Dentin is a permeable tubular composite and complex structure, and in weight, it is composed of 20% organic matrix, 10% water, and 70% hydroxyapatite crystalline matrix. Demineralization of dentin with gradient concentrations of ethylene diamine tetraacetic acid, 0.6 N hydrochloric acid, or 2% nitric acid removes a major part of the crystalline apatite and maintains a majority of collagen type I and non-collagenous proteins, which creates an osteoinductive scaffold containing numerous matrix elements and growth factors. Therefore, demineralized dentin should be considered as an excellent naturally-derived bioactive material to enhance dental and alveolar bone tissues regeneration.The PubMed and Midline databases were searched in October 2021 for the relevant articles on treated dentin matrix (TDM)/demineralized dentin matrix (DDM) and their potential roles in tissue regeneration.Several studies with different study designs evaluating the effect of TDM/DDM on dental and bone tissues regeneration were found. TDM/DDM was obtained from human or animal sources and processed in different forms  and different shapes , with variable sizes measured in micrometers or millimeters, demineralized with different protocols regarding the concentration of demineralizing agents and exposure time, and then sterilized and preserved with different techniques. In the act of biomimetic acellular material, TDM/DDM was used for the regeneration of the dentin-pulp complex through direct pulp capping technique, and it was found to possess the ability to activate the odontogenic differentiation of stem cells resident in the pulp tissues and induce reparative dentin formation. TDM/DDM was also considered for alveolar ridge and maxillary sinus floor augmentations, socket preservation, furcation perforation repair, guided bone, and bioroot regenerations as well as bone and cartilage healing.To our knowledge, there are no standard procedures to adopt a specific form for a specific purpose; therefore, future studies are required to come up with a well-characterized TDM/DDM for each specific application. Likely as decellularized dermal matrix and prospectively, if the TDM/DDM is supplied in proper consistency, forms, and in different sizes with good biological properties, it can be used efficiently instead of some widely-used regenerative biomaterials.The online version contains supplementary material available at 10.1007/s13770-022-00438-4. Dentin is chemically composed of approximately 70% mineral phase (40%–45% in vol), 20% organic matrix (30% in vol), and 10% water (20–25% in vol). Additionally, the organic component of dentin consists of 18% collagen and 2% noncollagenous proteins (NCP), proteoglycans, growth factors, phospholipids, and enzymes  in the crown and till the dentino-cemental junction (DCJ) in the root. Dentin exhibits regional differences in tubule density and diameter wherein tubule diameter can vary from 0.9 µm peripherally to 2.5 µm at the pulp side. In the meantime, density is approximately 59,000–76,000 tubules/mmr dentin .The dentinal tubule contains an odontoblast cell process, which is an extension of an odontoblast cell, and serum-like fluid which contains a mixture of proteoglycans, tenascin, transferrin, and albumin. Interestingly, odontoblast processes were seen only in the tubules near the pulp. Further, odontoblasts differentiate from ectomesenchymal cells of the dental papilla and are organized at the periphery of the pulp as a cellular palisade. They form the dentin matrix (predentin) by synthesizing collagen types I, III, and V; noncollagenous proteins as integrin-binding sialoprotein, matrix extracellular phosphoglycoprotein, osteopontin, dentin matrix protein 1, and sialophosphoprotein; glycoproteins as dermatan sulfate, keratan sulfate, heparan sulfate, and chondroitin sulfate . They arDuring tooth development and organogenesis, odontoblasts form the primary dentin which comprises the main bulk of the circumpulpal dentin. After root completion and throughout the life of the tooth, odontoblasts form secondary dentin bordering the pulp at a slow rate Fig. C. This tAt the micron length scale, crown dentin is similar to root dentin; however, unlike root dentin, the proportion of the tubular area is higher and tubules follow a gentle S-shaped curve in the crown part while they are straight in the root area. The dentinal tubules are surrounded by a 2–6 µm dense cuff of peritubular dentin, which suggests that the dentin mineral density is higher in the crown than in the root and the predentin is significantly wider in the crown than in the root .Considering the physical and biological properties of dentin, the thickness is approximately 3–10 mm or even more, and this thickness differs in the regional parts of the same tooth, among different teeth and as a result of aging. The color of dentin greatly affects the color of the tooth due to the translucency of enamel as dentin is a yellowish-hued material that becomes darker with age. In radiographic images, dentin is more radiolucent than enamel due to its lower mineral content whereas it is more radiopaque than cementum and bone. Dentin has no replacement mechanism for biologic turnover but it can be remodeled to a certain degree as odontoblasts and pulpal resident stem cells can produce secondary and tertiary dentin when it is damaged by excessive tooth wear, carious lesion, trauma, or through iatrogenic insult, such as accidental exposure. Dentin is a bone-like matrix that is a vital, sensitive and porous tissue, capable of responding to mechanical, thermal, chemical, evaporative, and osmotic environmental stimuli. Dentin can be regarded as both a barrier and permeable structure, depending upon its thickness, age, and other variables. The permeability to fluid flow through the dentinal tubules, as well as a directional design of these tubules, suggests that dentin has a sensory hydrodynamic function. Micropore-sized dentinal tubules that measure 0.9–2.5 µm diameter provide micropore spaces of 3.70%–5.88% porosity that increases the surface contact area of dentin ) AND (regeneration [Title/Abstract])/ AND (regeneration [Title/Abstract])} and the following one for Medline (OVID) databases)treated dentin matrix and regeneration).af  and .af. Figure in vitro and in vivo animal and human studies and excluding narrative reviews, systematic reviews, and meta-analyses.The relevant studies were selected according to the inclusion and exclusion criteria. The searches were not restricted by language type, however, were limited to original researches including A template was established and reviewed by each author. The authors were calibrated to extract the following data; authors, publication year, country of origin, study design, source of TDM/DDM , tooth part (crown or root), matrix form, matrix size, demineralization protocol, ways of sterilization, and preservation and the outcome.Meta-synthesis and integration of findings from qualitative studies were performed to provide a new and more comprehensive interpretation of the findings.Degree of chance–adjusted agreement  was used to determine the inter-reviewer reliability.in vitro, in vivo animal and human studies were obtained and were included in the present review  whereas the lowest ones were published in 2014 (1.47%), 2008 (1.47%), 2005 (1.47%), 2002 (1.47%), and 2001 (1.47%). The percentage of articles published in 2020, 2019, 2018, 2017, 2016, 2015, 2013, 2012, 2011, and 2009 were 8.82%, 5.88%, 8.82%, 10.29%, 10.29%, 13.23%, 5.88%, 4.41%, 2.94%, and 2.49%, respectively. No articles were published in 2010, 2007, 2006, 2004, and 2003. Regarding the country of origin, most of the studies were performed in China (50%), Republic of Korea (16.17%), Japan (10.29%), Brazil (7.35%), Iran (4.41%), Egypt (2.94%), Sweden (2.49%), Taiwan (1.47%), UK (1.47%), USA (1.47%), and Thailand (1.47%). The study designs were Is there a difference betweenTDM and DDM?3. In our opinion, it is devisable to use the term DDM for the dentin matrices prepared for regenerative purposes that obtained from different sources, fabricated in different forms and shapes, and demineralized with different protocols as the term TDD could mean physical treatment using laser therapy or mechanical one by means of abrasives.The search strategy of PubMed and Medline (OVID) databases using the appropriate search terms yielded 55 articles for PubMed database and 13 articles for Midline (OVID). Among them, there were 32 articles for TDM and 36 articles for DDM. Both terms were used interchangeably despite that the matrices were fabricated with the same protocols using gradient concentrations of EDTA, 0.6 N-HCl or 2% HNOTeeth and tooth parts involved in study designsThe majority of the published studies relied on harvesting vital and nonvital human permanent teeth. The human teeth were maxillary and mandibular premolars extracted for orthodontic reasons, nonfunctional third molars requiring removal for clinical reasons and exfoliated deciduous teeth. In addition, teeth obtained from other animal species were involved in a few study designs such as porcine deciduous incisors, rabbit permanent incisors, rat permanent molars, dog permanent premolars and rat permanent incisors, that were frequently selected whereas goat incisors, bovine posterior teeth, ovine lower anterior teeth and pig unerupted developing teeth were selected to less comparatively Fig. .Primarily and with the use of proper dental instruments, enamel, cementum, and periodontal tissues of the extracted teeth were completely removed from the outer tooth surface, and pulp tissue with predentin was completely removed from the internal one. Root dentin is the tooth part that is commonly used whereas crown dentin was used to a lesser degree Fig. .Forms and sizesThe TDM/DDM were produced in different forms likely as particles, liquid extract, hydrogel, and paste, and in different shapes such as sheets, slices, chips, blocks, discs, root-shaped, barrier membranes, and press-fitted according to the defect shape.2 solution. The paste form [Dentin grinder and ball mill machines were used for preparing particulate dentin , 77, 80.ste form  was prepSheets , 44, 78 Methods of demineralization, sterilization and preservation3 [51, , 55, To our knowledge, no standard protocol for demineralization was established for the different forms and shapes of dentin matrices used for tissue regeneration. Therefore, the protocol requires optimization of the concentration and pH of the demineralizing agent, and the exposure time needs to be properly adjusted for each form and shape. Before demineralization, it is necessary to prepare dentin matrix to remove the debris resulting from mechanical instrumentation. Accordingly, the dentin matrices were soaked in deionized water for 5–6 h and a cleaning cycle of 5–20 min was performed every hour using an ultrasonic cleaner , 40, 43.3 51, , 55, 62 Human-derived particles used for preparing liquid extracts were demineralized with 17%, 10%, and 5% EDTA with two different time frames as 5 min, 5 min, 10 min , 30 min,3 for 30 min [Human-derived sheet scaffolds were demineralized with 17% and 5% with two different time frames as 5 min, 5 min  and 4 mir 30 min  whereas r 30 min , 28, 30 r 30 min , or for r 30 min , respectr 30 min , or for r 30 min , respectr 30 min . Human-dr 30 min . Scaffolr 30 min , respectSterilization was performed by maintaining the matrices in sterile phosphate-buffered saline (PBS) with 100 units/ml of penicillin and 100 μg/ml of streptomycin at 37 °C, for 72 h and then washed in sterilized deionized water for 5 min , 38–44, The matrices were preserved in α-MEM media containing 50 units/ml of penicillin and 50 μg/ml of streptomycin or in 0.1 x PBS and kept in refrigerator at 4 °C , 44, 47 OutcomeThe TDM/DDM were considered for osteogenic differentiation , 49, 50 in vivo dentin defects. In addition, Mehrvarzfar et al. [Regarding dentin-pulp complex regeneration, Holiel et al.  evaluater et al.  comparedConsidering alveolar bone regeneration, Um et al.  evaluateRegenerative dentistry has widely been recognized as a promising field in the provision of functional and biocompatible dental tissues as alternatives for conventional materials. Current progress in tissue engineering has offered new methods and technologies for dentin-pulp complex and bone regeneration. As there are several reasons for dental extraction, including caries, mobility, orthodontic tooth reasons, and trauma, DDM can be prepared with low risks of infection and rejection with non-invasive attainability; thus, it should be considered as a natural resource to be used to full advantage for other applications.DDM is autogenous tooth dentin that has osteoconductive and osteoinductive potential since dentin contains extracellular COL-1 and various growth factors. Based on the demineralization process, the factors remain available to the host environment; however, extracting proper concentrations of collagen and bioactive molecules from the extracted teeth is a challenging task and requires meticulous preparation of the tooth dentin. DDM is used in dental surgery in the treatment of extraction socket preservation and guided bone regenerations. It functions in a dual capacity: First as a scaffold to support bone regeneration and second as a carrier for bone morphogenic protein (BMP-2). When DDM serves as a carrier, it combines the properties of the grafting material with those of the delivered substances .The type of demineralizing agents and time frames used to prepare DDM are dissimilar in different studies, and therefore they affect the amount of the mineral percentage remaining in the DDM. The DDM components have different inorganic/organic ratios compared to those originally found in the dentin matrix. Approximately, the powder form has mineral content of about 5%–10%, whereas block form has a mineral content of about 10%–30% . COL-1 wThe degree of demineralization is critical for optimal dentin regeneration; the partially demineralized dentin matrix (PDDM) is thought to have optimal conditions for dentin regeneration. Partial demineralization results in the elimination of the major part of the mineral phase and immunogenic components while retaining a very low fraction of minerals (5–10 wt%), providing an osteoconductive and osteoinductive scaffold containing several growth factors . On the In terms of particle size, the dentinogenic properties of DDM were greatly affected by the size and shape of dentin matrix particles. The larger-sized particles of the DDM, whose sizes ranged between 350 μm and 800 μm, were found to have better bone regeneration results than the smaller-sized particles that had more resorbability in the defect site before the initiation of new bone formation . PDDM wiDentin and bone are mineralized tissues known to be an organic–inorganic hybrid. They are almost similar.n their biochemical components but dentin is acellular matrix, while bone includes osteocytes. Autogenous bone is an ideal bone graft material as it has osteoconductive, osteoinductive and osteogenic capabilities but the major drawbacks of autogenous bone are that it requires a secondary donor site with an increase in the susceptibility risk of infection, therefore clinicians prefer commercially available non-autogenous graft materials. Allogenic and xenogeneic bone grafts have osteoinductive ability, but risk of viral infection still remains a considerable problem. Alloplastic bone grafts are clinically used, but they have disadvantages such as limited osteoinductivity and high cost . Among tIt is beneficial to utilize extracted teeth as bone substitutes in implant dentistry, even though there are limited cases with available teeth, in addition to a limited volume. However, there is no risk of transmitting diseases as it is autogenous tissue and no additional surgery is needed to harvest tissues since unwanted teeth are utilized and this raises the need for tooth banking. The Korea Tooth Bank, which was established in Seoul in 2009, is one such tooth-banking facility that can procure and store teeth, and then process them into bone graft substitutes. The Hospital Tooth Bank at Seoul National University Bundang Hospital, which was established in 2010 for performing storage and grafting of auto-tooth bone grafts based on experimental and clinical research.Before clinical application and for each specific purpose, optimizing protocols of demineralization, characterization, developing a proper consistency, and applying a proper handling technique are necessary for standardization. Further studies are required to determine the most suitable conditions of demineralization and particle sizes for clinical application in implant dentistry.Supplementary file1 (PDF 239 kb)Below is the link to the electronic supplementary material.


When dealing with COVID-19 notification rates, during the first wave, parent provinces of Italian small islands exhibited substantially lower estimates than those at the national level. Even though subsequent stages of the pandemic  saw a drastic increase in the number of confirmed cases and CMR, estimates from small islands remained generally lower than those from parent provinces and the national level. In regression analysis, notification rates and mortality in the parent provinces were the main effectors of EMRs in the small islands . Contrarily, the management of incident cases in hospital infrastructures and ICUs was characterized as a negative predictor for EMR . In summary, the study suggests a potential role of small geographical and population size in strengthening the effect of restrictive measures toward countering the spread and mortality rate of COVID-19.Small islands have been considered at an advantage when dealing with infectious diseases, including COVID-19, but the evidence is still lacking. Crude mortality rates (CMRs) and excess mortality rates (EMRs) were calculated for 35 municipalities on the Italian small islands for 2020 and 2021, and the corresponding estimates were compared to those of the parent provinces and the national estimates. Notification rates for COVID-19 were retrieved, but detailed data at the municipality level were not available. A relatively low CMR  was identified in 2020, compared to 1.180, 95% CI 1.098–1.269 for 2021. EMRs of small islands ranged between −25.6% and +15.6% in 2020, and between −13.0% and +20.9% in 2021, with an average gain of +0.3% (95% CI −5.3 to +5.8) for the entirety of the assessed timeframe, and no substantial differences between 2020 and 2021 (pooled estimates of −4.1%, 95% CI −12.3 to 4.1 vs. 4.6%, 95% CI −3.1 to 12.4;  AccorSince the inception of the SARS-CoV-2 pandemic, it was hypothesized that the small geographical and population sizes of small islands, coupled with the appropriate implementation of non-pharmaceutical interventions (NPIs) recommended by international authorities , could bHowever, scarce evidence has been collected, and mostly from small island states such as Malta and Cyprus, whose size and resources still appear as not comparable to those of small islands ,8,9,10.2  and serves a total population of around 200,000 individuals  [From this point of view, Italy may provide some interesting insights. In fact, the Italian peninsula includes two major islands (Sicily and Sardinia), and 30 small islands for a total of 35 administrative units. The pooled surface area of Italian small islands totals 874.41 kmulation) . To dateulation) ,13.2, with a total population of around 60,000,000 inhabitants. The first-level administrative entities are represented by the Regions (20); each region is divided into a number of provinces  that in turn include several municipalities , that vary considerably in size and population, both in terms of total population and population density [Italy has a total surface area of 301,230 km2 and 24,090 km2, respectively, and total populations of 4,875,290 and 1,611,621 inhabitants, respectively, in 2020), and a total of 30 Italian small islands (see 2) encompasses a total of eight municipalities, while the Aeolian Islands of Lipari, Vulcano, Salina, Stromboli, Filicudi, Alicudi, and Panarea are organized into a single municipality (Lipari), and similarly, the scarcely populated Tremiti Islands  constitute a single municipality of the province of Foggia.The main land mass is represented by the Italian peninsula, with two major Mediterranean islands . Open-source data included population estimates at various administrative levels . More precisely, we retrieved monthly estimates from the timeframe 2015–2021 about: (a) resident population at the provincial and municipality levels; (b) monthly estimates for deaths among residents at the provincial and municipality levels; and (c) income for the general population and renters.Demographic data were obtained from the official website of the Italian Institute of Statistics  provides open-source provincial-level estimates for SARS-CoV-2 infections, including: (a) notified cases; (b) COVID-19 related deaths; (c) COVID-19 related hospital admissions; (d) COVID-19 related admissions to intensive care units (ICUs). Data about incident cases 2020–2021 were retrieved at the lowest available administrative unit level .We performed a descriptive analysis of the data by calculating the corresponding annual crude mortality rates of the municipalities from the small islands for the time periods 2015–2019, 2020 and 2021. Municipality-level estimates  were then pooled at the provincial level  in order to compare them with general data from the parent province EMR. The difference between the reported number of deaths (RD) in a given month in 2020 and 2021 and the estimate of the expected deaths (ED) for that period was then calculated as follows:i,a = reported deaths in a given month i, at a specific administrative level a.RDi,a, 2015−2019 = average deaths in a given month i for the time period 2015–2019, at a specific administrative level a.EDAverage monthly estimates for COVID-19 notification rates, deaths, hospital admissions, and admissions in intensive care units (ICUs) were then calculated at provincial level in order to compare corresponding estimates with mortality and EM from the small islands municipalities pooled at the provincial level. Comparisons of crude rates were performed by means of Mann–Whitney or Kruskal–Wallis test for multiple independent samples. On the other hand, association between continuous variables was assessed through Spearman’s rank correlation coefficient. Eventually, the relationship between the excess mortality rates and demographic factors was investigated through a regression analysis model that included as the outcome variable the monthly mortality rates . The explanatory variables were represented by COVID-19 related factors such as: notification rates, mortality, hospital admissions, and ICU admissions. All variables were entered in the model as a single step. The analyses were then adjusted by main demographic factors .Eventually, a sensitivity analysis was performed in order to assess how vulnerable the results of regression analysis were to many or all unobserved confounders. In the analyses, we assumed COVID-19 mortality rates as the “treatment” , as we assumed that a large share of incident cases may have been not reported, particularly during the earlier stages of the pandemic . SimilarAll calculation were performed in R 4.0.3 , by meanEthical approval. No ethical approval was needed for this study, as no individual data were identifiable, and only aggregated data were analyzed and presented.p = 0.003).As shown in p < 0.001). Moreover, the proportion of individuals older than 40 years increased more steadily on the small islands (from 58.2% in 2015 to 62.1% in 2021) than in the general population . Interestingly, Italian small islands were characterized by an increased share of individuals of male gender than that reported at the national level .Compared to the Italian general population, the small islands were also characterized by a lower share of individuals aged less than 20 years (pooled estimate of 17.0% vs. 18.2%), a similar share of residents aged 20 to 39 years (22.3% vs. 22.7%), an increased proportion of age groups 40 to 59 years (31.2% vs. 30.5%) and 60 to 79 years (22.8% vs. 22.0%), and a reduced share of residents aged 80 years of older .Between 2015 and 2021, a total of 4,627,795 deaths were reported at the national level, with 15,569 of them occurring on the small islands (0.3%), with a substantial increase from 2015 to 2021 .Yearly mortality rates of municipalities from Italian small islands are reported in p = 0.130) and 2021 (p = 0.753). Moreover, monthly mortality rates of the small islands across all of the assessed timeframes were substantially lower than those of the parent provinces , and those of the national estimates as well .Additionally, monthly mortality rates for 2015–2021 from the 35 municipalities were quite heterogenous , rangingp < 0.001) and the national level (p < 0.001). When focusing on the estimates from 2020 (rho = −0.344) and 2015–2019 (rho = −0.339), a negative correlation with population density  was suggested, but the results were on the edge of statistical significance , and should be cautiously assessed. In fact, no significant correlation was found for 2021 .Mortality rates on the small islands were positively correlated with corresponding estimates both for parent provinces .When crude mortality rates from the small islands in 2020 and 2021 were compared to the background estimates for 2015–2019, no substantially increased risk was identified for 2020 , while it was substantially increased in 2021  . In both2 34.1%, 95% CI 0.0% to 66.8%), and substantial for 2020 .Contrarily, when mortality estimates were compared to those from the parent province , no subsp < 0.001), parent provinces of the small islands exhibited substantially lower notification rates . During the subsequent stages of the pandemic, parent provinces of small islands were more extensively involved, still exhibiting lower notification rates , with the notable exception of the month of August 2021.Detailed estimates of COVID-19 notification rates for the small islands are, to date, not available. The most reliable proxy  is reported in p < 0.001). Similarly to notification rates, in the subsequent stages of the pandemic, the trend remained quite similar , but the differences remained significantly different .A similar pattern was identified even when COVID-19 associated mortality rates were taken into account . As showp = 0.141). Contrarily, general mortality on the small islands was positively correlated with COVID-19 associated mortality in the parent provinces . Hospital admission rates and ICU admission rates were also compared, but while hospital admissions for COVID-19  were positively correlated with the mortality rates, the latter were not clearly correlated with ICU admission rates .A positive correlation between the number of COVID-19 positive cases and mortality rates in the parent provinces was expected as a result of the high infectivity rate and morbidity. However, no actual correlation was identified . In this regard, visual inspection of Municipality level estimates for EMRs on the small islands ranged between −25.6% and +15.6% in 2020, and between −13.0% and +20.9% in 2021 , with anp = 0.013, and rho = 0.592, p = 0.002). However, pooled estimates were unrelated with the national level . EMR was also unrelated with population density , and with demographic factors such as the share of individuals aged 60 years or more , or 80 years or more , or average per capita income .Both individual a and pooIn regression analysis, monthly EMRs on Italian small islands were included in a multivariable model where COVID-19 notification rates, COVID-19 related mortality, and admissions (both as a whole and in ICUs) were assessed as effector variables. The model was adjusted for main demographic factors . As summarized in Conversely, admission estimates for COVID-19—both in general , and to ICUs—were characterized as negative effectors  for EMRs on the small islands. In other words, EMRs were higher when notification rates and mortality associated with SARS-CoV-2 infections in the parent provinces were higher, while they were decreased by higher admissions in hospital infrastructures, both in general and in ICUs.In sensitivity analysis, the robustness value for bringing the point estimate of EMR exactly to zero  was 13.2%. In other words, unobserved confounders that explained 13.2% of the residual variance from the treatment variable  and outcome variable were sufficient to explain all of the observed effects. On the other hand, the robustness value for testing the null hypothesis that the coefficient of EMR was zero  fell to 6.5%. This means that unobserved confounders that explained 6.5% of the residual variance from treatment and outcome variables were sufficiently strong to force the lower bound of the confidence interval  to zero. However, unobserved confounders that did not explain at least 6.5% of the residual variance from both the treatment and outcome variables were not strong enough to do so.According to the pre-pandemic evidence, living on small islands was usually considered an advantage when dealing with infectious diseases because of their small populations, geographical size, easier implementation of containment measures, and absence of land borders ,9,10,18.However, our study suggests that Italian small islands were affected by the SARS-CoV-2 pandemic on a smaller scale than that reported at the national level, and particularly during its earlier stages . EMR estAfter a transition stage lasting from May to August 2020, Italy was involved in the “second wave” of the SARS-CoV-2 pandemic. During the “second wave”, the small islands exhibited a substantial increase in mortality rates, and again, such results were consistent with available international estimates, where this trend was explained by hasty relaxation of NPIs, including bans on national and international travel ,9,10. ThNevertheless, the “second wave” on the Italian small islands still exhibited some interesting specificities. On the one hand, during the “second wave”, an increase in crude and excess mortality rates was identified compared to the “first wave”, mirroring at a lower level a similar trend at the national level. In turn, the increase in crude mortality rates and EMRs at the national level was well-correlated with notification rates for SARS-CoV-2 ,20, withEven though notification rates and mortality rates for COVID-19 remained substantially higher than those reported in the first wave, during the first half of 2021 and until the end of May 2021, actual mortality rates on the small islands were far lower than those expected. Only afterwards, and particularly during the warm season, did the Italian small islands exhibited a clear increase in mortality rates. Not coincidentally, while during 2020 the risk for all-cause deaths was similar to the figures for 2015–2019 , the biphasic trend in mortality rates during 2021 for the small islands resulted in a clear surge (+9.6%) that was well below the estimates for the national level .This is particularly interesting for several reasons. First of all, during the “first wave”, Italy was severely affected by the SARS-CoV-2 pandemic ,23, but Even though the 2021 surge in EMRs on the small islands nearly halved that reported at the national level for the same time period , the oveAnother possible explanation for the better performance of Italian small islands during 2020 and 2021 compared to national estimates may be found in some further specificities of island communities. As recently suggested by Lu et al., communities characterized by higher acceptance of collective behavior are more likely to cope with NPIs, which in turn have been instrumental in slowing down pathogens such as SARS-CoV-2, particularly when effective vaccines were still unavailable ,35. FromAs expected, features of the SARS-CoV-2 pandemic were characterized as substantial effectors for EMR . While nLimits. Despite the potential interest, our study was affected by several limitations. First and foremost, it was an ecological study, and, therefore, it shared all of the implicit limits of this design, and particularly the potentially confounding factors represented by individual level variables [ariables ,46,47.The “ecological fallacy” in this specific case may have been amplified by the lack of detailed notification rates for SARS-CoV-2 positive cases at the municipal level. Particularly during the first stage of the pandemic, actual COVID-19 mortality may have been under-reported; according to a recent study on Italian data, missed diagnoses may have accounted for up to 96% of actual cases that occurred in the hotspot represented by the Italian province of Bergamo up to 25 September 2020 . In thisAnother bottleneck associated with the study design is represented by the quality of the data available from online sources  . For exaMoreover, as shown in In conclusion, Italy’s small islands were extensively spared from the first wave of the SARS-CoV-2 pandemic, and were considerably less affected afterwards. Despite the heterogeneity among the retrieved estimates and the potential role of confounding factors represented by the local specificities of Italian small islands, which strongly recommend a cautious analysis of the reported data , several specificities of the small islands may have contributed to their better performance when compared with the national level and other small island communities, both in Europe and in the Pacific. However, the small islands cannot be simplistically defined as “safe havens” from COVID-19, not only because of the limited availability of medical resources, but also because the better performances we were able to identify may be associated with lockdown measures that are hardly compatible with local economies that are largely dependent on tourism. Specifically tailored preventive measures are, therefore, forcibly required in order to protect their resident populations. In this regard, available data suggest that achieving high vaccination rates may substantially reduce mortality rates in those populations.


The incidence of melanoma, a very aggressive skin cancer, has increased over the past few decades. Although there are well-established clinical, dermoscopic and histopathological criteria, the diagnosis is often performed late, which has important implications on the patient’s clinical outcome. Unfortunately, melanoma is one of the most challenging tumors to diagnose because it is a heterogeneous neoplasm at the clinical, histopathological, and molecular level. The use of reliable biomarkers for the diagnosis and monitoring of disease progression is becoming a standard of care in modern medicine. In this review, we discuss the latest studies, which highlight findings from the genomics, epitranscriptomics, proteomics and metabolomics areas, pointing out different genes, molecules and cells as potential diagnostic and prognostic biomarkers in cutaneous melanoma. BRAF gene are present in 50–60% of melanomas and the CDKN2A gene is altered in 16–41% of melanomas [NRAS and C-KIT [Melanoma is the most frequent of the aggressive cutaneous malignancies, being the first cause of death for patients with skin cancer . Cutaneond C-KIT . The intnd C-KIT ,9,10. Thnd C-KIT . Althougnd C-KIT . In the We have performed a non-systematic review by browsing the PubMed and Google Scholar databases. We have selected articles written in English published in the last five years (July 2017–July 2022), based on their relevance and our expertise in the field. Search terms included “melanoma” and “diagnostic biomarker” or “prognostic biomarker” or “biomarker”. We have excluded the articles that evaluated types of melanoma other than cutaneous melanoma and biomarkers other than those related to the diagnosis and prognosis of melanoma. We have focused on the main domains that develop biomarkers that are applicable in the management of melanoma, including genetics, epigenetics, tumoral tissue, systemic environment, inflammation and metabolism.Melanoma exhibits significant heterogeneity, with diverse genomic alterations being one of the highest mutated tumors. Therefore, tumor genetic heterogeneity is an important player in the process of immune evasion, invasion and metastasis of new tissues. This genetic plasticity interferes with the proper diagnosis and treatment of melanoma . CurrentCDCA8 and DPF and upregulation of the genes ABCC3, CAPS2, CCR6, CLU, PTK2B, SATB1, and SYNE represent indicators for a positive prognosis of cutaneous metastatic melanoma [CDC20, GNB2, PPP2R1A, AURKB, POLR2E, and AGTR1, is associated with low overall survival [IQCE, RFX6, GPAA1, BAHCC1, CLEC2B, and AGAP2, as candidate genes for melanoma prognosis [Data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases provide new genetic profiles aimed to predict patient outcomes. It was identified that downregulation of the genes melanoma . Anothersurvival . Gao et rognosis . Liu et rognosis , its lowIL15, CCL8, CLIC2, SAMD9L, TLR2, HLA.DQB1, IGHV1–18, RARRES3, GBP4, APOBEC3G) involved in processes such as inflammation and immune response, which differentiate melanoma patients according to survival rate into two classes, with low and high risks [NOTCH3, DBN1, KDELC2, and STAB1) that support the infiltration of pro-tumoral M2 macrophages in melanoma and even validated a prognostic risk score to evaluate mortality in patients with melanoma, based on the expression of these genes [RTP4 (genes involved in the expression of interferon-responsive proteins) as a novel gene associated with cutaneous melanoma and revealed that there is a link between RTP4 and tumor inflammatory infiltrate [Gene expressions influence the tumor microenvironment that plays an important role in the progression and prognosis of melanoma. Yingjuan et al. analyzed genes related to stromal and immune cells in melanoma patients using TCGA database. They identified 10 genes  pathway has been described as being involved in several malignant tumors, including melanoma ,24. Receval rate . In liner effect . TherefoIn recent years, epitranscriptomics has gained its place in the biomarker domain, along with the important progress made in the field of sequencing methodologies . NoncodiThe investigation of miRNAs in melanoma is currently ongoing. In recent years, several new miRNAs related to the diagnosis and prognosis of melanoma have been reported. Downregulation or upregulation of certain miRNAs can predict patient outcomes. Sun et al. described miR-431 as a potential prognostic biomarker in melanoma. Low miR-431 expression in melanoma cells indicates tumor ulceration and is associated with a low survival rate . Low expSeveral studies have focused on identifying panels of miRNAs, not just one type of miRNA. Lu et al. identified a group of five miRNAs  that can be used to predict prognosis in melanoma patients. They identified a positive correlation between miR-204 and the prognosis of the disease, while the other four miRNAs correlated negatively with the prognosis . These rIt should be taken into account that miRNAs are degraded by RNA enzymes, but if they are packed in exosomes, degradation becomes more difficult. Thus, exosomes can be used in disease detection because they represent a simple method with good sensitivity and, moreover, are a stable family of molecules that can be identified in body fluids ,42. TengThe tumor microenvironment (TME) comprises a plethora of cells and molecules, including malignant cells, tumor vessels, stromal cells, extracellular matrix (ECM), signaling molecules, etc., that are interconnected and actively contribute to tumor progression, resistance to therapy and immunosurveillance. The main non-cancer stromal cells are represented by endothelial cells, pericytes, immune cells, fibroblasts, cancer associated fibroblasts (CAFs), activated adipocytes, and mesenchymal stem cells (MSCs) . In melaTumor-associated macrophages (TAMs) are a key component of the inflammatory infiltrate and have one of the most important roles in tumorigenesis. It is known that a high amount of TAMs in the TME is associated with a poor outcome. The identification of TAMs’ subtype is of outmost importance, as M1 macrophages exhibit anti-tumor effects, whereas M2 macrophages are involved in tumor growth . M2 macrImmune cells, key players of TME, have sub-populations that are involved in the pro-tumoral processes and can constitute important cellular biomarkers. Regulatory T cells (Tregs) induce an immunosuppressive microenvironment and contribute to tumor immune escape. Studies performed on murine models revealed that the transient depletion of Treg enhances the antitumor immunity and leads to a better clearance of the tumor . In a smHLA-B, HLA-DRA, CCL8, and IL2RA, have been shown to be associated with a good prognosis in melanoma [Using the TGCA and GEO databases, Wu et al. have identified three main tumor-infiltrating immune cells, CD8+ T cells, M0 macrophages and M1 macrophages, which can modulate melanoma progression. The analysis has revealed that CD8+ T cells and M1 macrophages operate as protective factors, whereas M0 macrophages display a deleterious effect. In the same study, four immune-related genes, melanoma . Wagner melanoma . Howevermelanoma .LCP2 gene located on chromosome 5q33. Under physiological conditions, the protein is expressed by hematopoietic cells; however, malignant cells have been shown to express the protein, as in [LCP2 mediates, in particular, the development and activation of T cells through the TCR signaling pathway, but it also regulates the function of other cells, such as natural killer (NK) cells [LCP2 influences the infiltration levels of immune cells in melanoma, especially CD8+ T cells, and the increased expression of LCP2 is correlated with good overall survival in patients diagnosed with cutaneous metastatic melanoma. Moreover, considering that LCP2 is involved in the regulation of several immune pathways, it can be used as a prognostic marker for progression-free survival in patients treated with anti-PD-1 immunotherapy [Tagawa et al. suggested that the leucine zipper transcription factor ATF-like 2 (BATF2), a type I IFN-inducible transcription factor, can be a biomarker of invasiveness in melanoma. Altered tumor cells in the advanced stages of melanoma release Toll-like receptor ligands, such as damage-associated molecular patterns that induce BATF2 expression . Lymphocn, as in . LCP2 meK) cells . LCP2 beK) cells . Wang etotherapy . TME is Host immunity plays a defining role in anti-tumor defense. A pro-inflammatory response can be associated with a better prognosis . HoweverPeripheral blood cell count ratios are a relatively new type of inflammatory indicators, including neutrophil-lymphocyte (NLR), platelet-lymphocyte (PLR), and lymphocyte-monocyte (LMR) ratios, and represent easy-to-measure biomarkers that are part of routine blood examination . Wagner Data from a multicenter cohort study that included 1489 patients with melanoma, conducted over a 10-year, period showed that there is a positive correlation between NLR and tumor volume upon presentation. In addition, NLR may predict occult sentinel lymph node metastases . NLR > 2Iacono et al. analyzed the LMR in the blood of 162 patients with advanced melanoma and observed that a high LMR is associated with a better prognosis in these patients. Elevated LMR was correlated with normal levels of lactate dehydrogenase (LDH), the absence of metastases in the central nervous system and fewer than three metastatic sites . It shouThe meta-analysis by Zhang et al., which included nine studies conducted between 2016 and 2019, aimed to evaluate the prognostic value of PLR in melanoma patients and concluded that a high PLR correlates with poor overall survival in melanoma patients . PeripheThe red blood cell distribution width (RDW) is defined as the variation in the volume of red blood cells. Increased RDW is specifically associated with anemia, chronic inflammation and malnutrition, characteristics of advanced stages of cancer . MoreoveThe link between eosinophils and cancer was discussed for the first time approximately 100 years ago, but many elements remain unknown. The accumulation of eosinophils was observed in the peripheral blood of patients with cancer and in the TME. Cancer cells release molecules with a chemoattractant effect on eosinophils, among the most important being IL-5 and GM-CSF . Using aPereira et al. have shown that patients with metastatic melanoma who have an increased number of circulating eosinophils have a better prognosis, regardless of the therapy they receive . RegardiAngiogenesis is essential for tumor development, progression and metastasis and represents an unfavorable prognostic marker for a variety of tumors. Rapid cell proliferation increases the need for oxygen and nutrients, leading to hypoxia, which is perceived by the immune system as a wound site. In these conditions, immune cells interact with tumor cells and stimulate the release of growth factors, cytokines and chemokines that contribute to the initiation of angiogenesis. Vascular endothelial growth factor (VEGF) is one of the most important factors associated with angiogenesis in melanoma, being involved in endothelial cell proliferation and vascular remodeling . HoweverVegfc, Angpt2, and Six1 and the degree of aggressiveness of melanoma cells. Furthermore, using data from TCGA, they observed that the angiogenic factor ANGPT2 and the lymphangiogenic receptor VEGFR-3 can be considered independent factors to predict overall survival in patients with melanoma [IL13Rα2 is a cell surface tumor antigen that has been identified in numerous tumors. IL13Rα2 promotes the activation of several pathways, such as MAPK, Akt/PKB, and Wnt/β-catenin, that induce cell invasion; therefore, the increased expression of IL13Rα2 was associated with an unfavorable prognosis in several neoplasms . Okamotomelanoma . In linemelanoma . Urokinase plasminogen activator receptor in overexpressed in numerous cancers and is associated with an aggressive phenotype of the tumor . The stuGlycosylation is a posttranslational modification of proteins that is involved in the regulation of numerous processes, such as protein folding and degradation or the interaction between cells and the extracellular matrix. Altered protein glycosylation leads to the stimulation of oncogenic signaling pathways and loss of intercellular adhesion, favors cell migration and dissemination, and induces a pro-metastatic profile . AberranGLT8D)1 expression was increased at the mRNA level in melanoma compared to nevi. Using immunohistochemical analysis, it was highlighted that GLT8D1 has tissue specificity. The expression of the GLT8D1 protein is higher in both cutaneous and mucosal melanoma than in nevi. In addition, GLT8D1 protein expression was higher in cutaneous melanoma compared to mucosal melanoma. When acral melanoma samples were compared with non-acral melanomas, the expression was higher in acral melanoma. Important correlations were identified between the high GLT8D1 protein expression and Clark level, AJCC stage, the presence of ulceration, Ki-67 expression and histopathological type [Glycosyltransferases add specific glycans to proteins, while glycosidases are involved in the trimming of glycans, and are found in the endothelial reticulum and Golgi apparatus, where they participate in the synthesis and processing of the glycans to obtain their final structure . Accordical type .Shan et al. used C8161 cells (high metastatic human melanoma cells) and A375P cells (low metastatic human melanoma cells) to evaluate the differences in glycosylation. They highlighted that the composition profile of fucosylated N-glycans was different in the two types of cells, and the expression of fucosyltransferase (FUT) 4 mRNA was higher in C8161 cells. Furthermore, aberrant expression of FUT 4 was associated with alterations in the migration and invasion capacity of melanoma cells by regulating the PI3K/Akt signaling pathway; therefore, the authors proposed FUT 4 as a regulatory marker of these processes in melanoma and a biomarker for detecting metastatic melanoma . When coTRE17 was observed in Ewing sarcoma [The TBC domain is a protein domain found in all eukaryotes and is named according to its initial discovery in the proteins Tre-2, Bub2, and Cdc16 . TBC fam sarcoma  and in l sarcoma .TBC1D13, TBC1D16, TBC1D7, TBC1D8B, TBC1D15, TBC1D19, and TBC1D10C) as prognostic markers in melanoma. They compared the transcription levels of these genes with the TCGA melanoma dataset and observed that the relative mRNA expressions of TBC1D10C, TBC1D19, TBC1D16, TBC1D13 and TBC1D7 were higher and expression of TBC1D15 was lower, while for TBC1D8B, there were no differences between the melanoma samples and normal tissues. Based on these genes, the authors developed a prognostic nomogram model for predicting survival in melanoma. They also showed that the alteration of TBC1D7 hinders the proliferation and dissemination of tumor cells in vitro [Considering that TBC1D16 has been previously shown to be involved in melanoma metastasis, Qi et al. studied whether other TBC proteins are involved in this process and identified the upregulation of TBC1D4, TBC1D14, TBC1D16, TBC1D7, and TBC1D10A and the downregulation of TBC1D24 proteins. They found an important correlation between TBC1D7 and distant metastasis-free survival. Using cultured melanoma cells, (primary and metastatic melanoma cell lines derived from the same patient), the authors highlighted that TBC1D7 increases cell invasion by influencing the activity of MMP2 and MMP9 . Tang etin vitro . TBC proNicotinamide N-methyltransferase (NNMT) is an enzyme that catalyzes the N-methylation of nicotinamide, and structurally related compounds; it uses S-adenosylmethionine (SAM) as a methyl donor and is responsible for the modulation of intracellular concentration of nicotinamide. NNMT is a cytosolic enzyme, which, under physiological conditions, is expressed especially in the liver and adipose tissue and in low amounts in the brain, skeletal muscles, kidneys, heart and placenta. Dysregulation of NNMT activity has been associated with numerous conditions, including diabetes mellitus, liver disease, neurodegenerative disorders, and cancer ,102.Altered levels of NNMT have been detected in various neoplasms, such as gastric, colorectal, pancreatic, etc. . NNMT isGanzetti et al. evaluated the role of NNMT in the diagnosis and prognosis of melanoma by analyzing the expression of the enzyme through immunohistochemical analysis of 34 melanomas and 34 nevi (control group). NNMT expression in melanoma was statistically significantly higher compared to nevi. An inverse correlation was identified between the enzyme levels and Breslow thickness, Clark level, mitotic count, and the presence of ulceration . In anotThe rapidly emerging field of metabolomics provides novel biomarkers in melanoma . Cancer Numerous metabolic pathways are altered in melanoma ,114. KimWasinger et al. showed that glutamic acid and alanine stimulate the proliferation and migration of melanoma cells in the early stages of evolution. This effect was not observed in the case of metastatic cells . AlteredMelanoma is a multifaceted tumor with a great ability of invasion and metastasis, characterized by high genomic, proteomic, epitranscriptomic, and metabolomic versatility. A significant number of biomarkers from many sources, including the TME, tumor metabolism, aberrant glycosylation, miRNAs and host immune response, have been analyzed and show promising results for the diagnosis and prognosis of melanoma. The investigation of a complex panel of biomarkers in melanoma is currently in progress, and further studies are required to establish the most reliable biomarkers.


Cervical pregnancy (CP) is an uncommon type of ectopic pregnancy with a rising risk to life. Currently, there is no universal protocol for the safe and effective management of CP. This study aimed to investigate the clinical efficacy of high-intensity focused ultrasound ablation (HIFU) vs. uterine artery embolization (UAE) in the management of CP to develop a standard for the treatment of CP.From January 2015 to October 2021, 36 patients with CP were diagnosed, treated, and followed up at the Department of Gynecology of Third Xiangya Hospital of Central South University. A total of 11 patients were treated with HIFU followed by suction curettage under hysteroscopic guidance, and 25 patients were treated with UAE followed by suction curettage under hysteroscopic guidance. Medical records and pregnancy outcomes were retrospectively analyzed.Compared to the UAE group, the HIFU group had a shorter interval time (1.5 ± 0.21 days vs. 2.6 ± 0.26 days), shorter duration of hospitalization (5.5 ± 0.31 days vs. 6.6 ± 0.21 days), shorter recovery time of menstruation (30.6 ± 7.09 days vs. 36.9 ± 5.54 days), fewer adverse reactions (0/11 vs. 9/25), and fewer postoperative complications (1/11 vs. 8/25). There were no significant differences in age, gravidity, parity, abortion, gestational age, cardiac pulsation, admission symptoms, hemoglobin level, largest diameter of the sac/mass, serum human chorionic gonadotropin (hCG) level at admission, hospitalization expenses, hospitalization days, blood loss during curettage, degree of hCG decline, residue after curettage, fertility requirement, and pregnancy outcomes.Both HIFU and UAE are safe and effective in the treatment of patients with CP. Compared to UAE, HIFU treatment for CP is a safer and more effective therapeutic schedule owing to the advantages of being more minimally invasive, shorter interval time, shorter hospitalization days and recovery time of menstruation, fewer adverse reactions, and fewer postoperative complications. Cervical pregnancy (CP) is a rare type of ectopic pregnancy implanted in the cervical canal, with an incidence rate of approximately 1/18,000 . Pregnanvia systemic or local injection is an optional drug treatment in women who are clinically stable; however, its curative effect is still uncertain. The estimated failure rate after systemic treatment is high, with a probability of hysterectomy in ~10% of cases (Methotrexate (MTX) delivered of cases –5. Uteriof cases , 7. Moreof cases –13. Chenof cases  reportedof cases . Jiang eof cases .Currently, no studies comparing the clinical efficacy of HIFU and UAE for the treatment of CP have been published. Therefore, this study aimed to preliminarily explore the clinical efficacy of HIFU and UAE in the management of CP and to follow-up on pregnancy outcomes to provide more choices for the management of CP.The clinical data of 36 cases of CP treated with HIFU or UAE in the Department of Obstetrics and Gynecology of the Third Xiangya Hospital from January 2015 to October 2021 were retrospectively analyzed. Each patient provided informed consent, and this study was approved by the ethics committee at our institution (project no.2020-s578) on 22 September 2020. All the patients were diagnosed using transvaginal B-ultrasonography (B-US). HIFU or UAE treatment was chosen for patients after diagnosis. Among them, 11 patients were treated with HIFU followed by suction curettage under hysteroscopic guidance, and 25 patients were treated with UAE followed by suction curettage under hysteroscopic guidance.The inclusion criteria were as follows: (1) history of amenorrhea and positive urine pregnancy test results; (2) diagnosis of CSP was confirmed by ultrasound showing a gestational sac in the cervical canal and no gestational sac in the uterine cavity; (3) gestational age <13 weeks; and (4) availability of complete clinical data.The exclusion criteria were as follows: (1) patients with pelvic inflammatory diseases; (2) a history of trophoblastic, cardiovascular, and cerebrovascular diseases; and (3) patients with intrauterine adhesions and other diseases affecting fertility.The UAE procedure has been previously described in detail , 15. Brivia the peripheral vein was used during the procedure, and real-time ultrasonography was used to confirm the location of the gestational sac and monitor the response to HIFU. The ultrasound waves produced by the HIFU treatment system have an acoustic power of 400 W, they penetrate the abdominal wall and are focused on the gestational tissue. Coagulative necrosis of the targeted tissue occurs when the temperature increases. When the grayscale changed at the target tissue or when the signal of the blood flow in the gestational sac disappeared, the treatment was considered complete. Suction curettage under hysteroscopic guidance was performed at an average of 1.5 ± 0.21 days  after HIFU treatment.The HIFU procedure has also been described in detail previously . The patThe procedure of suction curettage under hysteroscopic guidance has also been described in detail previously , in whicFollowing the approved protocol, all patients were advised to return to our department for a color Doppler ultrasound examination 1 month after suction curettage. Patient parameters such as age, gestational age, gravidity, parity, admission symptoms, hemoglobin, largest diameter of the sac/mass, cardiac pulsation, serum human chorionic gonadotropin (hCG) level at admission, hospitalization expenses, hospitalization days, interval time, adverse reactions, blood loss during curettage, degree of hCG decline, residue after curettage, recovery time of menstruation, fertility requirement, complications, and pregnancy outcomes were all recorded.Interval time refers to the time between pretreatment and hysteroscopic curettage. Adverse reactions refer to the negative symptoms reported by the patients in the interval, including lower abdominal pain, lumbago and sacrococcygeal pain, fever, right leg swelling, and increased vaginal bleeding. The degree of hCG decline (%) refers to the ratio of hCG level on the first day after curettage to that on admission. Complications refer to the secondary symptoms of patients after discharge, including infection, decreased menstruation, intrauterine adhesions, and secondary infertility.t-test, the chi-square test, and Fisher's exact test were utilized for univariate analysis. A p-value of < 0.05 indicated a statistically significant difference.SPSS version 23  statistical analysis software was used for data analysis. Normally distributed data are presented as mean ± standard deviation, and skewed distributed data are presented as the median and interquartile range (IQR). The independent-sample p ≥ 0.05) (The average follow-up time was 41.9 ± 21.31 months (range: 6–69 months). The average age of the patients was 33.3 ± 5.59 years (range: 26–44 years). Among the 36 patients, 6 (16.7%) patients had no symptoms, 27 (75%) patients had pure vaginal bleeding, and 3 (8.3%) patients had abdominal pain with vaginal bleeding; none of them had a history of CP. Among these patients, 12 (33.3%) patients had not given birth and 12 (33.3%) had a fertility treatment requirement. The average gestational age was 53.5 ± 17.48 days (range: 34–97 days). The average largest diameter of the sac/mass was 29.1 ± 21.27 mm (range 2.9–79 mm). We found no statistically significant differences in age, gravidity, parity, abortion, gestational age, admission symptoms, hemoglobin level, largest diameter of the sac/mass, serum hCG level, and cardiac pulsation between the two groups ( ≥ 0.05) .p < 0.05). We found no statistically significant differences in hospitalization expenses, blood loss during curettage, degree of hCG decline, or residue after curettage.We also evaluated the hospitalization conditions in the HIFU and UAE groups, including hospitalization expenses, hospitalization days, interval time, adverse reactions, intraoperative bleeding, degree of hCG decline, and residue after curettage . We founWe followed up with 36 patients with CP. Eight patients were lost to follow-up, and the remaining 28 patients who were followed up, included 11 patients from the HIFU group and 17 patients from the UAE group. Compared with the UAE group, the HIFU group had a shorter menstrual recovery time and fewer complications. There were no significant differences in fertility requirements or pregnancy outcomes between the two groups see .Patients with CP require early diagnosis and management to control bleeding as soon as possible and to avoid hysterectomy with the intention of preserving the future reproductive function of patients . There aIn this study, we analyzed 36 patients with CP, of whom 11 were treated with HIFU and 25 with UAE. The statistics showed no significant differences in age, gravidity, parity, abortion, gestational age, admission symptoms, hemoglobin, largest diameter of the sac/mass, serum hCG, cardiac pulsation, blood loss during curettage, degree of hCG decline (%), residue after curettage, and pregnancy outcome between the HIFU group and UAE group. Both groups of patients underwent suction curettage after the primary treatment. Therefore, HIFU was shown to be as effective as UAE.The safety of the treatment of CP is a major concern. Many studies have reported that UAE may cause severe complications and some irreversible adverse effects, such as infection, fever, abdominal pain, infertility, and ovarian dysfunction , 19, 21.The cost and prognosis of management are also key issues that need to be considered. In this study, the interval time and duration of hospitalization for the HIFU group were shorter than in the UAE group. Patients treated with HIFU had lower hospitalization expenses, although there was no significant difference in the duration and expense of hospitalization. Overall, HIFU has several advantages in terms of cost. We also followed the prognosis of these patients, including menstrual recovery, postoperative complications, and pregnancy outcomes. We found that, compared with the UAE group, the HIFU group had a shorter menstruation recovery time and fewer complications. Moreover, six patients in the UAE group and two patients in the HIFU group became pregnant again after treatment during the follow-up period; however, there was no significant difference in fertility requirements and pregnancy outcomes between the two groups. Therefore, compared to UAE, HIFU has better postoperative recovery and higher cost performance.The limitations of the study include the retrospective study design, which may have led to some bias. Future prospective studies with a larger sample size and more accurate comparisons are needed.In summary, this study showed that both HIFU and UAE combined with hysteroscopic curettage are safe and effective in treating patients with CP. Compared with UAE, HIFU is a safer and more effective therapeutic schedule owing to its advantages of being less invasive, shorter interval time, shorter duration of hospitalization and recovery time of menstruation, fewer adverse reactions, and fewer postoperative complications. This study provides promising guidance for future standards in the management of CP.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Written informed consent was obtained from the participants, this study was approved by the Ethics Committee at our institution (Project no.: 2020-s578).Material preparation, data collection, analysis were performed, and the first draft of the manuscript was written by WL. All authors contributed to the study's conception, commented on previous versions of the manuscript, design, read, and approved the final manuscript.We are grateful for the support of the Hunan Provincial Clinical Medical Technology Innovation Guiding Project (Grant No. 2020SK53605) and the Hunan Provincial Natural Science Foundation (Grant No. 2021JJ40953).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.


Nei = 0.40, I = 0.66, PIC = 0.43). This study provides a practical example of polymorphism EST-SSR markers developed from multiple transcriptomes for non-model plants. A future breeding program for colored calla lily will also benefit from the core germplasm defined by those molecular markers.The development of high-throughput sequencing technology has made it possible to develop molecular markers such as EST-SSR from transcriptome sequences in non-model plants such as bulbous flowers. However, the EST-SSR markers that have been developed are weakly validated and low polymorphic due to the short read size and poor quality of the assembled sequences. This study therefore used the CandiSSR pipeline to identify 550 potential polymorphic SSR loci among 487 homologous unigenes based on the transcriptomic sequences of three varieties of colored calla lily, and 460 of these loci with appropriate flanking sequences were suitable for primer pairs design. A further validation with 200 randomly selected EST-SSRs demonstrated an increase of more than 30% and 100% in amplification validity and polymorphism, respectively, in comparison with our previous study. In addition, since most of the current varieties of colored calla lily are hybridized from a few species, which have low genetic diversity, we subsequently identified primary core germplasm for 160 colored calla lily accessions using the aforementioned 40 polymorphic EST-SSRs. It was concluded that the core germplasm containing 42 accessions derived from the M strategy incorporated into the software Power Core was the most representative of all 160 original germplasm, as evidenced by the preservation of 100% of the EST-SSR variation, with a higher level of genetic diversity and heterogeneity ( Among worphisms . While worphisms . To addrThe construction and administration of a plant collection comprising many individuals is essential for the selection and development of innovative crop varieties. However, it requires extensive space, skilled staff, and plant identification skills, which may result in a more expensive process. Given the high degree of redundancy and similarity in those initial crop collections, it is vital to establish a core collection of unique and distinctive germplasm materials . Typicalvia conventional hybrid breeding. Using the CandiSSR pipeline, we firstly identified distinct conserved polymorphic EST-SSR markers based on three transcriptome assembled sequences of colored calla lily. Then we performed a genetic diversity analysis of 160 accessions based on the markers information and finally established a representative core germplasm using the M strategy. This research offers us a beneficial molecular marker-assisted tool that will enhance breeding efficiency and accelerate the development of new varieties of colored calla lily in the future.It is also essential to identify the colored calla lily’s core germplasm using molecular markers such as SSR or EST-SSR. Due to the narrow range and plastome-genome incompatibility among wild species , the maj22.1Z. hybrida cv. Florex Gold and Black Magic were used for RNA extraction, respectively. Each sample’s genomic DNA and total RNA were respectively extracted using the DNeasy Plant Mini Kit and RNeasy Plant Mini Kit . The quantity of genomic DNA or total RNA was checked by resolution in the 2.4% (w/v) agarose gel and determined with the NanoDrop™ One.A primary germplasm collection of colored calla lily was maintained at the Bulb and Perennial Flowers Genebank Collection, Yanqing Farm, Beijing Academy of Agriculture and Forestry Sciences  for the purpose of this study. These are 160 accessions in this collection, the majority of which originate from New Zealand, the Netherlands, the United States, and China. All of these accessions are detailed in 2.2Following synthesis of cDNA with the Thermo Frist Strand cDNA Synthesis Kit (Thermo Fisher Scientific), ten cDNA libraries were generated, nine for Florex Gold’s spathes and one for Black Magic’s bulb, which contained approximately 130-150 bp insertion fragments by using Illumina TruSeq RNA Sample Prep Kits , and then subjected to paired-end sequencing on an Illumina HiSeq 2000 or 2500 platform. The raw data for Florex Gold and Black Magic were deposited to the Genome Sequence Archive. Moreover, our previously published transcriptome of variety Rehmannii , which shttp://www.biocloud.net/, Beijing Biomarker Technologies Co., Ltd) has been first used to evaluate raw reads of those three varieties. After eliminating the sequence adapters and low-quality reads, the clean reads were de novo assembled, respectively, using Trinity software  was initially used to identify microsatellites for each variety’s assembled unigenes. The minimum number of repeats used to select the SSRs was ten for mononucleotide repeats, six for dinucleotide repeats, and five for tri-, tetra-, penta-, and hexanucleotide repeats. Furthermore, CandiSSR , the effective number of alleles (Ne), observed heterozygosity (Ho), expected heterozygosity (He), Nei’s expected heterozygosity (Nei), as well as the Shannon information index (I) and polymorphic information content (PIC) were respectively calculated using GenAlEx 6.4  was used to statistical analysis of P value. *, P < 0.05; **, P < 0.01; ***, P < 0.001; ****, P < 0.0001.Three distinct strategies were used to determine the core germplasm of colored calla lily employing 40 EST-SSR allelic information from 160 accessions. The M strategy applied in the program Power Core  primaril33.1de novo assembly was performed using the Trinity software. The three varieties of Florex Gold, Rehmannii, and Black Magic were reassembled to yield 109,286, 89,825, and 120,836 unigenes, respectively. The N50 length of each variety was 1030 bp, 960 bp, and 825 bp, while their respective average lengths were 611.7 bp, 604.4 bp, and 585.7 bp  and Elaeis guineensis (46), followed by Musa acuminata (31), Nelumbo nucifera (13), Vitis vinifera (7), Zea mays (5), Volvox carter (5), Theobroma cacao (4), Hordeum vulgare (4), and Prunus persica (4). The homologous hits were also represented in the Swiss-Prot database, but with different species. Annotated unigenes with the highest frequency in COG categorization included translation, ribosome structure, and biogenesis, as shown in As described previously, all 487 homologous unigenes containing EST-SSR loci were searched against multiple databases to extract as much annotated information as possible  and the lowest at locus Zacp134 (1.07). With an average of 0.63, the I was highest at Zacp169 (1.09), and lowest at Zacp134 (0.15). It has also been found that the genetic diversity level is correlated with Ho as well. The locus with the highest Ho was Zacp110 (0.94), and the lowest was Zacp14 (0.06), with an average of 0.40. As far as the He is concerned, the highest locus was Zacp158 (0.66), while the lowest loci were Zacp14 (0.07) and Zacp134 (0.07). The mean Nei for the entire collection was 0.39. Of the loci in the PIC, Zacp158 had the highest value (0.67), while Zacp134 had the lowest value (0.06).To determine the diversity of 160 colored calla lilies Table 1.3.5Core Hunter software was utilized by setting the weights of MR and SH to 0.5 each and sampling proportions of 10%, 15%, 20%, 30%, 40%, and 50%, which resulted in core germplasm samples of 16, 24, 32, 40, 48, 64, and 80, respectively. The sampling proportion in SA, which consists of SANA method-PM (SA) and SAGD method-PM (SD), was the same as in Core Hunter software. In However, it is not necessary to pre-set the Power Core software in this manner. Using the Mp (maximization Power Core) method, all genetic parameters were estimated better than described above when the sample size was 42 (26.25%), which captures all the alleles identified in 160 germplasms, thus allowing us to select those 42 accessions for further analysis. A summary of the final selection of primary core germplasm for colored calla lily was provided in 4Na) ranging from 2 to 5 per locus and an average value of 2.73. In contrast, in our previous study (Z. aethiopica), 111 alleles were detected in 34 EST-SSR loci, and their number of alleles per locus ranged from 2 to 10, with an average value of 3.58. Considering the collected materials are almost identical, we speculated that the polymorphic EST-SSR markers obtained using the CandiSSR pipeline may lose some genetic diversity due to homologous sequences being derived from each variety and being more conserved.DNA markers, particularly SSR, are a reliable and effective technique for identifying germplasm resources in several research . As a cous study  of the dIt has been proposed to develop core germplasm to improve the use of genetic resources in breeding programs. Core germplasm is a subset of accessions from the entire collection that encompasses the majority of the genetic diversity of the species, which may be examined in depth, and the information derived from the assessment can be used to guide the effective utilization of the entire collection . While mNa) and the genetic diversity, automatically generates a reasonable sampling ratio through software such as Power Core, which is scientifically and reliably accurate (Core collection are a vital component of plant breeding that can enhance the efficiency with which germplasm resources are utilized for plant genetic improvements and new variety development. As an important determinant of the result of the construction of the core germplasm, the sampling strategy can not only reduce genetic redundancy but also preserve its genetic diversity to the greatest possible extent. Generally, it is divided into two categories, random sampling and stratified sampling, with the latter being regarded as significantly superior to the former in many studies . There aaccurate . AdditioNa, I, and Nei, should be taken into consideration when determining whether the core accession is representative. While the Na is considered to be the most relevant indicator (PIC, Ne, may also be used. Moreover, in an ideal core population, heterozygosity, defined as the probability that two randomly selected samples within a population have different alleles, should be roughly equivalent to that of the original germplasm. As a measure of the representativeness of the core germplasm, multiple parameters, such as Na, Ne, I, Ho, He, Nei, and PIC, were therefore considered. We found (Core germplasm aims to represent the genetic diversity of original germplasm to the greatest extent possible using the fewest resources. The most critical aspect of achieving this goal is the selection of an appropriate sampling ratio. To date, different plant germplasms have been constructed at home and abroad to a proportion of 5% to 40% . All stundicator , other mWe found Table 3 The original contributions presented in the study are publicly available. This data can be found here: NCBI, PRJNA883926 and PRJNA316785; NGDC, PRJCA000375.ZW and XiW conceived the study. YW, XuW, XS, HL, DW and HW collected materials and performed experiments. YW and TY analyzed data and drafted the manuscript. ZW, TY, XiW, YL and GZ revised the manuscript. All authors contributed to the article and approved the submitted version.


The highest sensitivity and accuracy were found with the convolutional neural network (CNN) model. Its sensitivity was 0.93, specificity was 0.90, and accuracy was 0.90. In this present study, we found that age, sex, select biomarkers, and select morphological parameters of the aorta are independent predictors for the rupture of ATAAD. In terms of predicting the risk of ATAAD, the performance of random forests and CNN is significantly better than LR, but the performance of the support vector machine (SVM) is worse than LR.Logistic regression (LR) and artificial intelligence algorithms were used to analyze the risk factors for the early rupture of acute type A aortic dissection (ATAAD). Data from electronic medical records of 200 patients diagnosed with ATAAD from the Department of Emergency of Guangdong Provincial People’s Hospital from April 2012 to March 2017 were collected. Logistic regression and artificial intelligence algorithms were used to establish prediction models, and the prediction effects of four models were analyzed. According to the LR models, we elucidated independent risk factors for ATAAD rupture, which included age > 63 years (odds ratio (OR) = 1.69), female sex (OR = 1.77), ventilator assisted ventilation (OR = 3.05), AST > 80 U/L (OR = 1.59), no distortion of the inner membrane (OR = 1.57), the diameter of the aortic sinus > 41 mm (OR = 0.92), maximum aortic diameter > 48 mm (OR = 1.32), the ratio of false lumen area to true lumen area > 2.12 (OR = 1.94), lactates > 1.9 mmol/L (OR = 2.28), and white blood cell > 14.2 × 10 Acute type A aortic dissection (ATAAD) refers to the vascular emergency when an intimal tear creates a false lumen in the ascending aorta . This isIt is vital to establish a simple risk prediction model that can quickly assess the risk of ATAAD rupture. In recent years, some scholars have devoted themselves to this research. Kuang et al. used multivariate analysis to study the predictive factors of preoperative mortality in patients with ATAAD and established a prediction model . Wu et aAccumulating evidence has shown that logistic regression (LR) and artificial intelligence (AI) can generate disease prediction models with high prediction accuracy ,7. HowevThe present study aims to analyze the risk factors for ATAAD rupture based on the CTA imaging and clinical features using LR and AI algorithms to establish the ATAAD rupture prediction models.The present study was a retrospective case-control study. The protocol of the study was approved by the Ethics Committee of the Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, China. Due to its retrospective design and anonymous characteristics, the requirement for informed patient consent was waived.Patients diagnosed with ATAAD in the Department of Emergency of Guangdong Provincial People’s Hospital from 1 April 2012 to 31 March 2017 were screened. Inclusion criteria: (1) age ≥ 18 years, (2) onset time ≤ 14 days, (3) CTA diagnosed as ATAAD. Exclusion criteria: (1) age < 18 years; (2) ATAAD patients who died of other serious complications such as myocardial infarction or cerebral infarction caused by coronary artery dissection and branch dissection of aortic arch; (3) iatrogenic or traumatic aortic dissection; (4) patients with previous serious diseases of other systems, such as heart failure, uremia, liver cirrhosis, advanced malignant tumors, etc.; (5) patients with aortic dissection who refused active treatment. An overview of the flow through the study is given in The primary outcome was death due to the dissection rupturing within 72 h after the CTA. The rupture was diagnosed by the bedside color Doppler ultrasound examination , which sPatient data were collected from medical records, including demographic and patient measurements, such as patients’ clinical data, clinical symptoms, general conditions, complications, X-ray findings, color ultrasound results, laboratory tests, clinical results, etc.p < 0.20 in univariate analysis were selected for multivariate analysis, and gender was forced to be included. The independent variable screening adopts the forward step method (Forward: LR) based on the likelihood ratio test.The cut-off value was achieved using the receiver operating characteristic (ROC) curve. the factors with a k samples from the original training sample set N to generate new training subsets. The new training subsets were different from each other and then build k decision trees according to the k training subsets. For data whose response variable was categorical, the final classification of each record was determined by voting on the basis of the classification results of multiple trees [The ATAAD rupture risk prediction model based on an RF algorithm was established with a training data set. We applied an RF algorithm for classification and regression trees (CART) as a meta-classifier to build an integrated classifier. The bootstrap sampling method was used to randomly extract le trees .Variable importance scores were used to evaluate the influence of variables on the occurrence of rupture. We sorted the variables according to their importance scores. Starting with the variable with the highest score, a stepwise RF analysis was performed, and the model was constructed.The goal of constructing an SVM model was to create an optimal classification boundary (highest-spaced hyperplane) in a high-dimensional space and distinguish different types of samples. The maximum interval hyperplane was the classification boundary, where the distance between the closest points reaches the maximum. Support vectors refer to the points in each class that are closest to the largest spaced hyperplane .Another alternative classifier in our study is CNN, which is a type of artificial neural network. Commonly used loss functions include root-mean-square error, negative log-likelihood, and cross-entropy. During the training of the network, the parameters M) and interquartile range , and the difference was compared by two independent sample rank sum tests. Count data were expressed as the number of cases (percentage), and comparison between groups was analyzed using the χ2 test or Fisher exact probability. p < 0.05 was considered statistically significant. The LR model was performed by Statistical Package for Social Sciences (SPSS) 22.0 . Python software was used to build RF, SVM, and CNN models. The performance measurement of the models was used to compare the generalization ability of the classifier. Precision and recall were more important than other evaluation indicators in disease risk prediction. We used the following indicators for the performance evaluation of the four models: AUC of ROC, accuracy, precision, specificity, recall, and F1-score.The Shapiro-Wilk test was used to determine whether the data conformed to the normal distribution. Normal distribution data were expressed as (mean ± SD), and t-tests were used for comparison between groups. Non-normal distribution data were expressed as median , 55 cases of diabetes (27.50%), 132 cases of smoking (66.00%), and six cases of Marfan syndrome (3.00%). According to whether the interlayer ruptures occurred within 72 h after CTA inspection, the patients were divided into the rupture group (100 cases) and an unruptured group (100 cases). We summarized relevant clinical indicators as the risk factors related to dissection rupture, which are presented in p < 0.20 were selected for multiple logistic regression analysis, and finally, ten independent risk factors were included in the model  = −5.82 + 1.69× (if age 9/L). The predicted rupture probability was a value derived from the LR equation. The observed rupture probability was the actual frequency of rupture observed in the case group. The prediction performance of the model was tested. The ROC AUC of the rupture risk score was 0.91 , as shown in χ2 = 3.38, p = 0.91, sensitivity was 0.83, accuracy was 0.85, precision was 0.90, F1-score was 0.88, specificity was 0.86, and recall was 0.90.Based on the LR analysis results, an ATAAD rupture risk prediction formula is established: logit . Then, we performed a stepwise random forest analysis. The results showed that the error rate of the data outside the bag was the lowest when the number of variables was 10. Therefore, the top 10 variables of variable importance scores were included in the RF algorithm to establish the ATAAD rupture risk prediction model. The top 10 variables of importance score were: pH, lactates (Lac) 2, ventilator assisted ventilation, respiratory rate, maximum diameter 2, heart rate, and cTnT  were more likely to experience dissection rupture than younger ones, which is similar to other reported evidence ,17. In t9/L and cTnT were important risk factors for ATAAD rupture.Prior reports have shown that many biomarkers, including white blood cell count, platelet count, C-reactive protein, cardiac troponin T, N-terminal brain natriuretic peptide, D-dimer, fibrinogen, and matrix metalloproteinase, are closely related to the progress and prognosis of interlayer rupture ,20,21. TAs an emerging machine learning algorithm, the RF algorithm has a wide range of applications in disease risk assessment. For instance, Casanova et al. used the Jackson cardiac study cohort data, LR analysis, and RF algorithm to predict diabetes and found that the accuracy of the RF algorithm was higher than that of the LR analysis . In the SVM is a machine learning method proposed by Vapnik et al. based on the principle of structural risk minimization in the mid-1990s . DiffereCNN has a wide range of applications in medical image processing and data processing ,23. It hMedical decision support systems based on AI have received increasing attention from the public. However, some models have low explanatory power and are difficult to apply in clinical work. Therefore, medical experts must be involved in the entire process of data collection, modeling, and data analysis to ensure that the model is interpretable. The four models we explored have their advantages, which can help clinicians to improve the accuracy of early ATAAD rupture risk prediction. However, there are limitations to the study. As a retrospective study, we cannot avoid the information bias of collecting data from medical records. Next, the sample size is small. A prospective, larger-scale study is needed to confirm our findings.In the present study, we found that age, sex, select biomarkers, and select morphological parameters of the aorta are independent predictors for the rupture of ATAAD within 72 h after CTA. In terms of predicting the risk of ATAAD, the performance of RF and CNN is significantly better than LR, but the performance of SVM is worse than LR.


To explore how self-disclosure leads to post-traumatic growth (PTG) in adults who have experienced traumatic events, this study identified the relationship between self-disclosure and post-traumatic growth in Korean adults. We examined a parallel multiple mediating model for this relationship.Participants were 318 Korean male and female adult participants aged 20 years or older who had experienced trauma. We measured deliberate rumination, positive social responses, and the meaning of life as mediating variables.The results revealed that the study variables positively correlated with PTG. Self-disclosure was positively correlated with deliberate rumination, positive social responses, and meaning of life. In the multiple mediating model, deliberate rumination, positive social responses, and meaning of life mediated the relationship between self-disclosure and PTG.Self-disclosure, deliberate rumination, positive social responses, and meaning of life play an important role in the growth of adults who have experienced traumatic events. The findings of this study should provide valuable information for future research and for mental health professionals who want to promote the PTG of their clients. Disaster is a part of life, both in the past and present, and people may experience trauma. Moreover, modern people live with different risks, such as traffic accidents, that did not always exist and could be big or small; nevertheless, everyone experiences trauma. The high possibility of trauma implies that it is not only we who might be traumatized in the case of a disaster or accident, but also our family members or close acquaintances. After analyzing the number of patients treated for post-traumatic stress disorder (PTSD) in Korea over the past 5 years, the To ensure that trauma works positively beyond just clinically preventing it from negatively affecting PTG, many researchers have been compelled to study the variables that affect PTG. First, studies have indicated that psychosocial intervention  as well Depending on the ruminative response styles, either PTSD or PTG may occur after experiencing trauma . People This study assumes that self-disclosure is a variable that could induce deliberate rumination. Self-disclosure is the act of revealing private information to others, and previous studies  have fouSelf-disclosure can arouse feelings of intimacy as well as cognitive awareness when listeners empathize and are supportive . Self-diAnother assumption that this study adopts is that discovering the meaning of life after experiencing trauma also leads to PTG. This study aimed to identify the relationship between self-disclosure and PTG of Korean adults, and examine the mediating effects of deliberate rumination, positive social responses, and the meaning of life on the relationship. So, this study analyzed the relationships among self-disclosure, deliberate rumination, positive social responses, the meaning of life, and the PTG of Korean adults; additionally, we analyzed a multiple mediating model of deliberate rumination, positive social responses, and meaning of life on the self-disclosure and PTG of Korean adults . These a*Power 3.1.9 indicated that a minimum sample size of 307 was required to reach a statistical conclusion based on the number of predictors, a significance level of 0.001, power of 0.95, and effect size of 0.10. Thus, we planned to collect about 320 samples.Participants were 318 Korean male and female adults aged 20 years or older who had experienced trauma. They were selected by convenience sampling. GAmong the participants were 210 women (66%) and 108 men (34%). The participant groups comprised 30 people (9.4%) in their 20s, 45 (14.2%) in their 30s, 164 (51.6%) in their 40s, 63 (19.8%) in their 50s, and 16 (5.0%) in their 60s or older. Regarding marital status, 63 (19.8%) were unmarried, 245 (77.0%) married, 8 (2.5%) divorced, 1 (0.3%) separated, and 1 (0.3%) answered otherwise. The most shocking traumatic events that participants reported were the death of a loved one (19.5%), followed by betrayal of a loved one (14.2%), fatal disease of a loved one (9.7%), accidents and injuries (9.1%), interpersonal breakdown (8.5%), and their own serious diseases (7.5%). Further, 236 participants (74.2%) reported experiencing negative emotions such as anxiety, fear, and depression after such traumatic events.Participants’ self-disclosure of stress events or negative emotional experiences was measured using the self-disclosure Scale developed by not at all) to 7 . The internal consistency (Cronbach’s α) was 0.94 in this study.Participants’ deliberate rumination related to the traumatic experience was measured with the Korean version of the Event-Related Rumination Inventory, which was developed by not at all) to 7 , and the internal consistency (Cronbach’s α) of these 18 items was 0.97 in this study.We used the Social Reactions Questionnaire (SRQ) that was developed by absolutely true) to 7 (absolutely untrue). Cronbach’s α for the presence of meaning, search for meaning, and the total MLQ were 0.92, 0.94, and 0.95, respectively.To measure the meaning of life perceived by participants, the Meaning in Life Questionnaire (MLQ) developed by not at all) to 7 . The internal consistency (Cronbach’s α) of the 16 items was 0.95 in this study.To measure positive changes after experiencing traumatic events among Korean adults, this study used no pain) to 7 (very painful).This study measured how severe the traumatic events were to the participants, identified their relationships with the study variables, and then determined whether they should be controlled as covariates. For this purpose, This study was approved by an Institutional Review Board (IRB) before study commencement . Data were collected through an online survey with a questionnaire and informed consent was posted on an internet portal site, Google. This survey was promoted on social networking services, such as NAVER BAND and KakaoStory. We gave the participants disclosed research information to facilitate their understanding of this study and to encourage their participation before conducting survey. Participants were informed that they could withdraw at any time while responding to the survey. Each participants spent 20 min, on average, completing the questionnaire.IBM SPSS Statistics for Windows 26.0 and PROCESS Macro 3.5 were used for all the statistical analyses. They checked not only the mean and standard deviation, but also the skewness and kurtosis of the data for parametric statistical analyses. None of the skewness absolute values exceeded 1.5, and none of the kurtosis absolute values exceeded 3.5, indicating that the variances of each variable are close to a normal distribution .Pearson-Product Moment correlational analysis was performed with SPSS, and parallel multiple mediating effect was performed with PROCESS Macro 3.5 model 4. Finally, bootstrapping with 5,000 resamples with 95% confidence intervals was used to analyze the significance of the indirect effects in the mediating model and to examine the differences in each of the indirect effects.Statistical multicollinearity problems occur when tolerance is less than 0.2 or 0.1, and variance inflation factors (VIF) are greater than 5 or 10 . Becauser = 0.07, p > 0.05). Additionally, the severity of traumatic events was significantly correlated with self-disclosure, deliberate rumination, and positive social responses, but there was no significant relationship between the severity of trauma events and meaning of life or PTG . These results suggest that the regression analysis with PTG as the criterion variable or outcome variable does not need to be adjusted by the frequency or severity of traumatic events.The correlation analysis revealed that the frequency of traumatic events experienced by the study participants was positively correlated with self-disclosure, but not significantly to PTG , self-disclosure was also positively correlated with deliberate rumination , positive social responses , and meaning of life . In addition, deliberate rumination , positive social responses , and meaning of life,  were positively correlated with PTG. Both presence of meaning and search for meaning were positively correlated with self-disclosure and PTG.Although there was a significant positive correlation between self-disclosure and PTG , and deliberate rumination had a positive influence on PTG . In addition, self-disclosure also affected positive social responses positively , and positive social responses influenced PTG positively .This study examined a parallel multiple mediating effect of deliberate rumination and positive social responses on self-disclosure and PTG . The resp < 0.001), the direct effect from self-disclosure to PTG was 0.092 (p = 0.113) and was not significant when deliberate rumination, positive social responses, and meaning of life are used as the mediating variables in this model. In The total effect of self-disclosure on PTG is 0.370 . The patients/participants provided their written informed consent to participate in this study.J-HR designed the study, collected data, and conducted the literature review. K-HS led analyzed and interpreted the data and wrote the final manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.