention deficit hyperactivity disorder. A protocol of standardized tests assessed the neuroadaptive profile, allowing deep neuropsychiatric phenotyping. In addition to the diagnosis of dyslexia and attention deficit hyperactivity disorder, such methodology led to endeavor cognitive, adaptive, and academic skills. Chromosomal microarray analysis detected a 452.4 Kb de novo heterozygous microdeletion in chromosomal region 1p34.3, including seven OMIM genes. The authors took a thorough evaluation of the association to the phenotype of the deleted genes. Further reports could strengthen such association. DYX1C1, CYP19A1, DCDC2, KIAA0319, ROBO1, C2Orf3, and MRPL19, and some of these play a role in specific biological processes, such as migration of neurons during early brain development or out-growth of dendrites and axons [Dyslexia or reading disability (RD) consists in a deficit in reading ability in individuals with normal intelligence . It is ond axons ,5,6. Copnd axons . To dateAttention deficit hyperactivity disorder (ADHD) is a disorder marked by pattern of inattention and/or hyperactivity-impulsivity, often persistent into later life and with a reported frequency in approximately 5% in school-aged children .RD seems to co-exist most clearly with ADHD, and according to many studies, between 15 and 50% of individuals with ADHD have dyslexic problems and vice versa ,11,12,13Using chromosomal microarray analysis (CMA), we identified a single heterozygous microdeletion at 1p34.3 in a boy with RD and ADHD. The deleted interval, of approximately 452.4 Kb in size, is de novo and encompasses seven genes.The proband is the second-born boy of healthy, non-consanguineous parents. The paternal uncle shows paranoid schizophrenia and the paternal grandmother epilepsy, but no cognitive and genetic testing was performed.His pregnancy was uneventful, and the delivery was at-term by cesarean section. At birth, weight was 2980 g (−1 SD), length 49 cm (+0.5 SD), and head circumference 34 cm (0 SD). Apgar scores were 10 at 1′ and 5′. He held his head up without support at 3–4 months, sat unsupported at 7–8 months, walked independently at 14 months, and spoke the first words at 18 months. At three years, he presented with hyperkinesis, oppositive behavior, and night awakenings (pavor nocturnus). He attends the fourth primary class at the current age of 9 years and 8 months. He is hyperactive and shows impairments in speech, language, and learning. Clinical genetics evaluation does not show any birth defect or morphologic anomaly.A protocol of standardized tests assessed the neuroadaptive profile. The Raven’s Colored Progressive Matrices (CPM) evaluated nonverbal intelligence ,16; the Database of Genomic Variants , DECIPHER , and the ClinVar database .Whole-genome CMA analysis was performed on DNA isolated from peripheral blood lymphocytes drawn from the proband and his parents, using the standard Agilent SurePrint G3 Human CGH + SNP 4 × 180 K Microarray , with overall median probe spacing of 25.3 Kb. Labeling and hybridization were carried out according to the manufacturer’s instructions . The image of the array was acquired using the Agilent laser scanner G5761A  and analyzed with Agilent Cytogenomics software (v.5.0.2.5). Genomic coordinates were reported according to the GRCh37/hg19 genome assembly, and the data were compared to known copy number variation listed in available public databases, such as the No further genetic testing was performed.The administration of tests and multi-evaluation checklists led to the following cognitive, behavioral, and adaptive profiles. The Raven’s test was normal (38th percentile). The selective and sustained visuo-spatial attention function (BTR) fell below the 10th percentile; inattention and impulsiveness were confirmed by the MFFT test, with a score falling below the 5th percentile. The behavioral assessment forms (CPRS-R:L), completed by the caregiver, highlighted hyperactivity and inattention components: ADHD (95th–98th percentile), inattention (>98th percentile), and restlessness/impulsivity (95th–98th percentile), thus confirming significant behavioral issues. The behavioral assessment using the CBCL forms showed the presence of externalization problems (T score 70) falling within the clinical attention scope, while internalization problems (T score 60) were in the borderline scope. The subscales falling within the clinical range were those relating to attention (T score 70) and social (T score > 60) issues. Scores obtained at the ABAS-II relating to socio-adaptive skills were low. In the conceptual (CON 56), social (SO 58), and practical domains (PR 60), the scores were <2 SD. In addition to attention, these low scores might be due to the motor and behavioral impairments and dysfunctional educational styles within the boy’s daily life. The receptive lexicon (PPVT-R) was normal, and the receptive syntax (TROG-2) was below the normal range (<5th percentile). Decoding skills of letters, words, pseudo-words, and text were impaired for reading speed (<2 SD) and accuracy (<5th percentile). The administration of a text dictation unveiled a significantly deficient performance (<5th percentile).http://genome.ucsc.edu/cgi-bin/hgGateway, accessed on 31 August 2022) and the OMIM database , we observed that the deleted region included the following OMIM genes: KIAA0319L (OMIM: 613535), NCDN (OMIM: 608458), TFAP2E (OMIM: 614428), PSMB2 (OMIM: 602175), CLSPN (OMIM: 605434), AGO4 (OMIM: 607356), and AGO1 (OMIM: 606228). Breakpoint analysis revealed that the deletion includes the exons 1–16 of KIAA0319L (NM_024874.5) and the exons 1–8 of AGO1 (NM_012199.5). A review of the DGV (Build GRCh37) revealed that there were no CNV in the general population similar in size and genomic endpoints to our patient’s deletion. The DECIPHER database yielded regions considerably larger than the deletion reported here. In the ClinVar database, a similar deletion was reported (VCV001526873.1). SNP analysis detected no region of copy neutral loss of heterozygosity in the proband. The patient is listed in the DECIPHER database as patient ID# 366790.CMA displayed  a de novKIAA0319L, possibly leading to its haploinsufficiency. According to the gnomAD , the KIAA0319L gene has a probability of loss-of-function intolerance (pLI) of 0, and thus, heterozygous loss is less likely to be contributing to our patient’s clinical phenotype. However, the hypothesis that KIAA0319L is a candidate gene for RD is supported by suggestive linkage studies [KIAA0319, already associated to RD [KIAA0319L, in adult mice, is expressed in brain regions that in the human brain are crucial for reading performance, supporting its possible involvement in RD [KIAA0319L, during rat corticogenesis, caused aberrant neuronal migration patterns with periventricular heterotopias [KIAA0319, DCDC2, and ROBO1, resulted in neuronal migration disorders [KIAA0319L gene in the RD of our patient. The identification of KIAA0319L in a group of ADHD-associated genes and pathways suggests that the alteration of transcription, resulting from the deletion of its critical region, could also contribute to the complex NDD of our subject [NCDN gene encodes neurochondrin (NCDN), a cytoplasmatic neural protein of importance for neural growth, glutamate receptor signaling, and synaptic plasticity. The gnomAD database revealed that the NCDN is predicted to be severely intolerant to haploinsufficiency with a pLI score of 1. Conditional loss of NCDN in mice neural tissue causes depressive-like behaviors, impaired spatial learning, and epileptic seizures [NCDN have been reported in six affected individuals with variable degrees of developmental delay (DD), intellectual disability (ID), and epilepsy [NCDN were identified in three individuals with ID and motor and speech delay but not seizures [NCDN haploinsufficiency was associated to variable clinical features, therefore warranting further investigations for a more precise explanation. TFAP2E is a member of the AP2 family of transcription factors; such proteins bind to and regulate the promoters and enhancers of numerous genes involved in a wide spectrum of physiologic processes during development, cell cycle, and differentiation. PSMB2 encodes a member of the B-type proteasome family, responsible for degradation of short-lived and misfolded cytosolic and nuclear proteins. CLSPN encodes an essential upstream regulator of checkpoint kinase 1 and triggers a checkpoint arrest of the cell cycle in response to replicative stress or DNA damage. This protein is also required for efficient DNA replication during a normal S phase. According to the gnomAD database (31 August 2022), TFAP2E, PSMB2, and CLSPN genes have a pLI score of 0, 0.91, and 0, respectively. No disruption of them has been implicated in the pathogenesis of RD and ADHD.This case report describes the detailed neuroadaptive profile of a patient with a de novo 452.4 Kb microdeletion in 1p34.3. He presented with a complex NDD, including severe RD, spelling disorder, speech delay, and ADHD. RD and its comorbidities, such as ADHD, are critical for educational performance, impairing adulthood. It is important to identify the etiology of reading and language disorders and their comorbidities, such as ADHD, to plan intervention strategies. The view that RD is caused largely by genetic factors is now generally accepted although the underlying etiology appears polygenic and multifactorial [ studies ,28,29,30ed to RD ,33,34. Ant in RD . KIAA031nt in RD . Embryonrotopias . Severalisorders ,39,40. Tisorders ,42,43. A subject . The NCDseizures . Monoallepilepsy . Furtherseizures . DD, ID,AGO4 gene and the first 8 of 19 exons of AGO1 gene. AGO genes encode members of the argonaut family of proteins, which associate with small RNAs and have important roles in RNA interference and RNA silencing. According to the gnomAD database, the AGO4 gene has a pLI score of 1, but to our knowledge, the effect in humans of AGO4 dosage alterations has not been reported. Therefore, there is no direct evidence of a link between AGO4 deletion and the phenotype in our patient. The pLi score of AGO1, provided in the gnomAD database, is 1, suggesting that haploinsufficiency is likely to be the main disease driver. De novo missense variants have been reported in AGO1 in individuals with a broad spectrum of NDDs, including global DD, ID, autism spectrum disorder (ASD), hypotonia, dysmorphism, behavioral features, and language impairment with or without epilepsy [AGO1 gene are mainly nucleotide changes, while in our patient, a deletion including the first eight exons of the transcript was revealed. Large deletions at the 1p34.3 locus including AGO1 together with AGO3 (and sometimes AGO4), among other genes, were previously reported in five children with psychomotor DD as well as additional non-specific features, such as feeding difficulty, language impairment, and dysmorphic features [AGO1 as a promising candidate gene for NDDs. This can be confirmed by the complex NDD including severe RD, spelling disorder, and ADHD of our case report. More variants and functional studies are necessary to reveal the real pathogenic mechanism of AGO1. Furthermore, a 2.6 Mb microdeletion in 1p34.3 involving the region of the present case was reported in a girl with severe DD predominantly affecting her language and fine motor skills [ClinVar database in a patient with a similar deletion of uncertain significance. It would be interesting to know if RD was excluded or simply not reported. The deleted region also encompasses the epilepsy ,50,51,52features . These dr skills . ASD, abClinVar in an individual with a NDD is not sufficient to proof causation. There is no functional evidence that the CNV is the culprit of the disorder of our patient, and it could be a coincidence. The actual genetic cause of RD and ADHD in our patient remains to be fully elucidated. We encourage the report of individuals, whether patients or healthy, harboring overlapping microdeletions to investigate the clinical relevance and delineate the potential contribution to RD.Our case is the only one presenting with RD and not with DD or ID. That can be linked to the small size of deletion of our patient versus the many deleted genes in the other reports, resulting in a more severe phenotype hiding RD. In conclusion, we document a boy with RD and ADHD without major dysmorphism and ID/ASD, maintaining the likely role of genes included in the deletion. There is no real evidence that the ADHD and RD in our patient is due to the his CNV, as there are many cases reported where even larger euchromatic genes containing CNVs were found without any clinical consequences. The fact that a similar microdeletion was seen in


The aim of this was to analyze the effect of different treatment options on radial neck fractures in children and to explore the factors affecting the prognosis of fractures.The clinical data of 131 children with radial neck fractures admitted to our hospital from 2010 to 2018 were retrospectively analyzed, and the patients were divided into 6 groups according to treatment methods . Postoperative elbow function and complications were analyzed.Among the 131 patients with fractures, the median age was 8 years, the median preoperative angulation was 52°, the follow-up rate was 86.3% (113/131), the average follow-up time was 58.3 months, and the postoperative complication rate was 17.7% (20/113). The comparison among the different treatment groups showed that group B had the best recovery of elbow function, postoperatively, and the lowest postoperative complication rate. Age, duration of hospitalization, and preoperative angulation were independent factors affecting postoperative complications. Older age, longer duration of hospitalization, and higher angulation increase the postoperative complications.Different treatment options have different efficacies for radial neck fractures in children, of which manipulative reduction with internal fixation using ESINs can achieve good efficacy and a low postoperative complication rate. Age, duration of hospitalization, and preoperative angulation are independent factors for postoperative complications. Radial neck fractures in children are an uncommon type of fracture, accounting for 1% of all body fractures and 5–10% of elbow fractures . BecauseAll patient records in our hospital from January 2010 to December 2018 were retrospectively reviewed. The exclusion criteria were as follows: (1) multiple fractures, (2) conservative treatment, (3) nontraumatic radial neck fractures, and (4) accompanying medical diseases requiring special treatment, such as leukemia or malignant tumors. Preoperative fracture angulation and displacement were measured according to the Judet classification . PostopeManipulative reduction was performed mainly with the Patterson technique, Israeli technique, or Neher and Torch technique with pressure over the radial head and rotation of the forearm in various positions of elbow flexion and extension –11. Percα = 0.05, and P < 0.05 was considered to indicate statistical significance.All 14 surgeons who participated in this study received standardized training in pediatric orthopedics, were certified, and had at least 5 years of working experience in pediatric orthopedics. All data were statistically analyzed using SPSS 20.0 software . The clinical data of the patients are described by statistical indicators such as the mean, standard deviation, median, interquartile range (IQR), and percentage. The Kruskal–Wallis, Chi-square, Mann–Whitney, Fisher’s exact, and Student’s t tests were used to statistically analyze the differences among different treatment groups. A logistic model was used to identify the prognostic factors affecting radial neck fracture results. All analyses were performed with two-sided tests and a test level A total of 131 patients were included in this study, of whom 18 were lost to follow-up, with a median follow-up rate of 86.3% and a mean follow-up time of 58.3 months . The median age of the patients was 8 years (IQR 6–10 years), and 45% were male. The median preoperative angulation in the 131 patients was 52° (IQR 39–65) . Among these factors, group B had the most “excellent” elbow scores (84.6%) without any “poor” scores, and group F had the minimal “excellent” elbow scores (43.8%) with most “poor” scores (18.8%). However, there was no significant difference in gender, weight, time of receive surgery, and postoperative complications among groups Tables  and 3.Tan = 14, 14.4%), open reduction group: ] and relatively good Tibone function evaluation results . However, the patients in the open reduction group had relatively large preoperative angulation degrees . The clinical data were compared between the K-wire group and the ESIN group, and significant differences were found in age , weight , time of implant removal , and hospitalization cost  (P < 0.05). Under the same conditions, ESINs were preferred for older patients.In addition, the patients in the closed reduction group had relatively few postoperative complications , 1 case of heterotopic ossification, and 2 cases of joint stiffness Table . The logAt present, there are many treatment options for radial neck fracture in children, and the reported conclusions differ –15. A smThrough statistical comparisons of the clinical data of patients who received different treatment regimens, we found that there was a statistically significant difference in age. Moreover, despite further statistical analysis, we failed to find a significant correlation between age and postoperative function, which is different from previous studies , 19, 20.P = 0.464), and there was also no significant difference in the Tibone elbow outcome score and postoperative complications ; we did not find the time of receive surgery to be an independent predictor of efficacy, which was different from the results of previous studies [As the blood supply to the radial head mainly passes through the reverse supply of the radial neck in children , it is c studies , 21. We At present, there is no consensus on the application ranges of different surgical treatment options for preoperative angulation , 22–24. P = 0.047). Overall, group B had the most excellent and good scores , because the effective manual reduction method together with the hook structure of the ESINs assisted in the reduction of the fracture, and the fracture site was firmly fixed with little damage to the surrounding soft tissues. These factors were conducive to repairing the fracture site, and good functional recovery was achieved. However, it should be noted that ESINs are not applicable to younger patients due to size limitations, and indwelling in the body for a longer time, and cost is higher. After comparing different treatment groups, we found no significant difference in postoperative complications (P = 0.164). The main evaluation indexes of the Tibone elbow outcome scoring system include patient symptoms (pain) and range of motion and carrying angle [In this study, the Tibone elbow outcome scoring system was used to evaluate and compare the postoperative function of patients receiving different treatment regimens, and the results were statistically significant (ng angle , 25, whiAge, duration of hospitalization, and preoperative angulation were independent risk factors for postoperative complications. The probability of postoperative complications was higher for patients with an older age, longer duration of hospitalization, and greater preoperative angulation. We inferred that these factors were associated with postoperative nosocomial infection. Previous studies have shown an association between the duration of hospitalization and postoperative nosocomial infection . We founThis study is a single-center retrospective study and the research level is relatively low. However, based on the large number of samples from this clinical retrospective study, we can learn about the relevant clinical characteristics of radial neck fractures in children and also evaluate the efficacy of different treatment options, but further studies are required to confirm it.To obtain good functional recovery and a low incidence of postoperative complications, manual reduction combined with ESIN internal fixation may be the preferred treatment for radial neck fractures in children. However, for patients with large preoperative angulation degrees and severe injury, open reduction is still an indispensable approach. Performing reasonable and effective preoperative planning, shortening the duration of hospitalization, and applying other measures can reduce the occurrence of postoperative complications.