Thyroid autoimmunity is common in papillary thyroid carcinoma (PTC) and was believed to confer a better prognosis; however, controversy still remains. This study aimed to investigate the prognostic value of chronic lymphocytic thyroiditis (CLT) and preoperative thyroid peroxidase antibody (TPOAb) in PTC patients.A retrospective analysis was performed on 5,770 PTC patients who underwent surgical treatment with pathologically confirmed PTC in our institution between 2012 to 2016. The patients were divided into groups with respect to the coexistence of CLT or preoperative TPOAb levels. The clinicopathological characteristics and disease-free survival (DFS) rates were compared between the groups.p = 0.007) and higher rates of bilaterality and multifocality than those with TPOAb− (TPOAb< 100 IU/L), while for lymph node metastasis and extrathyroidal extension, there is no statistical difference. Tumor recurrence was found in 15 of 425 (3.5%), 9 of 436 (2.1%), and 56 of 3,519 (1.6%) patients with TPOAb++, TPOAb+, and TPOAb−, respectively (p = 0.017). On univariate analysis, TPOAb++ was correlated with tumor recurrence, with a hazard ratio of 2.20 , which remained as an independent risk factor at 1.98  on multivariate analysis. PTC patients with TPOAb++ had the lowest DFS rates .The coexistence of CLT was likely to have bilateral, multifocal tumors. Particularly, PTC patients with TPOAb++  had a larger tumor size (CLT is not a protective factor in PTC patients. We provide initial evidence that the preoperative TPOAb instead predicts recurrence in papillary thyroid carcinoma. Thyroid cancer ranks as the most common endocrine malignancy, and its overall incidence increases annually , 2. PapiThyroid peroxidase antibody (TPOAb) is a serological marker of CLT . Its levIn the current study, we aimed to investigate the clinical value of coexistent CLT in a cohort of 5,770 consecutive PTC patients. We also evaluated the clinicopathologic and prognostic significance of preoperative TPOAb levels in these cases. The large sample size provided us with an opportunity to study the prognostic effect of TPOAb levels in PTCs.The medical records of 6,723 patients who underwent total or hemithyroidectomy with a final histopathological diagnosis of PTC at the First Affiliated Hospital, Zhejiang University School of Medicine , from 2012 to 2016, were retrospectively reviewed. In total, 190 patients with a history of thyroidectomy, 141 patients with a history of thyroid disease or radiation exposure, and 622 patients lacking preoperative TPOAb levels were excluded. A total of 5,770 patients were finally included in the retrospective study , free thyroxine (FT4), thyrotrophin (TSH), and TPOAb. TPOAb was measured by an automated chemiluminescent immunoassay system  at 1 to 2 days before surgery. The postoperative pathological reports, including tumor size, bilaterality, multifocality, extrathyroidal extension (ETE), lymph node metastasis (LNM), and tumor stage (AJCC 8th), were also studied. According to previous studies, CLT was diagnosed based on either preoperative TPOAb higher than 100 IU/L or the presence of diffuse lymphocytic infiltration in the surrounding thyroid tissue , 22. ForAt the end of the study, 4,380 patients were available for survival analysis. These patients were followed postoperatively with measurements of serum thyroglobulin and thyroglobulin antibody, neck ultrasound, and iodine-131 whole-body scans to monitor for disease recurrence and survival. The mean follow-up was 3.5 years . A total of 696 (15.9%) cases received adjuvant radioactive iodine (RAI) treatment. Moreover, 80 of 4,380 patients (1.8%) were diagnosed with recurrent disease or metastases, including 17 in the thyroid bed, 60 in the cervical lymph nodes, and 3 with lung metastases. In most patients, recurrence was confirmed by pathologic examination, while 10 patients were diagnosed based on increased thyroglobulin levels and imaging evidence from iodine-131 scans.The clinicopathological features and disease outcomes were assessed between the 2 groups according to the coexistence of CLT or not. Based on the preoperative TPOAb levels, we also divided all PTC patients into those with TPOAb−, TPOAb+, and TPOAb++ to investigate the prognostic values of different preoperative TPOAb levels.p-value of less than 0.05. Continuous variables were presented as mean ± SD, and categorical variables were presented as the number of cases, with percentage (%). Pearson’s chi-square test was used for categorical variables, and Student’s t-test or one-way analysis of variance was used for continuous variables. The variables associated with clinical outcomes were evaluated using Cox proportional hazard models in univariate/multivariate analyses. Disease-free survival (DFS) curves were constructed using the Kaplan–Meier method, and the log-rank test was used to compare DFS.The SPSS 25.0 software was used for all statistical analysis. Statistical significance was defined as a 2-tailed vs. 45.6 ± 11.8, p < 0.001), female gender , more bilateral  and multifocal  tumors as well as a higher proportion of early stage . No difference was observed between the 2 groups regarding the prevalence of ETE  and the frequency of LNM . For disease recurrence, however, we even found that PTC patients with CLT had a relatively higher recurrence rate than those without CLT, with borderline significance .CLT was present in 1,482 of 5,770 (25.7%) PTC patients, and their clinicopathologic characteristics are shown in vs. 44.5 ± 11.3 vs. 45.5 ± 11.8, p < 0.001), female preponderance , higher rates of bilaterality  and multifocality . However, there was no difference among the 3 groups regarding the prevalence of ETE  or LNM . Furthermore, we found that TPOAb ++ group was significantly characterized by younger age, female preponderance and more aggressive features: higher rates of bilaterality, multifocality, tumor size ≥ 10mm and recurrence. Additionally, we compared the levels of TPOAb with the pathological features on inflammation degree. Oxyphilic metaplasia, follicular atrophy or follicular disruption, which indicate high degree of thyroid inflammation , and TPOAb++  were identified as independent risk factors for tumor recurrence.We then investigated the prognostic value of preoperative TPOAb levels. Tumor recurrence was found in 15 of 425 (3.5%), 9 of 436 (2.1%), and 56 of 3,519 (1.6%) PTC patients in the TPOAb++, TPOAb+, and TPOAb– groups, respectively . Particularly, in patients with TPOAb++, the possibility of bilaterality and multifocality was as high as 28.7 and 38.2%. Therefore, total thyroidectomy may be favored in these PTC patients. However, it seems not rational to perform a more aggressive prophylactic cervical lymph node dissection for PTCs with CLT since the rate for lymph node metastasis was almost the same as that of patients without CLT (39.8 vs.38.1%).The extent of initial thyroidectomy is a major concern when treating PTC patients, and it is usually determined by multiple factors. Here we found a much higher incidence of bilaterality and multifocality in patients with CLT  correlates aggressive features, including larger tumor size, bilaterality, and multifocality, and is an independent risk factor for tumor recurrence. Hence, a preoperative evaluation of the TPOAb level is worthwhile for risk stratification and post-treatment surveillance in PTC patients.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 The Clinical Research Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.WW, LW, SC, LT, and ZL designed the current study and wrote the manuscript. WW, LW, ZM, and YD conducted the statistical analyses. WW, LW, SC, XS, ZM, YD, ZC, YC, JR, JY, JZ, and XT created the original databases to collect the clinicopathological data. TF, ZL, and LT reviewed and revised the manuscript. All authors contributed to the article and approved the submitted version.This research was funded by the National Natural Science Foundation of China , the National Natural Science Foundation of Zhejiang (number LY18H160012), and the Key Project of Scientific and Technological Innovation of Zhejiang Province (number 2015C03031).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. 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To assess the longitudinal effect of double burden of malnutrition (DBM) on the risk of developing child and adolescent overweight or obesity. Analysis of the Peruvian Young Lives Study, younger cohort: baseline (2002) and 4 follow-ups . Outcomes were the incidence of overweight and obesity as defined by the World Health Organization standards. The exposure comprised a variable with 4 categories: non-stunted child with a non-overweight mother (reference group), non-stunted child with an overweight mother, stunted child with a non-overweight mother, and stunted child with an overweight mother . Poisson regression models were built to assess the association of interest, and relative risks (RR) and 95%CI were reported. Data from 2,034 children; 50.0% were girls and the mean age was 12.0 (3.6) months at baseline. Non-stunted children with an overweight mother had greater risk  of developing overweight, compared with the risk for stunted children with a non-overweight mother , and for those with DBM . When compared with the reference group, obesity risk was greater among non-stunted children with an overweight mother , greater among stunted children with a non-overweight mother , and greater among those with DBM . DBM is a risk factor for childhood overweight and obesity in Peru. Dual-duty policies tackling both undernutrition in children and overweight in mothers are needed to reduce DBM and its future effects in Peru. Nevertheless, the BMI changes over time are highly variable across countries, highlighting distinct nutritional quality and different exposure to health risks during life2.The trends of a rising body mass index (BMI) among children and adolescents have reached a plateau in different high-income countries but started to hasten in low- and middle-income countries (LMIC)3. Such coexistence may be present at the individual level (stunted children with obesity), household level (stunted children with overweight mother), and at population level 5. According to the World Health Organization (WHO) and other reports7, the DBM at the household level is the more common form of DBM in middle-income countries undergoing rapid nutrition transition. Worldwide, the prevalence of DBM within household ranged from 0% to 26.8% by country8. The exposure to early undernutrition  is widely documented as having negative effects on child health9, with increases in overweight and obesity rates10 and subsequent emergence of non-communicable conditions12. Thus, one hypothesis considers that intrauterine growth retardation, low birth weight, and premature birth have a causal relationship to the origins of non-communicable conditions such as overweight and obesity (Barker hypothesis)13. On the other hand, the thrifty gene hypothesis proposes that some genes determine the increase of fat storage, which represent a survival advantage in times of famine, but may result in obesity in a non-famine environment14. Studies, however, have shown, separately, the effect of both conditions (undernutrition and obesity) on child health, resulting in limited evidence on the effect of the DBM on overweight and obesity during childhood.The double burden of malnutrition (DBM), a condition defined as the coexistence of overnutrition and undernutrition, usually in mother and child, has emerged as a health concern in LMICversus -2.6%, respectively)16. Overweight and obesity rates, however, have increased among mothers since 199216. Nevertheless, the composition of the DBM has almost not changed during the last 30 years: 90% of children with DBM in Peru are stunted17. Although relevant, much of this information is descriptive and comes from analyses of repeated Peruvian Demographic Health Surveys, instead of longitudinal data on the same subjects.Peru has seen a significant reduction in the prevalence of children with stunting, especially in the urban settings when compared with rural In Peru, the Young Lives Study comprises two different cohorts: the younger cohort that enrolled 2,052 children from the ages of 6 to 18 months at baseline, and the older cohort that included 1,000 children from the ages of 7 to 8 years. The baseline (2002), and the first (2006–2007), second (2009–2010), third (2013–2014), and fourth (2016–2017) follow-ups of the younger cohort were used for analysis. This decision was taken to include children with early undernutrition . 19. Briefly, the sampling strategy was based upon a multistage, cluster stratified, random sampling technique. The sample frame was conducted at the district level with a random selection of 20 sentinel sites from a total of 1,518 districts available in Peru. Since an oversampling of poor areas was required, the top 5% richest districts were excluded from the sampling approach.The Young Lives Study used a sentinel site sampling approach as described in a previous studyFurthermore, the maps of census tracts, with blocks or sets of houses, were used to randomly select one census tract in each district using a table of random numbers. Finally, all households in any given block or set of houses were visited to identify one household with at least one child accomplishing the inclusion criteria for study purposes. Different blocks or sets of houses were approached until the total eligible households were completed. For data collection, three teams – comprising of fieldworkers, a data-entry clerk, and supervisors – were responsible for six or seven sentinel sites.20. Overweight was defined as ≥ 2 standard deviations (SD) above the median of the BMI-for-age, if the child was < 5 years of age, or ≥ 1 SD above the median of the BMI-for-age if the child was ≥ 5 years of age; whereas obesity was defined as ≥ 3 SD above the median of the BMI-for-age if the child was < 5 years of age, or ≥ 2 SD above the median of the BMI-for-age if the was child ≥ 5 years of age. Child weight and height data were available for all the assessments.Outcome: The outcomes of interest were the incidence of overweight and obesity, both defined using the BMI according to the WHO standards21. If a mother had a BMI ≥ 25 kg/m2, she was considered overweight22. A variable was created by combining anthropometrical markers from both children and mother and then split into 4 categories: non-stunted child with a non-overweight mother (reference group in regression models), non-stunted child with an overweight mother, stunted child with a non-overweight mother, and stunted child with an overweight mother. This categorization was done to explore differential risk between nutrition categories as pointed out by our initial hypothesis.Exposure: The exposure of interest was DBM defined, for our purposes, as a stunted child with an overweight mother. A child was considered stunted whether they had a height-to-age z-score < 2 SD below the average z-score, according to the WHO standardsversus female); age (in months) in each assessment; whether the child was born by cesarean delivery, reported by the mother (no versus yes); and if it was premature at birth, reported by the mother (no versus yes). Other variables were at the mother level, such as maternal age (in years) and maternal education level . Variables at the household level were socioeconomic status, based on a wealth index, created as a simple average of housing quality , access to services , and consumer durables 23, which was finally split into tertiles  for analysis, natural region , and area type .Covariates: Other variables were also included in the analysis as potential confounders. Variables at the child level include sex  was used to analyze data. Initially, the study population was described at baseline according to DBM categories. Means and standard deviation (SD) for numerical variables, and proportion and frequencies for categorical variables were used. Comparisons were performed with analysis of variances or Chi-square test, depending on whether it was a numerical or categorical variable.versus stunted children with non-overweight mother versus stunted children with overweight mother) was conducted using Wald test of simple and composite linear hypothesis about the parameters of the multivariable model, and p-values were reported when appropriate.The changes in the proportion of stunted children, overweight and obese mothers, and DBM categories were tabulated using a bivariate approach. Incidence and 95% confidence intervals (95%CI) for overweight and obesity were also estimated. To assess the association of interest – i.e., whether DBM is a risk factor for future overweight and obesity – crude and adjusted models were built using Poisson regression considering the repetitive assessment (panel data) of variables and the multilevel design of the study using random intercepts. The first level was defined by the child’s characteristics and its different evaluations over time, whereas in the second level, the sentinel site was included to account for potential clustering as participants in one cluster are more similar compared to other different clusters. All the models were controlled for potential confounders, and relative risks (RR) and 95%CI were reported. Finally, differences between DBM categories  females, with a mean age of 12.0 (3.6) months. A total of 623 (30.6%) non-stunted children had an overweight mother, whereas 392 (19.3%) stunted children had a mother without overweight. Finally, 184  children were stunted and had an overweight mother, compatible with the usual definition of DBM .Overall, the proportion of stunted children is decreasing over time, from 28.3% at baseline to 16.1% at the last follow-up . The proDuring the 14.0 (SD = 0.5) years of follow-up, the incidence of childhood overweight was 7.9 (95%CI: 7.6–8.2) per 100 person-year. Such incidence was 5.4 (95%CI: 4.9–6.0) among non-stunted children with non-overweight mother, 10.2 (95%CI: 9.8–10.7) among non-stunted children with an overweight mother, 4.6 (95%CI: 3.8–5.4) among stunted children with a non-overweight mother, and 5.1 (95%CI: 4.5–5.9) among those with DBM.The incidence of childhood obesity was 2.2 (95%CI: 2.0–2.4) per 100 person-year of follow-up, and incidence estimates were 1.1 (95%CI: 0.8–1.5) for non-stunted children with non-overweight mother, 3.2 (95%CI: 2.9–3.5) for non-stunted children with an overweight mother, 1.1 (95%CI: 0.8–1.5) among stunted children with non-overweight mother, and 2.1 (95%CI: 1.6–2.7) among those with DBM.The multivariable model showed evidence that non-stunted children with an overweight mother had 64% (95%CI: 35–99) greater risk of developing overweight when compared with non-stunted children with non-overweight mother, and this risk was higher  if compared with the 38% (95%CI: 10–72) risk for stunted children with a non-overweight mother and the 28% (95%CI: 2–61) for those with DBM. Nevertheless, there was no difference between the latter two risk estimates (p = 0.31).Similarly, when compared with the reference group, the evidence showed that the risk for future obesity was 133% (95%CI: 68–222) greater among those non-stunted children with an overweight mother, 159% (95%CI: 75–284) greater among stunted children with a non-overweight mother, and 114% (95%CI: 39–228) greater among those with DBM . The thrAlthough the results did not support our initial hypothesis, our findings shows that DBM at childhood has a strong association with the risk of developing overweight and obesity. Thus, in the case of overweight, the risk was lower among stunted children (having or not having an overweight mother) compared with non-stunted children with an overweight mother, whereas there was no difference in the increased risk for obesity.24. A cross-sectional study in Peru evaluated data from children under-5 years of age and their mothers, using information from the Demographic Health Surveys from 1996 to 2016, and reported that during this period there was an important increase in the proportion of children with and without undernutrition that have an overweight or obese mother17. We found similar results, suggesting the importance of understanding why overweight and obesity in mothers has increased while undernutrition in their children has decreased over time.Our study expands current literature by using a wide definition of DBM and assessing the potential differential effects of children stunting and mother overweight. Thus, within our model we could determine the joint effect of stunting in children when having an overweight mother, but also the effect of only child stunting. Literature regarding this topic is scarce, especially in Latin America, where most of the manuscripts are focused on cross-sectional analyses reporting changes in the DBM over time9. Thus, stunting has been associated with irreversible long-term effects on health, including cognitive impairment, reduced physical growth potential and birth weight of offspring, and increased risk of diet-related non communicable diseases5. A systematic review reported that famine exposure during early life increased the mean BMI as well as the risk of overweight and obesity27. In the same line, overweight, type 2 diabetes, hyperglycemia, metabolic syndrome, and schizophrenia were more common among adults born during the famine in China compared with those born after the famine28. It is expected that early nutrition impairment may have an effect on future organ size, structure, and function, affecting diverse hormonal axes regulating growth and appetite, and influencing on both the risk and the metabolic effects of subsequent overweight and obesity29. Nevertheless, scarce literature has used DBM to assess its effect on the risk of overweight and obesity.Early undernutrition exposure, including stunting and famine, has been associated with future poor health outcomes30. In the case of stunted children, regardless of the mother’s BMI status, the effect of malnutrition on child overweight and obesity is clear but lower than that of the non-stunted child with an overweight mother group. As undernutrition may affect different hormonal axes9, a delay in child development might explain these findings31. Moreover, despite of the obesogenic niche, stunted children with an overweight mother still have a potentially long way to go from undernutrition to obesity.Our results show that different factors should be considered when assessing the risk of child overweight and obesity. In the case of non-stunted children with an overweight mother, the environment seems to be relevant as children are in an obesogenic niche, which may affect diet and physical activity patterns32. Our findings suggest that, despite the risk DBM represents for future overweight and obesity among children, non-stunted children with an overweight mother (a condition that is increasing over time) are at an even greater risk of developing overweight and obesity. In Peru, actions to prevent malnutrition are one-sided policies to reduce undernutrition. Although it is not possible to attribute the great reduction of stunting in Peru to any program alone, the CRECER strategy, which includes food assistance programs (FAP) that provide access and increase food consumption, has been considered as one of the catalysts for that improvement34. However, the effect of FAP in the same Young Lives cohort showed that mothers have a 93% risk of developing obesity compared with those who were not exposed to FAP; and that, even though children exposed to FAP showed a low risk of obesity, these programs tend to provide excess of carbohydrates and few servings of fruits, which could result in overnutrition of mothers and children35. This shows how the unintended consequences of one-sided policies like FAP could affect the quality of the diet; thus, accelerating the rapid weight gain and increasing the risk of developing obesity32. Therefore, dual-duty policies that simultaneously address all forms of malnutrition32, for both children and mothers, must be developed to combat the DBM and the future risk of overweight and obesity in children.Additionally, our findings enhance the importance to address DBM in Peru through the development of dual-duty policies to avoid unintended effects of one-sided programsOur analysis used data from a well-known long-term cohort study with information from the first year of life until adolescence. Our models considered the repetitive nature of several variables, including DBM, child and maternal age, and socioeconomic position. Our outcome was evaluated as categorical variable to ensure appropriate interpretation of findings. Notwithstanding, this study also has limitations that should be highlighted. First, selection bias may be an issue since 5% of the richest districts were excluded according to the sampling strategy. Moreover, changes in BMI and overweight and obesity rates are initially seen in wealthiest individuals among countries undergoing nutrition transition, which may hinder the inference of our results. Second, we only used the definition of DBM at the household level in detriment of any other definition. However, this kind of DBM has been recognized as more common in countries such as Peru. Third, some variables, potential confounders, were not included in the analyses since they were not available . Fourth, the attrition rate, although small (< 10%), may have affected our results. Finally, other noncommunicable conditions, such as hypertension or hyperglycemia were not available, limiting the analysis to only overweight and obesity. Nevertheless, our findings are relevant to understand the potential long-term effect of the DBM on health markers.Our findings show strong association between childhood DBM and the risk of adolescent overweight and obesity. Our results suggest the need of interventions tackling both children undernutrition and overweight in mothers, known as dual-duty policies.


This was a retrospective cohort study, which aimed to investigate the factors associated with hesitancy to receive a third dose of a coronavirus disease 2019 (COVID-19) vaccine. A paper-based questionnaire survey was administered to all participants. This study included participants who provided answers in the questionnaire about whether they had an intent to receive a third dose of a vaccine. Data on sex, age, area of residence, adverse reactions after the second vaccination, whether the third vaccination was desired, and reasons to accept or hesitate over the booster vaccination were retrieved. Among the 2439 participants, with a mean (±SD) age of 52.6 ± 18.9 years, and a median IgG-S antibody titer of 324.9 (AU/mL), 97.9% of participants indicated their intent to accept a third vaccination dose. The logistic regression revealed that participants of a younger age  and with a higher antibody level  were positively associated with hesitancy over the third vaccine. The efficacy of the COVID-19 vaccine and concerns about adverse reactions had a significant impact on behavior regarding the third vaccination. A rapid increase in the booster dose rate is needed to control the pandemic, and specific approaches should be taken with these groups that are likely to hesitate over the third vaccine, subsequently increasing booster contact rate. Coronavirus disease 2019 (COVID-19) was first confirmed in China in December 2019, causing pneumonia and other respiratory diseases, and rapidly spreading worldwide, with a cumulative total of 400,846,690 confirmed cases and 5,764,834 deaths as of 9 February 2022 [Previous studies examined the factors associated with vaccine hesitancy. Ethnicity, work status, religion, politics, sex, age, education, and income were reported to be factors associated with COVID-19 vaccine hesitancy ,11. HoweFukushima Prefecture experienced a surge in COVID-19 cases between August 2021 and January 2022, wherein a total of 17,327 cases, equivalent to 194 cases per 100,000 people, were reported by 9 February 2022 . In addiThe purpose of this study was to investigate factors associated with hesitancy over a third dose of the COVID-19 vaccine in order to increase the booster contact rate required to control the COVID-19 pandemic. This study was supported by the Japan Agency for Medical Research and Development and was conducted as part of the FVCS, a study carried out to evaluate antibody titer dynamics after the second dose of the BNT162b2 vaccine and the mRNA-1273 vaccine in rural communities in Japan.A total of three participants received two doses of mRNA-1273 and all other participants received two doses of BNT162b2. All the participants who received mRNA-1273 were non-healthcare workers. The vaccination dose was the same for all the participants. The blood sampling was performed between 8 September and 8 October 2021. The mean (SD) of the interval days between the second dose of the vaccination and the serological tests was 180.5 (±32.2) days, ranging from 64 to 252 days. Participants were a predominantly homogenic Japanese group, recruited mainly from rural Fukushima Prefecture, including Ishikawa gun, Soma City, and Minamisoma City.In December 2021, a paper-based questionnaire survey inquiring information regarding sex, age, area of residence, adverse reactions after the second vaccination, whether the third vaccination was desired, and reasons for wanting or not wanting the vaccination was distributed to all participants. Subsequently, the eligibility criterion for the study participants was that they provided an answer in the questionnaire to whether they had an intent to receive the third dose of the vaccine. Children aged ≥12 years were allowed to receive the COVID-19 vaccination; thus, we included 58 participants aged 12–19 years.We conducted a questionnaire survey on the acceptance of the third vaccination. The questionnaire items concerning the reasons for acceptance or hesitancy towards the third vaccination could be answered in multiple ways. Papers on vaccine hesitancy ,11 were Blood sampling was conducted between 8 September and 8 October 2021, at each facility in the rural Fukushima Prefecture. Centrifugal separation of blood samples was performed at each facility, and serum samples were sent to Tokyo University. The levels of immunoglobulin G (IgG) antibodies against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S1) protein were measured at Tokyo University. Serological assays were performed using the CLIA assay with iFlash 3000  and iFlash-2019-nCoV series (YHLO Biotech) as reagents. The cut-off value for the IgG antibody against the S1 protein was ten arbitrary units per milliliter (AU/mL), which was the standard cut-off value. The testing process complied with the official guidelines . The rest-test for age; and a Wilcoxon rank-sum test for the IgG antibody titer. The reasons to accept or hesitate over the third vaccination dose were tabulated separately. A logistic regression was used to assess the relationship between third vaccine hesitancy and age, sex, number of adverse reactions after the second vaccination, whether an IgG-S antibody titer was higher or lower than the median (324.85 AU/mL), and place of residence. Since the antibody titers were affected by days since the vaccination (Correlation coefficient was −0.38), we used the antibody titer only as the model from the perspective of multicollinearity. A logistic regression was used to assess the relationship between third vaccine hesitancy and age, sex, fever above 37.5 °C, fatigue, headache, joint pain, nausea, whether an IgG-S antibody titer was above or below the median (324.85 AU/mL) after the second vaccination, and place of residence. We considered p values of 0.05 or less to be significant. The statistical software STATA IC  was used for all analyses.We compared the characteristics of participants according to their willingness to receive a third COVID-19 vaccine dose. We conducted a chi-square test for sex, municipality, and adverse reactions; a p = 0.001), while the median IgG-S score was significantly higher in the vaccine-hesitant group (p < 0.001). The frequency of nausea as an adverse reaction after the second vaccination was also significantly higher in the vaccine-hesitant group (p < 0.001)  age of 52.6 ± 18.9 years, median IgG-S antibody titer of 324.9 (AU/mL), and of whom 41.7% were male, 97.9% indicated their intent to accept the third vaccination dose. The mean age was significantly lower (< 0.001) .The main reasons for accepting the third vaccination were as follows: “necessary for infection control” (81.8%); “vaccines are highly effective” (47.3%); and “adverse reactions are not a major concern” (27.1%). The main reasons to hesitate over the third vaccination were as follows: “worried about adverse reactions” (57.7%); “two doses of vaccine are sufficient” (25.0%); and “efficacy is unknown” (19.2%) . Concernp < 0.001)  and higher antibody level  are predominantly positively associated with third vaccine hesitancy. In contrast, sex and the number of adverse reactions at the second vaccination are not significantly associated with third vaccine hesitancy . Further< 0.001) .Reducing vaccine hesitancy is important in controlling the COVID-19 pandemic. In this study, we conducted a retrospective cohort study by distributing questionnaires in December 2021 to populations with measured IgG-S antibody titers for COVID-19 between 8 September and 8 October 2021 in rural areas of Japan to investigate the factors associated with third vaccine hesitancy.In this study, we found that participants who acquired relatively high humoral immunity after two doses of vaccination were associated with third vaccine hesitancy. Categories such as younger age  and previous antibody titers higher than the median  were positively associated with vaccine hesitancy. This result is consistent with previous reports that younger individuals are less likely to accept vaccines in the primary vaccination series as well as the booster dose ,24,25,26Approximately 97.9% of FVCS participants who had their own antibody titers measured accepted a third vaccination. This result was higher than other reports of third vaccination acceptance ,14,15. IThe efficacy of the COVID-19 vaccine and concerns about adverse reactions had a significant impact on the reasons for behavior regarding the third vaccination. Previous studies have shown that vaccine efficacy, safety, and a lack of concern regarding adverse reactions increase vaccine acceptance ,36,37,38A limitation of this study was that the participants were recruited in a disaster-affected area, using a unique network developed with more than 10 years of disaster recovery through a multi-sectoral partnership. These participants were interested in vaccines and health issues, and voluntarily signed up to participate in the FVCS. This may have introduced a sampling bias and may not be conclusive of other populations. In addition, a few people hesitated over the third vaccination, and only 58 of the approximately 2500 participants were under the age of 18, which made the statistical analysis challenging. In addition, it was not possible to eliminate potential confounding factors such as media preferences, education, and income. Moreover, we were unable to collect information on the occupations that might affect vaccine acceptance. Furthermore, nearly everyone had received the BNT162b2 vaccine, making it difficult to verify whether vaccine acceptance differed between the different types of vaccines. Finally, considering the development of vaccination strategies, vaccine equity and immune competition are also key determinants .In this study, we found that younger age groups and participants with antibody levels higher than the median were associated with third vaccine hesitancy. A rapid increase in the booster dose rate is needed to control the virus, and specific approaches should be taken in these groups that are likely to hesitate over the third vaccine. Further research on factors associated with third vaccine hesitancy should also be explored.


To observe the effect of intestinal probiotics in the treatment of nonalcoholic fatty liver disease (NAFLD) and the effect on liver function and inflammatory factors. α (TNF-α) were lower than those in the control and model groups, and the differences were statistically significant (P < 0.05).  34 healthy rats were selected for the study and divided into 10 rats in the control group, 12 rats in the model group, and 12 rats in the treatment group according to the random number table method. The control group was given behavioral and lifestyle interventions, and the treatment group was given Bifidobacterium minus Black enteric capsules 5 g/(kg-d) by strong feeding method on the basis of the control group. The fatty liver index (FLI), liver ultrasound examination results, liver function, and inflammatory factor levels were compared among the three groups. After 8 weeks of treatment, there were statistically significant differences between the FLI values and liver ultrasound results of the three groups, and the serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), triacylglycerol (TG), and total cholesterol (TC) levels of the observation group were lower than those of the control group and the model group. The levels of serum high molecular weight lipocalin (HMW-APN) and interleukin 22 (IL-22) in the observation group were higher than those in the control group, and the levels of tumor necrosis factor- Intestinal probiotics can improve the clinical efficacy of patients with NAFLD, improve liver function, and alleviate the inflammatory response, in order to provide a theoretical basis for the clinical treatment of patients with NAFLD. NAFLD is a clinicopathological syndrome characterized by diffuse hepatocellular steatosis, excluding alcohol and other definite hepatoprotective factors, and is classified into simple fatty liver, NAFLD, and associated cirrhosis based on the presence of inflammation and fibrosis . The preThe pathogenesis of NAFLD is currently considered to be the hepatic manifestation of the metabolic syndrome and has not been fully elucidated, but recent studies have shown that its development is closely related to changes in the intestinal flora and that disturbances in the intestinal flora and increased intestinal wall permeability play an important role in the development of NAFLD, mediated by an immune response . ProbiotThe pathogenesis of NAFLD is not fully understood. Recent theories suggest that because simple steatosis is a benign process in many patients, whereas NASH is a progressive process, NASH may have a unique pathogenesis in which the liver is exposed to a combination of insulin resistance, oxidative stress, enteric-derived endotoxins, bacterial endotoxins, altered adipocytosine profile, and reduced bile secretion, leading to an inflammatory response . The traThe human intestinal flora contains more than 1000 species of bacteria with a total of 1 × 1014 species, a mass of 1-2 kg, and a total number of genes exceeding 150 times the total number of host genes . The intNonalcoholic fatty liver disease (NAFLD) is a metabolic disease characterized by diffuse steatosis of hepatocytes, except for excessive alcohol consumption or other diseases based on fatty degeneration of hepatic parenchymal cells, which can progress to steatohepatitis, cirrhosis, and liver cancer . The patWe used 34 SD male rats , SPF grade, production license number SCXK  2016-0006, age about 8 weeks, weight about 300 g. TNF, IL-6 radioimmunoassay kits were provided by Wuhan Dr. Biotechnology Co. Basic feed formulation is as follows: 35% standard meal, 15.5% bran, 20% soybean meal, 20% corn meal, 0.5% soybean oil, 5% fish meal, 2.5% bone meal, and 1% yeast; high-fat feed formulation is as follows: 60% basal feed, 15% cooked lard, 10% egg yolk powder, 8% skim milk powder, 5% casein, and 2% white sugar. Japan Hitachi U2200 double-beam spectrophotometer, 7170 automatic biochemical analyzer, vortex mixer, low-temperature high-speed centrifuge, and Olympus IX71 inverted microscope were used. The animal room environment and cages were kept clean during the experimental period. During the experimental period, animals were provided with humane care according to the “3R” principle. The study was approved by the Animal Ethics Committee.Thirty-four rats were divided into 3 groups, 10 in the control group, 12 in the model group, and 12 in the treatment group, and continued to be fed a high-fat diet. The control group continued to be fed a basal diet. The treatment group was given Lactobacillus bifidum triple solution (4 tablets mixed with 20 mL distilled water) 5 g/(kg-d), 1 time/d by the strong feeding method, and 1 time/d; the same volume of saline was given to the model group by the strong feeding method. At the end of week 16, at 8 weeks, healthy subjects were performed and blood was collected for testing.At the end of 8 weeks of dosing, rats are fasted for 12 hours. The abdominal cavity is rapidly opened, and blood is drawn from the abdominal aorta at 12,000 r/min. The serum is isolated and stored at -80°C to detect adipokines, lipids, and liver function. The rest of the liver is immediately frozen in liquid nitrogen and transferred to -80°C for freezing and storage.α, lipocalin, and IL-6 were determined by ELISA. Each section was examined under light microscopy for 5 × 400 fields of view to grade the degree of hepatic steatosis and inflammatory cell infiltration. The diagnosis was made by an experienced pathology faculty member who read the slides blindly.The liver index was calculated by weighing the wet mass of the liver and the body mass of the liver, and the liver/body ratio was calculated as the liver index. The fasting blood-glucose (FBG) was measured by a fully automated biochemical analyzer. Fasting insulin (FNS) was determined by the immunoassay method, and the insulin resistance index (HOMA-IR) was calculated as FPG × F N S/22.5. TNF-t-test was used for comparison between two groups, and one-way ANOVA was used for comparison between groups, and P < 0.05 was considered statistically significant.Statistical analysis data were described as mean ± SD. The SPSS 16.0 statistical software was used for analysis, P < 0.01); compared with the model group, TG, transaminases, and liver index were significantly lower in the treated group rats (P < 0.05); however, compared with the normal control group, they remained elevated (P < 0.05); TC levels in the treated group were not significantly reduced compared with the model group , total cholesterol (TC), alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and liver index were significantly higher in the model group rats compared with the normal control group (P < 0.01). Compared with the control group, steatosis was still present in the treated group, and the hepatocytes were sparsely arranged; however, the lipid droplets were smaller and more restricted, and the number of inflammatory cells infiltrating the confluent area was significantly lower compared with the model group . After 8 weeks of probiotic treatment, serum HOMA-IR, IL-6, and TNF-α levels decreased significantly (P < 0.05), while lipocytin levels increased but did not return to normal serum levels /signal transduction-activated transcription factor-3 (STAT3) signaling pathway and downregulating TG synthesis-related genes; the expression of fatty acid transporter protein (FATP) was downregulated to inhibit hepatocyte steatosis. Therefore, probiotics have significant anti-inflammatory and antistatogenic effects and can also reduce TG synthesis [The intestinal flora is a complex symbiotic system in the human body, and probiotics can regulate the intestinal microecological balance and play the role of protecting intestinal mucosa, anti-inflammation, and improving lipid metabolism. The dysbiosis of intestinal flora causes acute immune response, and thus, TNF-ynthesis . The resThere is no ideal drug for the treatment of NAFLD, but recent studies have found that probiotic preparations are effective in the treatment of NAFLD. The therapeutic principle is to use the interaction between the intestine and liver to promote the growth and reproduction of normal microorganisms in order to inhibit the growth of pathogenic bacteria, reduce the production of bacterial endotoxins, inflammatory factors, and other harmful substances, rapidly establish the microecological balance of the gastrointestinal tract and maintain the stability of the intestinal biomucosal barrier. For this reason, more and more physicians tend to use probiotics and other intestinal barrier modulating drugs in clinical practice for the prevention and treatment of NAFLD, but the results are still controversial due to the small number of large-scale clinical studies and ethical issues .The probiotic preparation used in this study is a live preparation of Bifidobacterium longum, Lactobacillus bulgaricus, and Streptococcus thermophilus. All three form a combined flora that grows under different conditions and has a fast and long-lasting effect.This study demonstrated that the probiotic preparation improved liver function and dyslipidemia in a healthy population with NADLD and significantly improved hepatocyte steatosis, possibly by regulating the intestinal flora and thereby reducing inflammatory factors and improving insulin resistance. The role of intestinal dysbiosis in the pathogenesis of NAFLD should not be overlooked, and probiotic preparations have many advantages such as less adverse effects and good tolerability, but in terms of the prevention and treatment of fatty liver, its long-term efficacy and the causal relationship with insulin resistance need to be studied more thoroughly.


Neospora caninum and Leptospira spp. The objective of this study was to diagnose the presence of BoHV-1, bovine viral diarrhea (BVD), PI3, Neospora caninum, and Leptospira spp. by serology and identify the risk factors associated with infectious agents of reproductive interest in bovines of Boyacá (Colombia). A descriptive cross-sectional study was developed, with simple random sampling, where a sample size of 601 female cattle of Holstein, Jersey, and Normande breeds of different age groups was determined. Blood samples were taken and processed using the indirect ELISA technique  and the MAT test for the diagnosis of bovine leptospirosis. The data were processed with the statistical program Epi Info™. The highest apparent seroprevalence was established for infectious bovine rhinotracheitis (61.1%), followed by BVD (37.6%), PI3 (40.9%), neosporosis (51.1%), and leptospirosis (14.8%). Variables such as age >4 years and Holstein breed for IBR and >4 years for BVD were established risk factors. Considering our results, we suggest implementing prevention and control plans that include vaccination as a prophylactic measure and biosecurity tools that reduce the probability of contagion and transmission of pathogens.The productivity of cattle farms is affected by infectious and noninfectious factors that generate economic losses and cause reproductive failure represented by low conception rates, embryonic mortality, abortions, and fetal mummification. The infectious agents that most impact the reproductive health of the bovine species from conception to birth are bovine herpesvirus type 1 (BoHV-1) causing infectious bovine rhinotracheitis (IBR), bovine viral diarrhea virus (BVDV), bovine parainfluenza virus type 3 (PI3),  The sustainability of a livestock farm begins with an adequate state of animal health, which depends mainly on the effective management of the multiple pathogens found in the farm . In partNeospora caninum, and Leptospira spp. are considered the main causative agent of reproductive disturbances in cattle around the world. Resulting in the presentation of clinical manifestations generated by the diseases infectious bovine rhinotracheitis (IBR), bovine viral diarrhea (BVD), bovine parainfluenza, bovine type 3 (PI3), neosporosis, and bovine leptospirosis, respectively [Infectious agents such as bacteria, viruses, protozoa, chlamydiae, and fungi are known to directly impact the reproductive health of cattle . Bovine ectively –8. The rectively . The ecoectively .Considering the above impacts, prevention and control practices, preventive vaccination tools, and effective and efficient treatment protocols form the basis for preparing the immune system of each animal for possible exposure to pathogens on livestock farms. However, the implementation of other strategies focused on improving collective immunity through external factors such as nutrition, environment, and genetics also play a significant role in the management of animal production .Neospora caninum, and Leptospira spp. and to identify risk factors potentially associated with such infectious agents in cattle in Boyacá (Colombia).Based on the best available scientific information, effective recognition, prevention, and treatment of reproductive disorders are essential in the practice of veterinary professionals and farm owners. Thus, prevention and control protocols must be based on diagnostic tests that fit into the overall biosecurity production programs and must have measures to prevent pathogens' introduction and spread ,3. ThereThe study was conducted in the town of Chiquinquirá, located in the west of the department of Boyacá . The township is the economic and commercial center of the western region of the department, where the agricultural sector relies on milk production and its derivatives .n = sample size, E = accepted error, p = expected value of the proportion, and α = tail probability. Parallel to the sampling, an epidemiological survey was designed to collect information such as the age group and the breed of the animal and those reproductive events related to the diseases evaluated.The livestock census conducted by the Colombian Agricultural Institute - ICA reported that for the year 2020, Chiquinquirá had 31082 heads of cattle . As a rex 1 (Vacutainer®). Seven ml of biological material was collected and deposited in the BD Vacutainer® tubes without anticoagulant. The samples were refrigerated (4°C) and transported to the Veterinary Parasitology Laboratory of the Universidad Pedagógica y Tecnológica de Colombia. In the laboratory, the blood samples were centrifuged at 2500 r.p.m. for 10 minutes to separate the cells from the serum. Then, with a Pasteur pipette, the serum or the supernatant was transferred to the 1.5 ml Eppendorf type storage tube for storage at −20°C until testing [Blood samples were collected by puncturing the coccygeal vein using the multiple needle gauge no. 21 g  testing .An indirect enzyme-linked immunosorbent assay (ELISA) for the detection of specific antibodies against IBR, BVD, PI3, and neosporosis was carried out, using the commercial kits SYNBIOTICS® , SERELISA® BVD p80 Ab Mono Blocking, , PRIMACHECK VPI-3® , and Ingezim R.12NC.K1 (Ingenasa S.A) , by following the manufacturer's protocol. In addition, leptospirosis was diagnosed by the microscopic agglutination test (MAT); animals were considered to be positive when titers were ≥1 : 100 .An observational, descriptive, cross-sectional study was carried out with a simple random sampling of animals, where the sampling unit was female cattle. The apparent prevalence (AP) and the real prevalence (RP) were determined with the WinEpi statistical program. After consolidating and filtering the database, the data were analyzed using statistical program Epi Info® version 7.2.4.0. To estimate the prevalence ratio (PR), the proportion of animals and herds affected by the disease exposed to a factor was compared to the same proportion of the population not exposed to that factor. This PR was used to measure the association between reproductive agents and hypothesized causal factors, as well as the significance of these associations using Fisher's exact test . The depThe study was conducted under the laws 576 of 2000 and 84 of 1989 of the Republic of Colombia. Informed consent was obtained from the owners of the specimens prior to sample collection.The apparent prevalence (AP) and the real prevalence (RP) of the infectious diseases were determined where seropositivity was 61.1% and 62.9% for IBR, respectively,  98.8% and negative predictive value (NP-) 93.8%), 37.6% and 38.4% for BVD, 40.9% and 41.6% for PI3, 51.1% and 73% for neosporosis, and 14.8% and 24.7% for bovine leptospirosis, respectively, .N. caninum, while BVD and Leptospira spp. were more prevalent in cattle of the Normande breed . In contrast, for PI3, neosporosis, and leptospirosis, cattle 1–4 years old presented the highest seropositivity . Concernde breed .Statistical significance was established between the breeds and age groups evaluated through the presence of antibodies against IBR. Likewise, the presence of BVD was associated with the age groups of the cattle. Furthermore, a significant statistical association was determined between seropositivity to the disease and the reproductive events taken into account in the epidemiological survey. Cattle >4 years old, Holstein breed, AI, fetal death, cows with a history of inseminations without reproductive success, and noncertified semen were considered possible risk factors for IBR. In addition, individuals older than four years were established as possible risk factors for BVD occurrence. Natural mating and weak calves at birth presented the same condition but for neosporosis seropositivity .Neospora  and wild animals (rodents) in the herd [Regarding BVD, the values determined in the present study are 37.6%, which are between the ranges reported for the disease, which range from 29.7% to 76.4% ,21,23,31the herd .Similarly, it is relevant to note that cattle are commonly grouped in herds, where prevalence estimates depend on the sampling strategy; thus, the presence of antibodies may vary from one investigation to another . Hence, Cattle older than four years presented the highest seropositivity to BVDV, which is in agreement with previous studies. González-Bautista et al.  found thRegarding PI3, neosporosis, and leptospirosis, cattle aged 1–4 years presented the highest seropositivity, which is not in agreement with the studies by Betancur et al. , Betancu; however, this can occur due to the different management practices implemented on the farms and because these are dairy herds. No significant statistical association was obtained between PI3, leptospirosis, and neosporosis with the breed and age group of the cattle evaluated. This agrees with the findings of Fernandez et al. [Neospora. Doria-Ramos et al. [Holstein and Jersey cattle are the breeds that had the highest amount of antibodies against PI3 and neosporosis, which does not agree with Fernandez et al. , who indz et al. , Betancuz et al. , Cruz-Esz et al. , and Ansz et al.  but diffz et al. , who fous et al.  reportedIn the present study, artificial insemination (AI) showed a significant association with seropositivity to BoHV-1 and leptospirosis. The transmission of pathogens occurs when there are no prior preventive measures in reproductive technologies; hence, mitigation of this risk should be considered during their development. Likewise, implementing biosecurity protocols and excellent quality control is imperative to prevent contamination and transmission of diseases while using these tools ,40. The p ≤ 0.05), and bovines with a history of fetal death in pregnancy, cattle with a history of inseminations without reproductive success, and dairy cows pregnant with uncertified semen have possibilities of being positive for the IBR. This is associated with what was reported by de Barros et al. [Dystocic parturition, natural mating, fetal death, and weak calves at birth presented a significant statistical association with the seropositivity to neosporosis antibodies (s et al.  who mentN. caninum y and Leptospira spp. were found in bovine females in Chiquinquirá, Colombia, indicating the dissemination of pathogens in different herds and a high transmission level. Cattle older than 4 years presented the highest seroprevalence for BoHV-1 and BVDV, while cattle aged 1–4 years had higher seropositivity to PI3, neosporosis, and leptospirosis. Regarding breeds, Holstein showed the highest prevalence for BoHV-1 and PI3, Jersey for neosporosis, and Normande for BVD and leptospirosis. Bovine >4 years and Holstein breed for IBR and >4 years for BVD were considered as risk factors.High seroprevalences of antibodies against BoHV-1, BVDV, bovine parainfluenza virus type 3,


Background: The Locus of Control (LOC) is a mental disposition indicating the individuals’ belief that disease-related outcomes are under their own control , dependent on others , or dependent on chance (Chance). Quality of Life (QoL) and LOC may have complex effects on self-care activities and diabetes management in subjects with type 2 diabetes (T2D). The aim of the present study was to evaluate the predictive role of LOC and QoL scores on metabolic control in elderly T2D outpatients, secondly evaluating potential gender differences. Methods: An extensive set of questionnaires was administered to a group of consecutive elderly T2D outpatients on oral glucose-lowering drugs attending a single diabetes center. Personal and clinical variables were analyzed at baseline (between 1 February and 31 March 2015) and after 6 years of follow-up. Results: At baseline, study participants showed an overall good metabolic control. Diabetes Specific Quality of Life (DSQoL) scores indicated an overall good QoL in both genders, with a higher DSQoL satisfaction score in women. Both genders presented higher scores in the LOC-Internal domain, with men reaching higher scores in the LOC-External domain than women. At the 6-years follow-up, subjects with baseline higher LOC-External score presented better metabolic outcome. In the regression analysis, LOC-External score was an independent predictor of good metabolic control maintenance, but this result was only statistically significant in men. Conclusions: LOC scores may influence long-term glycemic control in elderly T2D patients on oral glucose-lowering drugs. The rising prevalence of type 2 diabetes (T2D) represents a public health challenge worldwide, especially in older adults. T2D profoundly affects various aspects of daily life in elderly subjects, including quality of life and psychological well-being. Due to the intrinsic age-related characteristics, elderly subjects with T2D require a personalized treatment, which takes into account their comorbidities, subjective risk of hypoglycemia, cognitive and the other domains of health status ,2.Therefore, in addition to physical health, a people-centered management of chronic patients, in particular of elderly diabetic subjects, must also include the evaluation of adherence to therapy, independence in activities of daily living (ADL) and psychological status.Current T2D guidelines for the elderly also recommend the preservation of Quality of life (QoL) overtime among the goals of diabetes treatment, in addition to the prevention of long-term complications .Quality of Life (QoL) is a subjective concept, which can be measured by reliable instruments with a good analytical power . NotablyWhile the role of QoL in diabetes management has been increasingly recognized, other psychological factors may influence patients’ behavior and their adherence to diabetes care, including the Locus of Control (LOC), an expression that literally means “place through which control is exercised”. LOC is a mental disposition, and includes 3 domains: Internal, External (or Powerful Others), and Chance . These dLOC domains may affect a patient’s mood and psychological well-being; furthermore, they may impact on the approach to diabetes management, in its multifaceted aspects , potentially influencing clinical and psychological outcomes ,7,8. ForHowever, to date, the impact of LOC domains on diabetes management and outcomes has not yet been fully investigated, especially in elderly patients, who are more vulnerable to the risk of anxiety and mood disorders.Moreover, the impact of QoL and LOC in T2D management and outcomes may be affected by gender. Thus, men and women behave differently in relation to various aspects of the disease, including psychological aspects . SeveralNotably, gender-differences have also been observed in cognitive status and LOC, showing a greater impact of diabetes-related distress on metabolic control in T2D women than in T2D men .However, to date, the impact of QoL and LOC on T2D management has not yet been fully clarified, especially in elderly T2D subjects. In particular, whether elderly patients’ control orientation (LOC domains) and QoL might influence long-term metabolic, and micro- and macro-vascular diabetes outcomes, their potential relationship with QoL, and whether these associations are different in elderly men and women, deserves further investigation.Therefore, the purpose of this study was to determine the long-term predictive role of QoL and LOC on metabolic control and T2D long-term complications in elderly T2D outpatients observed for 6 years, secondly taking into account any potential gender differences.All consecutive T2D subjects on oral hypoglycemic agents aged ≥65 years attending the Metabolic Disease Outpatient Clinic of the University Hospital of Messina, (Sicily), Italy, between 1 February and 31 March 2015, were included in this single-center observational study.The following exclusion criteria were applied: T2D diagnosis for less than two years, treatment with hypoglycemic injectable therapy (either insulin or GLP-1 RAS) or with diet only, and having co-morbidities such as active cancers, chronic renal failure in the hemodialysis phase, severe sensory deficits, severe psychiatric or neurological conditions. Subjects with severe cognitive impairment  were also excluded.All study subjects were of Caucasian ethnicity. They regularly attended the outpatient diabetes clinic of the University Hospital of Messina (Sicily) in Italy. The clinic is part of a university hospital, that is located in in an urban area, and all patients regularly attend the clinic at least twice a year.Information on the level of school education, duration and complexity of T2D management was also collected.At baseline, information on the level of school education was expressed in years and the following classification was applied according to the Italian educational system: 1–5 years, elementary level; 6–13 years, high-school level; >13 years, University degree.Duration of the disease was collected since T2D diagnosis, and the complexity of diabetes management was defined on the basis of the number of specialist outpatient visits in the previous two years. The presence of hypoglycemia was defined on the basis of at least one episode of hypoglycemia in the six months preceding the study.Weight, BMI, waist circumference, glycemic control, lipid profile and creatinine levels, as well as any ongoing chronic therapy and the presence of diabetes chronic complications, were analyzed at baseline and after 6 years of observation.At baseline, all study subjects underwent an extensive psychometric evaluation: cognitive status, functional autonomy, patients’ satisfaction with their diabetes treatment, Quality of Life (QoL) and Locus of Control (LOC) were explored by validated questionnaires. All study subjects responded to self-administered questionnaires by handwriting their responses.The cognitive status was explored in all patients at baseline, by the Mini Mental State Examination (MMSE).The MMSE is a brief screening test for the assessment of global cognitive status . It asseThe functional status was investigated by the basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales ,14. We eThe Katz Activities of Daily Living (ADL) Assessment Form  exploresThe IADL scale evaluates the performances in 8 instrumental daily activities in older people, including using the telephone, shopping, meal preparation, cleaning house, managing finances, communication, transportation, and medications .The score ranges from 0  to 8 .The Diabetes Specific Quality of Life (DSQoL) questionnaire was originally used in the late 1980s in the Diabetes Control and Complications Trial (DCCT), to assess the impact of diabetes on QoL; the Italian validated version of the questionnaire  was admiThe DSQoL evaluates the impact of diabetes on a patient’s life, the degree of satisfaction with the treatment and the extent of concern about chronic complications.The questionnaire consists of 39 questions divided into three evaluation domains: satisfaction , impact , and worry . Lower scores in the three examined domains are an expression of a better quality of life.The Locus of Control (LOC) questionnaire is used to determine the attribution of responsibility by the patient for the evolution of diabetes .The questionnaire consists of 18 items investigating three different evaluation domains, with scores ranging from 6 to 36: the Internal domain, in which the responsibility is attributed to internal factors (such as self-efficacy and commitment), the External domain, in which the responsibility is attributed to the involvement of external factors or the involvement of other people , and the Chance domain, in which the responsibility is attributed to destiny, luck and chance.The highest test score is the expression of the predominant domain of control.The Diabetes Treatment Satisfaction Questionnaire (DTSQ) evaluates a patient’s satisfaction to with their diabetes treatment , regardlThe questionnaire consists of 8 items, the scoring based on a Likert scale from 0  to 6  for each question. Six questions measure treatment satisfaction, and ask about “satisfaction with current treatment”, “flexibility”, “convenience”, “understanding of diabetes”, “recommend treatment to others” and “willingness to continue the current treatment”. These six scores are added up to produce a DTSQ total score (range 0–36): higher scores indicate higher treatment satisfaction .DTSQ items 2 and 3 are rated differently and evaluate the burden from hyper- and hypo-glycemia (0 being “none of the time” to 6 being “most of the time”).DTSQ is broadly used, and officially approved by WHO and the International Diabetes Federation ,17.Both micro- and macro-vascular complications of T2D were screened according to national and international diabetes guidelines ,19.Macrovascular disease: coronary heart disease was defined on the basis of clinical documentation and of the reports of cardiologist specialists and/or hospital discharge ; a standard electrocardiogram and a cardiologist visit are performed annually in all T2D patients as part of the usual screening program. Cerebrovascular disease and peripheral arterial disease were assessed by color-doppler ultrasonography by B-mode real-time ultrasound, as part of the periodic screening of macrovascular complications.Microvascular disease: diabetic retinopathy was diagnosed based on direct ophthalmoscopy performed by an expert ophthalmologist and/or by fluorescein angiography within 1 year before the start of study.Diabetic kidney disease was assessed according to albuminuria measurement and estimation of Glomerular Filtration Rate (eGFR) by CKD EPI formula .Statistical analysis was performed using IBM SPSS  version 26 . Continuous variables were expressed as means ± standard deviation (SD). Categorical variables were expressed as number of cases and percentages. Since the majority of the investigated variables were normally distributed, as verified by the Kolmogorov-Smirnov test, a parametric approach was applied; the chi-square (χ²) test for categorical measures was used for comparisons. The analysis of variance (ANOVA) test was used to compare continuous variables. A hierarchical adjusted logistic regression was conducted to test the contribution of several variables to the maintenance of good metabolic control; precisely, socio-demographic and clinical variables were included in the first step, the psychological variables in the second step.A post-hoc power analysis was performed, by using the G*Power software ; with a determined effect size of 0.30, a power (1-β error prob) of 0.86 was calculated.A total of 108 elderly T2D subjects agreed to participate in the study and answered the set of questionnaires at baseline. Among them, four patients were lost at follow-up ; therefore, the present analysis covers the 104 subjects with complete clinical information available at the time of follow-up.As shown in 2, mean waist circumference 100.80 ± 11.39 cm), and presented good metabolic control (mean HbA1c 6.7%), with 71% of them showing HbA1c levels ≤ 7%. Men had higher mean body weight compared to women ; conversely, BMI, waist circumference values and HbA1c levels were similar in the two genders.The mean duration of diabetes was of 12.5 years; study participants were overweight (mean BMI 27.21 ± 6.42 kg/mp = 0.040). As for lipid profile, mean levels of HDL-cholesterol (49.32 ± 12.85 mg/dL) and triglycerides (130.02 ± 60.45 mg/dL) were similar in men and women; total cholesterol levels were higher in women (170.53 ± 29.97 mg/dL) than in men (159.11 ± 28.05 mg/dL), although this difference was not significant (p = 0.058).Mean transaminase levels were within the normal range, and men had higher levels of GGT , although eGFR did not differ in men and women .Men had higher levels of creatinine  had chronic complications, without any differences between men and women: 18 patients (17.3%) were affected by micro-vascular complications, 43 subjects (41.3%) had only macro-vascular complications, and 10 patients (9.6%) had both micro- and macro-vascular complications.The mean number of specialist outpatient visits in the previous 2 years, a measure of the intensity of the care, and the percentage of subjects reporting at least 1 episode of hypoglycemia in the six months preceding the study were also similar in the two genders. As for T2D treatment, the majority (87%) of patients were on metformin, 12.5% on acarbose, 29.8% on secretagogues, 23.1% on DPP-4 inhibitors (DPP-4i) and 2.9% on pioglitazone, without any gender differences.p = 0.028). Women also showed lower ADL scale scores as compared to men ; conversely, IADL scale scores were similar in the two genders .Women showed lower MMSE scores compared to men , suggesting a better quality of life in men.Mean DSQoL scores indicated an overall good quality of life in both genders, with a higher DSQoL satisfaction score in women as compared to men (p = 0.958), indicating a good awareness of the patient’s role in diabetes management.As for LOC, there was a high prevalence of the Internal domain over the other two domains in both genders , suggesting a greater perception of the impact of external factors.Men presented higher scores in the LOC-External domain as compared to women .Scores in the Chance domain were the lowest LOC score in both genders  while HbA1c levels did not show any significant variation overtime; as for renal function, creatinine levels increased  and eGFR values showed a mean 5 mL/min reduction (p > 0.05). At follow-up, mean HbA1c was 6.66%, with 59% of study subjects showing at-target values (HbA1c ≤ 7%). After 6 years, most of the subjects maintained a good glycemic control, whereas 30 subjects (28.8%) required an intensification of hypoglycemic therapy , defined as the increase in the number of prescribed OHAs and/or the prescription of injection drugs (insulin or GLP-1 RAs).The first occurrence of chronic diabetes complications (micro- and/or macro-vascular complications) was recorded in 27 subjects (26%); in particular, 4 subjects were diagnosed with retinopathy, 5 patients with diabetes kidney disease (DKD), 16 with CVD and 2 subjects with both CVD and DKD.p > 0.05)  .Notably, no significant differences in baseline DSQoL and LOC scores were noted between subjects developing or not developing new chronic (micro- and/or macro-vascular) complications .At the end of the follow-up, all of the study participants were divided into two groups, according to the course of their glucose control over time. In particular, those who showed a worsening of glycemic control  overtime and/or required an intensification of hypoglycemic treatment during the 6-years observations, were grouped in the <worsening control> group (n = 64); study participants improving their glycemic control or maintaining a good glycemic control over time (HbA1c ≤ 7%), without any intensification of hypoglycemic treatment, were grouped in the <maintaining good control> group (n = 40).Baseline clinical characteristics and scores of the Mini Mental State Examination, ADL, IADL, DTSQ, DSQoL and LOC tests of these two groups are shown in p < 0.001).No significant differences emerged between the two groups in age, duration of diabetes, mean values of BMI and waist circumference; mean creatinine levels and eGFR values were also similar in the two groups. The <worsening control group> had higher mean HbA1c levels at baseline than the <maintaining good control> group  compared to subjects in the <worsening control group>.Regarding the questionnaires, the two groups had similar scores in the MMSE, IADL, DTSQ and QoL. Subjects in the <maintaining good control group> had lower ADL score 5.60 ± 0.87 vs. 5.98 ± 0.38, p = 0.0007), while the LOC-Internal and LOC-Chance scores were similar in the 2 groups.Significant differences were also noted in baseline LOC scores domains in the two groups . In partp = 0.032). Accordingly, men maintaining a good glycemic control reported significantly higher LOC-E score (27.31 ± 4.43), compared to those in the <worsening control> group (24.22 ± 5.52 p = 0.021). Other LOC domains were not significantly different in the two subgroups.Similar results were observed when this analysis was performed for in men and women, separately: women maintaining a good glycemic control reported a significantly higher baseline LOC-E score (25.88 ± 6.74), compared to those with a worse glycemic control , ADL  and LOC-E scores  were independent predictors of good metabolic control maintenance in the study population  and LOC-E score  were independent predictors of good metabolic control maintenance in men; none of the analyzed variables were associated with good metabolic control maintenance in women.When we stratified by gender the study population, baseline-HbA1c levels , demonstrating a greater sense of trust and willingness to accept outside help. Current guidelines on T2D management recommend the active involvement of the patient in the treatment plan, with the aim of making them aware and active. Although our study is not conclusive, our results suggest that a predominantly LOC-External could have a positive value in specific subgroups of patients, and we may speculate that, in elderly subjects, this attitude may lead to a lower level of stress and to a greater adherence to the treatment plan, with less impact of anxiety and depression. Consistently, in our elderly population, higher LOC-External scores were associated with improved glucose control overtime, as assessed by HbA1c values.Conversely, we may hypothesize that higher LOC-Internal domain scores might be more advantageous in younger adults, indicating self-independence in T2D management, whereas relying on oneself for T2D-related activities may cause anxiety or concern in elderly subjects.Importantly, LOC scores should not be interpreted in a rigid or inflexible way, since each LOC domain can have a positive value, and none is, in absolute terms, more functional or adaptive over the other two ,22,23. TSome of the previous studies evaluated the impact of LOC on glucose control in adult subjects with diabetes, with conflicting results. Thus, some authors found a positive relationship between Internal LOC and diabetes management , conversMoreover, in 2010, a meta-analysis of 17 studies (published between 1985 and 2006) investigated the effect of LOC on diabetes control in a very heterogenous population of adult patients with T2D or T1D, suggesting that there is only a slightly positive correlation between External and Chance LOC domains with metabolic control of diabetes .However, these studies differed from each other by in their sample sizes, assessment of clinical characteristics and measures of LOC. These discrepancies may also depend on the heterogeneity of the investigated study populations, in various aspects, including ethnicity, diabetes treatment and age.However, the available data do not seem to suggest an impact of age, ethnicity or geographic origin on the relationship between LOC and diabetes control; other clinical and social variables could therefore play a more decisive role.Moreover, at variance with our study, the majority of these studies were cross-sectional, and the few longitudinal ones had a very short follow-up observation, and none of them specifically addressed elderly T2D subjects, or the evaluation of evaluating potential gender-specific differences, as in our analysis.Moreover, the time frame of the investigation should be taken into account, since the the majority of the reported studies are not recent and diabetes management has profoundly changed over the last decades, thanks to the availability of more efficacious hypoglycemic drugs with low hypoglycemic risk.Our study also demonstrated that metabolic control in elderly T2D subjects is independently influenced by their capability to perform basic self-care tasks, expressed by ADL scores. Our study subjects had high baseline scores of IADL, ADL, and MMSE, indicating a high level of autonomy and cognitive function.Notably, subjects included in our study were all people living in an urban context, far from a rural setting, with easy access to hospital facilities (they attended the clinic at least twice a year) and with a relatively high level of education (>9 years), without significant differences between the two genders; these aspects may all potentially influence QoL and LOC domains and should be taken into account when interpreting our data.The inclusion of exclusively elderly subjects is another relevant point, since age may modulate the impact of LOC and QoL on glucose control. Diabetes has a profound impact on patients’ psychological health and some studies found an increased risk of psychosocial distress and depression among younger adult T2D patients, than in their older counterparts. The greater psychological impact of diabetes in younger adults could be also due to social factors and it suggests a greater need for of psychosocial and self-management support in younger T2D patients than in older subjects ,29,30. AAnother aspect to consider is that our study is mono-centric, therefore our patients were habitually followed at the same second level diabetes outpatient clinic, undergoing at least two specialist visits throughout the year, and this aspect might have influenced the perceived impact of external help on diabetes management. Thus, the doctor-patient relationship is an acknowledged factor influencing adherence and consequently glucose control . In lineIn addition, the type of treatment and the achievement of glucose targets are relevant issues. Study subjects were overall in fair/good glycemic control and reported few episodes of hypoglycemia, all characteristics that can profoundly influence QoL and LOC. According to the study design, we selected elderly subjects on OHA in order to exclude the potential bias of injectable therapies, including insulin therapy and the consequential influence of intensive glucose monitoring and hypoglycemic risk on QoL and LOC. Moreover, the majority of them were on metformin and only few required an intensification with insulin after follow-up. Certainly, diabetes treatment as well as adherence to dietary advice have an important role in glucose control overtime, but in our relatively stable T2D elderly patients, hypoglycemic drugs were not independent predictors of HbA1c variation at follow-up.Thus, the majority of our patients were already on a good control at baseline and were able to maintain a good control during the follow-up. This aspect is very important because maintaining at target HbA1c levels overtime is essential to prevent long-term complications .Our study also demonstrates that QoL and LOC did not influence the risk of developing chronic complications. In this regard, it is likely that the overall low incidence of new chronic complications, the monocentric nature of our study, and the relatively small sample size played a role.Notably, the multivariate analysis, testing all the study variables, showed that, together with higher LOC-External scores, baseline-HbA1c levels and lower ADL scores were independent predictors of good metabolic control maintenance in our population.The role of baseline HbA1c in the achievement of long-term glucose control is well-documented and it has been recently confirmed as the main determinants of the achievement of HbA1c levels < 7 and no weight gain also with the machine learning technique in the data of over 1.5 million patients .As for ADL scores, metabolic control in elderly subjects could be influenced by their capability to perform basic self-care tasks and, in our population, differences in ADL were noted between the “worsening” and the “maintaining glucose control” groups.It is important to point out that study subjects had mean ADL and IADL scores indicative of preserved functional abilities. Elderly people with diabetes are at increased risk of frailty and disability ,34, whicFinally, our study explored potential gender differences in the impact of QoL and LOC on metabolic control and long-term diabetes complications in this elderly population, because of the numerous differences in clinical manifestations, risk factors, outcomes and psycho-social aspects reported between T2D men and women ,10,11,36Notably, the IADL evaluation might be affected by gender, due to social and culture-related aspects; however, no significant differences were noted in our study in baseline IADL scores between men and women . MoreoveWe also observed a better QoL and higher external LOC domain scores in T2D men, indicating that the two genders may suffer differently due to the impact of diabetes and may respond differently in terms of self -management. In line with recent reports, our results suggest that not only genetic and metabolic factors, but also social and psychological variables determine the known differences in terms of goal achievement in T2D men and women; functional limitations and behavioral factors, could make an indirect contribution to gender disparities in clinical outcomes .We cannot explore the contribution of sex-related variables including the role of estrogens, since our results refer to a population of elderly T2D subjects and we cannot extend them to younger females with preserved hormonal milieu. On the other hand, in elderly subjects it is likely that “gender” differences in social, behavioral aspects would prevail in determining the observed differences in QoL and LOC scores.Several limitations must be taken into account when evaluating our results. In particular, we acknowledge that the relatively small sample size might narrow the generalizability of our findings, despite the performed post-hoc power analysis. Another limitation is the lack of LOC evaluation at follow-up. However, LOC could be generally considered a dispositional trait, therefore no significant changes are expected over time and a single assessment may provide a reliable estimate of the LOC of adults ,40. MoreAnother limitation of the study is the absence of information on several important variables such as marital status, income, family status , which could influence their LOC and QoL, and the lack of information on behavioral changes, since change in diet and physical activity overtime may affect metabolic control; however, on this aspect, subjects participating to in our study were all elderly people with a mean diabetes duration of 12 years, all regularly followed at our center and we may hypothesize that diet and physical activity did not significantly change over time in this population of elderly patients with a chronic disease.The extensive psychometric evaluation, the accurate evaluation of chronic micro- and macro-vascular complications, the length of follow-up, and the periodic regular assessment of our outpatients are among the strengths of the study.In conclusion, these results suggest that in elderly patients on oral glucose-lowering drugs, attending a single third-level facility of diabetes care in Southern Italy, with a good QoL, LOC scores may influence long-term metabolic control.If confirmed on a large scale, our results may have important clinical implications. They suggest that, in outpatient clinical practice, the evaluation of important psychological and psycho-social variables in subjects with T2D, especially if elderly, could be useful to create a personalized approach focused on the subjective needs of patients. In their everyday life, patients constantly reformulate the prescribed therapy based on their personal concept of disease, on their perception of the cure, and on their Locus of Control. Knowing the patient’s LOC can allow the physician to formulate shared and actionable requests.