Ficus carica L.) leaves alleviated allergy and AD symptoms in cultured cells and animals. Therefore, here, we conducted a double-blind, randomized, controlled study in patients with mild AD to evaluate the safety and AD-relieving effects of prolonged consumption of fig leaf tea. Positive effects of fig leaf tea consumption were confirmed in 14 of 15 participants. Eczema Area and Severity Index values were significantly lowered in the fig leaf tea-treated group than in the placebo-treated group. The effect weakened 4 weeks after the end of the intervention, suggesting that continued intake of fig leaf tea was effective. Further assessments confirmed the safety of fig leaf tea consumption and revealed no variations that might pose a health hazard. Therefore, we postulate that fig leaf tea is a natural and safe therapeutic option for AD.Atopic dermatitis (AD) is a chronic, recurrent pruritic skin disease with repeated remissions and exacerbations. Various factors, such as allergies, skin conditions and lifestyle, combine to cause AD, making it difficult to cure completely. Although AD symptoms are suppressed with medications, this is a long-term effort and burden on patients. Thus, safer drugs and alternatives are needed. We previously found that consumption of tea prepared from fig ( Atopic dermatitis (AD) is a chronic, recurrent pruritic skin disease. The number of people with AD in Japan was approximately 510,000 in 2017, with a particularly high incidence in younger age groups. The causes of AD include abnormalities in the skin barrier, immune function, and lifestyle ,4,5. AltThe main symptom of AD is itchy eczema. Epidermal keratinocytes, responsible for the barrier function of the skin, produce the filaggrin protein, and mutations in the filaggrin-encoding gene are a major risk factor for AD . AbnormaFicus carica L.) belongs to the fruit tree family Moraceae, and its fruits are eaten fresh and also processed into other products. Consumption of fig fruit is reported to suppress DSS-induced colitis and relieve constipation [Fig . The inclusion criteria for this study were as follows: (1) age between 20 and 59 years, (2) symptoms of AD in the range of 2–15 on the Eczema Area and Severity Index (EASI) evaluated visually (range 0–72) by a dermatologist, and (3) written informed consent given to participate in the study. The exclusion criteria were as follows: (1) history of serious illness such as diabetes, renal, hepatic, or gastrointestinal disease, (2) abnormal laboratory values for hepatic and renal functions, (3) history of gastrointestinal tract surgery, (4) currently undergoing any treatment, (5) use of oral medications or topical steroids for AD, (6) food and drug allergies, (7) anemia symptoms, (8) excessive exercise and weight loss, (9) consumption of dietary supplements, quasi-drugs, or medications for AD or allergic symptoms, (10) excessive alcohol consumption, (11) pregnancy or planned pregnancy during the study period, (12) participating in other clinical trials, or (13) other individuals deemed ineligible by the investigators.The study was conducted in accordance with the ethical principles based on the Declaration of Helsinki (revised in 2013) and the main purpose of the “Ethical Guidelines for Medical Research Involving Human Subjects”  after approval by the Ethical Review Committee of Miura Clinic, Medical Corporation Kanonkai . The doctor explained the purpose, methods, and expected results of the study to the participants and obtained their written informed consent. The study protocol was registered with the University hospital Medical Information Network .This was a double-blind, parallel two-arm study conducted from March to July 2020. The number of participants was calculated with an estimated effect size of 3.3, which corresponds to 60% of the EASI criterion of 5.5 at the time of selection, and a standard deviation of 3.5, because there was no precedent for a study of mild AD symptoms. The number of participants required was estimated to be 18 per group but was set at 15 per group considering the feasibility of the study. A staff member not directly involved in the study randomly assigned the participants to two study groups, namely, the fig leaf tea and placebo (colored water) intake groups, to prevent bias. The allocation method used was stratified randomization with an allocation ratio of 1:1. Assignment factors were gender, age, and EASI value. All but the person in charge of allocation were blinded to the allocation list until the data were collected and made public. However, in case of serious adverse events, necessary information was made available for disclosure. The study period was 12 weeks, with an 8-week intervention period and a 4-week non-intervention observation period. During the intervention period, the participants were asked to ingest 500 mL of either fig leaf tea or a placebo daily. The dose of fig leaf tea was set at 0.6° Bx, 500 mL/day, as this dose could be taken continuously without any discomfort. The intervention period was set at 8 weeks, the maximum period of time that could be supplied drinks at the set concentrations and volume. The participants visited the clinic before intervention (week 0), at weeks 4 and 8, and during the non-intervention observation period (week 12) and examined .sensu Condit) a fig cultivar that does not contain furanocoumarin [Fig leaf tea was prepared from the leaves of ‘Griśe de Tarascon’ , alanine aminotransferase (ALT), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), gamma-GTP, total bilirubin, total protein, albumin, creatinine (Cre), amylase, total cholesterol , low-density lipoprotein cholesterol (LDL-Cho), triglycerides (TG), glucose, Na, K, Cl, Ca, Mg and Fe) and urine analysis . Blood and urine samples were collected at the time of selection (–2 weeks) and during the hospital visits at 8 and 12 weeks.m/z, capillary voltage: 4500 V for cations/2800 V for anions, nebulizer gas: N2 (1.6 bar), drying gas: N2 (7.0 L/min at 200 °C), quadrupole ion energy: 5.0 eV, collision energy: 10.0 eV. Mass spectra were analyzed through Compass Data Analysis . Flavonoid standard reagents were purchased as follows: rutin from Fujifilm Wako Pure Chemicals, Q3MG from Merck , ISS from Funakoshi , 8-HC from MedChemExpress .The main components of fig leaf tea are shown in t-test or Mann–Whitney U test was used to compare the fig leaf tea- and placebo-treated groups. Repeated measures ANOVA or Friedman test was used to compare the variation (Δ measurements) at each time point relative to the values before intervention. The significance level was set at p < 0.05.Data are expressed as mean ± standard deviation. The All statistical analyses and sample size estimation were performed using EZR (ver. 2.7.–1), a modified version of R commander designed to add statistical functions frequently used in biostatistics .Subject sampling and study profile for this study are summarized in There was an improvement in the EASI in the fig leaf tea group compared with that in the placebo group . The chap = 0.028) and 8 (p = 0.012) than before intervention . However, 8 weeks after intervention, there was no significant difference between the two groups (p = 0.900).No significant differences were observed between the two groups using the POEM or VAS questionnaires, which are self-assessments of eczema in AD patients . Before p = 0.045) and 12 (p = 0.028) compared to that before intervention. However, VAS showed no variation in either skin symptoms or interference with QOL between the two groups during the intervention period.POEM in the placebo group decreased significantly at weeks 8 . However, no changes in TARC levels were observed in the fig leaf tea group before and during intervention (p = 0.058).The TARC levels were markedly higher in one patient in the placebo group , but the other items did not show any significant changes, and thus data were included in the analysis. No significant differences were observed between the two groups in terms of TARC levels. In the placebo group, a significant increase in TARC levels was observed at week 4 compared to that before intervention . There was a significant decrease in LDH levels in the fig leaf tea group (−10.4 ± 16.6 U/L) compared to those in the placebo group (4.3 ± 19.9 U/L) at week 8 (p = 0.037). In addition, ALP levels were significantly lower in the fig leaf tea group at week 8 compared to thosebefore intervention (p = 0.015). For chloride (Cl), the measured value at week 8 was significantly higher in the fig leaf tea group (104.87 ± 1.13 mEq/L) than in the placebo group,(103.27 ± 1.79 mEq/L)  to standardize clinical trial outcomes and is determined by a dermatologist’s visual assessment of AD symptoms in patients. We found that ingestion of fig leaf tea significantly reduced EASI values, indicating that fig leaf tea alleviates AD symptoms. As the effect of fig leaf tea was observed from the 4th week after intake, it was proven that the effect could be obtained if the intake was continued for at least one month. Moreover, EASI values increased 4 weeks after the end of fig leaf tea ingestion. Thus, the effects persisted for less than a month, and prolonged intake was recommended. Symptoms worsened during the intake period in seven participants in the placebo group, but only one participant in the fig leaf tea group. The study only required the consumption of 500 mL/day of the provided sample and did not restrict lifestyle practices . Nevertheless, the fact that EASI was reduced in most of the subjects in the fig leaf tea group indicated that the improvement was little influenced by diet and lifestyle.Subjective symptoms were assessed using the POEM and VAS questionnaires. The POEM questionnaires focused on the evaluation of the patient’s own eczema, whereas the VAS questionnaires evaluated itching and decreased quality of life. In POEM responses, both groups reported a decrease in values and no significant difference was identified, but the placebo group reported a larger decrease (maximum decrease of 4.9). In POEM, a total variation of 3.4 or greater is considered clinically significant . Thus, pBlood tests were conducted to compare blood levels of TARC, Th1/Th2 ratios, and total IgE, which are involved in immunity. TARC is a ligand for the chemokine receptor CCR4, which binds to CCR4-expressing Th2 cells, causing Th2 cells to migrate to the inflammatory site and worsen AD symptoms . The amoPyrus ussuriensis Maxim, which mainly comprises rutin, has been reported to significantly suppress skin scratching and transepidermal water loss (TEWL) in mice [The components of fig leaf tea that contribute to mitigating the effects of AD have not yet been identified. Fig leaf tea contains several flavonoids, such as rutin, Q3MG, ISS, and 8-HC. In AD mouse models, it is reported that rutin suppresses the induction of inflammatory cytokines such as IL-4 and IL-5, which promote allergic reactions, and thus reduce ear thickening and blood IgE levels . In addi in mice . A couma in mice . Fig leaTh1/Th2 ratios were lower in the placebo group than in the fig leaf tea group before intervention. Because AD is an allergic disease that develops when the Th1/Th2 ratio decreases (Th2 cell type predominance), there was concern that the placebo group with a low ratio would be the group most likely to experience worsened symptoms. However, a comparison of the Th1/Th2 ratio in the two groups showed a decreasing trend in Th1 cell numbers in the placebo group, but no difference in Th2 cell numbers. Therefore, the decrease in Th1/Th2 ratio values in the placebo group was attributed to a decrease in Th1 cell numbers. Therefore, we determined that there was no difference in the predisposition to AD in the two groups. Total IgE levels increased in the placebo group, while they decreased in the fig leaf tea group throughout the study period. As total IgE levels increase or decrease depending on the predisposition of the individual to allergies and the external environment in addition to AD, it is difficult to discuss the results of this study in isolation; however, the inhibitory effect of fig leaf tea on the increase in IgE antibody levels may have likely contributed to the AD alleviation effect.Laboratory tests performed as part of the safety assessments showed significant reductions in AST, LDH, and ALP levels upon fig leaf tea consumption. These enzymes are considered indicators of liver function, because they are abundantly expressed in hepatocytes and are released into the blood when hepatocytes are damaged. Although fig leaf extract has been reported to reduce blood levels of these enzymes in animal studies ,49,50,51We also observed increased blood Cl in the fig leaf tea group. Because increased Cl is associated with worsened renal function; there was a concern about renal function impairment due to fig leaf tea ingestion. However, no significant differences in blood creatinine (Cre) levels, a highly reliable indicator of renal function, were observed during the study period in both groups . TherefoThis study is valuable in that it is was a randomized, double-blind, subject-controlled trial that established that fig leaf tea consumption is beneficial in improving the dermatitis symptoms of AD. This study is limited in that the sample size was small. The sample size estimate based on the value of change at week 8, when a significant difference was confirmed , showed that 21 participants per group was an appropriate sample size. This estimate focused only on the EASI value. In complex diseases such as AD, it is necessary to evaluate not only EASI values but also TARC values, TEWL, subjective symptoms, and various other disease signs to determine efficacy. Therefore, more trials with a larger number of subjects are needed to obtain statistically and clinically meaningful results on the effects of fig leaf tea in the future.We evaluated the safety and AD-relieving effects of prolonged fig leaf tea consumption. Prolonged consumption of fig leaf tea was shown to significantly reduce EASI values. Fig leaf tea use was largely found to be safe. Therefore, prolonged consumption of fig leaf tea may be a safe and effective alternative to current therapies for AD. The findings of this study must be further validated in a larger sample size.


Aloe vera juices fermented by probiotic Enterococcus faecium and Lactococcus lactis. Aloe vera juices were digested using the standardized static INFOGEST protocol. During digestion, phenolic compounds and antioxidant activity  were accessed. The digestion process was seen to significantly increase the total phenolic content of the fermented Aloe vera juices. The fermentation of Aloe vera increased the bioaccessibility of juice biocompounds, particularly for kaempferol, ellagic acid, resveratrol, hesperidin, ferulic acid, and aloin. The phenolics released during digestion were able to reduce the oxidative radicals assessed by ABTS and FRAP tests, increasing the antioxidant action in the intestine, where they are absorbed. The fermentation of Aloe vera by probiotics is an excellent process to increase the bioavailability of beverages, resulting in natural added-value functional products.Plant-based beverages are enriched by the fermentation process. However, their biocompounds are transformed during gastrointestinal digestion, improving their bioaccessibility, which is of primary importance when considering the associated health benefits. This study aimed to evaluate the effect of in vitro gastrointestinal digestion on phenolic compound bioaccessibility and antioxidant activity of novel  The food industry has been seeking to innovate its products in order to provide foods that are not only nutritious but also have added functionality, leading to improved human health and well-being and/or reduced risk of disease ,2. In thThe fermentation process itself increases the release of the plant’s bioactive compounds, increases bioaccessibility and bioavailability, and consequently improves the nutritional and functional properties of the food, with beneficial effects on health. Beverages fermented with probiotic bacteria may act as vehicles for the delivery of probiotic species into the gut, having a fundamental role in microbiota modulation ,4. Even Lactic acid bacteria (LAB) can (bio)transform polyphenols during the fermentation process into simple phenolic compounds with improved bioactivity. These compounds are bio-transformed again during gastrointestinal digestion, and their content and bioactivity  can be changed . TherefoLactobacillus, Bifidobacterium, Lactococcus, and Enterococcus [Lactococcus lactis and Enterococcus faecium have been referred to as some of the strains most widely used in the food industry [E. faecium has been isolated from human milk [E. faecium has been used in the production of different fermented food products, such as artisanal cheese, sausages, and olives, mainly because it plays an important role in the development of organoleptic characteristics due to proteolytic and lipolytic activity [L. lactis strains have been recognized as probiotics [The most frequently found LAB species in commercialized probiotic products include rococcus . Lactocoindustry . E. faecman milk ,11. E. factivity ,13. On tobiotics . They haobiotics ,15. HaviAloe vera [Aloe vera contains polysaccharides, proteins and amino acids, minerals, phenolics, anthraquinones, and enzymes in its composition [Aloe vera has been largely used for wounds and inflammation and has been used in the treatment and prevention of several diseases, namely cancer, ulcers, diabetes, microbial and skin diseases, and others [Aloe vera may result in very interesting products for consumers and ultimately for the food industry market.A wide variety of research on fermented beverage production may be found in the literature, including fruits such as oranges, apples, lemons, passion fruits, pomegranates, carrots, etc. , and morloe vera ,18. Aloeposition . Due to d others . TherefoAloe vera juice inoculated with E. faecium and L. lactis during in vitro digestion. Therefore, this study aims to explore the behavior of bioactive compounds, antioxidant activity, and bioaccessibility of Aloe vera juice fermented with LAB during simulated in vitro gastrointestinal digestion. It may provide useful information to promote the development of functional beverages with added value, promoting the use of natural resources that improve human health.To our knowledge, there is no report on the release efficiency and bioavailability of phytochemicals from the fermentation of p-coumaric acid, ellagic acid, naringenin, hesperidin, resveratrol, ferulic acid, quercetin, 3,4-dihydroxybenzoic, taxifolin, aloin, kaempferol, ferric chloride hexahydrate, sodium acetate trihydrate, glacial acetic acid, hydrochloric acid, and sodium acetate trihydrate were purchased from Sigma-Aldrich Ltd. . All chemicals used were of analytical grade, and the water was ultra-pure Milli-Q water.Pepsin, pancreatin, Folin–Ciocâlteu phenol reagent, 2,2-diphenyl-1-picrylhydrazyl (DPPH), 2,2′–azinobis-(3-ethylbenzothiazoline-6-sulfonate) (ABTS), 2,4,6-tris(2-pyridyl)-S-triazine (TPTZ), gallic acid, 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (Trolox), vanillic acid, chlorogenic acid, catechin, epicatechin, Aloe barbadensis Miller (Aloe vera) leaves (four years old) were purchased from Ulíavera , and harvested from Ibiza plantations. Leaves were washed and disinfected (2% sodium hypochlorite solution) and rinsed with distilled water. The spikes and the inferior and superior parts of each leaf were removed before longitudinally slicing of the leaf to separate the epidermis from the parenchyma (gel). The gel was pressed using a laboratory manual roll processor, lyophilized, and stored at −20 °C until further use.Fresh whole Aloe vera (2 g) was subject to an enzymatic-assisted solid–liquid extraction with cellulase (1.5 mg/mL) in a water volume of 60 mL. The reaction occurred for 1 h at 45 °C in a 200 mL cylindrical reactor, duly protected from light, in a thermostatic water bath with agitation (150 rpm). The supernatants were then filtered through Whatman No. 4 filter paper. Finally, the Aloe vera samples were sterilized with a 0.22 µm membrane. Juice conditions applied were previously studied in another work [The lyophilized gel of her work .Aloe vera juice fermentation, two LABs were used: Enterococcus faecium (isolated from human breast milk) and Lactococcus lactis BS-10 . Fermentation was carried out using the same conditions as reported in previous work [Aloe vera was inoculated with 1400 µL of each LAB (1 × 106 CFU/mL) for 48 h at 37 °C. After fermentation, samples were collected and stored at −20 °C until in vitro digestion analysis. The experiments were performed in triplicate.For ous work . BrieflyAloe vera juices (non-fermented and fermented ones), with small modifications [The harmonized INFOGEST in vitro digestion model (static method) mimicking the mouth, stomach, and small intestine conditions  was applications ,23. Tabl2 (H2O)2). Samples were returned to the shaking water bath and incubated at 37 °C for 2 min. Note that α-amylase was not used since the samples did not contain starch.In the oral phase, 5 mL of samples (previously kept in a water bath for the necessary time until reaching 37 °C under constant agitation (120 rpm)) were exposed to simulated mouth conditions (SSF solution and CaCl2 (H2O)2 (0.15 mmol/L) were added. The pH was adjusted to 3  and the volume was completed with Milli-Q water. Samples were incubated at 37 °C for 2 h. After the gastric phase, a sample was taken and cooled in ice to stop the enzymatic reaction.For the stomach simulation, porcine pepsin solution , SGF solution, and CaCl2 (H2O)2 (0.6 mmol/L), pancreatin , and bile solutions  were added to the gastric phase. The pH was adjusted to 7 , and the final volume was adjusted with Milli-Q water. The mixture was incubated for 2 h at 37 °C. At the end of the intestinal phase, the reaction was stopped by adding 1 mmol/L of an enzyme inhibitor (Pefabloc SC). Samples were digested at least in triplicate.Finally, for the intestinal phase simulation, SIF solution, CaClAloe vera juices and the gastrointestinal digestion system is shown in A representative diagram of the preparation of 2CO3 (75 g/L), 15 µL of Folin–Ciocâlteu reagent, and 200 µL of Milli-Q water and incubated at 60 °C for 5 min. The absorbance was measured at 700 nm using a spectrophotometer . A standard curve was performed using gallic acid , and the results were expressed in mg of gallic acid equivalents (GAE) per liter of Aloe vera juice (mg/L).The total phenolic content (TPC) was determined using a 96-well microplate colorimetric assay by the Folin–Ciocâlteu method adapted from Ferreira-Santos et al. . Brieflyp-coumaric acid, ellagic acid, naringenin, hesperidin, resveratrol, ferulic acid, quercetin, 3,4-dihydroxybenzoic, taxifolin, aloin, and kaempferol (R2 > 0.99)). Results were expressed in milligrams per liter (mg/L).Individual phenolic compounds were identified and quantified by ultra-performance liquid chromatography (UPLC) as defined and validated by Ferreira-Santos et al. . A Shima3, and acetate buffer). The resultant reaction mixture was incubated at 37 °C for 15 min. The absorbance was measured at 593 nm in a spectrophotometric microplate reader , against water as a blank. A standard curve was prepared using an aqueous solution of FeSO4 7H2O (200 to 1000 µM). FRAP values were expressed as micromoles of ferrous equivalent per liter of Aloe vera juice (µmol Fe (II)/L).A FRAP test was performed according to the method described by Benzie and Strain , with a •+ cation radical solution was prepared using ABTS solution (7 mM) and potassium persulfate (2.45 mM) in a ratio of 1:1, at 4 °C for 12–16 h, in the dark. A stock solution was then diluted with 80% ethanol solution, up to an absorbance of 0.700 ± 0.02, determined at 734 nm. Briefly, 10 μL of samples were mixed with 200 μL of ABTS•+ solution in a 96-well microplate. The plate was placed at room temperature for 30 min in the dark, and the absorbance was read at 734 nm. An SA standard curve was performed using a Trolox solution in ethanol (50 to 500 µM). ABTS values were expressed as micromoles of 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (Trolox) equivalent (TE) per liter of Aloe vera juice (µmol TE/L).The radical cation decolorization (ABTS) assay was performed according to the method described by Ferreira-Santos et al. , with miAloe vera juice (µmol TE/L).The DPPH radical scavenging activity was determined using the method described by Ferreira-Santos et al. , with miAloe vera juices  were centrifuged at 18,000× g for 30 min, and two distinct phases were obtained: an opaque sediment phase at the bottom and a clear micelle phase at the top (supernatant). It was assumed that the model bioactive compounds were in the clear micelle phase , which were available for absorption and metabolization. Then, the micelle phase was used to quantify the content of bioactive compounds released after in vitro digestion. Bioaccessibility was determined using the following equation:Micelle phase is the concentration of bioactive compounds in the micelle phase, and the CIntestinal phase is the concentration of bioactive compounds after in vitro digestion.Bioaccessibility was determined using the method described by Simões et al. . Brieflyp < 0.05 and p < 0.001, using the statistical software GraphPad Version 6 .Analyses were carried out in three independent replications of each sample. Results are represented as mean ± standard deviation (SD). Data were subjected to two-way ANOVA; pair-comparison of treatment means was obtained using the Bonferroni procedure at Aloe vera juices was investigated during gastrointestinal digestion. In general, the behavior of phenolic compounds of fermented Aloe vera juices with E. faecium and L. lactis was more affected (positively) during the in vitro digestion than was the behavior of the non-fermented juice , Aloe vera fermented with E. faecium (AvF), and Aloe vera juice fermented with L. lactis (AvL) was found to be significantly released during simulated in vitro digestion.The Folin–Ciocâlteu method was used to determine the TPC, as it is commonly applied in food matrices and natural extracts ,28. The AvF, and 427 ± 17 mg GAE/L for AvL samples, respectively).Before digestion, in the initial phase, the TPC were not significantly different between fermented and non-fermented juice , althougAloe vera juice does not contain starch in its composition and therefore α-amylase was not mixed in the SSF.As expected, no significant differences between the initial and the oral phase were observed for all samples, since Av samples increased by 17% (up to 244 ± 4 mg GAE/L). Notably, for the fermented juices, TPC increased even more. For AvF, TPC increased up to 696 ± 16 mg GAE/L, and for AvL up to 695 ± 4 mg GAE/L, which was reflected in an increase of 90% and 62%, respectively, as compared to the amount determined in the initial samples. The low pH and the enzymatic action in the gastric digestion phase led to the release of some phenolic compounds bound with the carbohydrates, which increased the bioaccessibility of these bioactive compounds. The fermentation of the juice probably favored the positive results achieved in this study, since phenolic compounds increased in the gastric phase in comparison with other works where certain phenolic substances were lost in the stomach [In the gastric phase, the TPC for  stomach .Av samples (1115 ± 23 mg GAE/L); the AvF fermented samples obtained an increase up to 12,253 ± 729 mg GAE/L, and the AvL up to 14,220 ± 1402 mg GAE/L, which was about a 95% increase as compared to the respective initial samples. In both the AvF and AvL samples, the amounts of TPC released during simulated intestinal digestion were significantly higher than in the earlier stages of digestion and in the undigested fermented juice .The great release of TPC was, however, determined in the last stage of digestion, at the intestinal phase. In this stage, an increase of 78% of TPC was observed for the non-fermented Aloe vera juice, whose structures are shown in p-coumaric and ferulic acids), flavonols (kaempferol), flavan-3-ols (epicatechin and catechin), stilbene (resveratrol), flavanones (naringenin and hesperidin), flavones (quercetin and taxifolin), and anthracenes .Fourteen individual phenolic compounds were identified in the Av, as shown in Aloe vera, was the third most concentrated in the Av, and decreased about 73% in the intestinal phase (p < 0.05). Naringenin (10.49 ± 0.87 mg/L) began to be degraded or biotransformed after the oral phase.All fourteen phenolic compounds selected for the UHPLC analysis were identified in the Aloe vera juices agrees with the expected theory.Ellagic acid was one of the hydroxybenzoic acids whose amount significantly increased during digestion . The content of flavonoids quercetin and kaempferol also increased significantly during the digestion process. It is important to note that kaempferol is obtained from naringenin by a biosynthetic pathway. The naringenin is converted into dihydrokaempferol, and dihydrokaempferol is converted into kaempferol . Therefop-coumaric acids, were probably degraded or biotransformed during the digestion process, since their concentrations decreased (or were not detected) at the end of the digestion.Resveratrol, naringenin, taxifolin, catechin, and vanillic, as well as 3,4-dihydroxybenzoic, ferulic, and AvF, thirteen phenolic compounds were identified in its initial composition ; however, its amount decreased significantly after the intestinal phase, as observed also for Av. This trend is in line with the results reported by Marchese et al. [For position . Catechie et al. , which rAvF, the ellagic acid was the compound with the third-highest concentration in the initial phase (15.09 ± 0.23 mg/L), almost twice the amount as compared to Av (8.20 ± 1.31 mg/L). Its concentration gradually increased throughout digestion, reaching an amount of 62.00 ± 1.53 mg/L at the intestinal phase, where its absorption begins. This phenolic acid was metabolized with the help of digestive enzymes and pH changes through digestion. As compared to Av, the ellagic acid of AvF juice increased three times more after the digestion process. Resveratrol, kaempferol and taxifolin also significantly increased during the digestion .In the Aloe vera, and one of the most important secondary metabolites of the plant due to its numerous functions as anti-inflammatory, anticancer, antibacterial, laxative, and purgative properties [E. faecium. However, its content decreased in the intestinal phase by up to 71% (p < 0.05). This trend was similar to the digestion of Av (76% of reduction). Aloin, the major anthraquinonic component of operties ,27, incrp-coumaric acids were quantified in small amounts in the initial phase, becoming not detected after the digestion. They showed to be sensitive to the changes in pH, and/or to the presence of salts and enzymes existent in the gastrointestinal system. The content of naringenin and ferulic acid decreased during digestion, and quercetin was totally biotransformed or degraded at the intestinal phase. Other compounds like 3,4-dihydroxybenzoic, vanillic, and AvF increased during digestion up to 24.5%. A total amount of 102 ± 10 mg/L was quantified in the initial phase and 127 ± 4 mg/L in the intestinal phase  , although it decreased by 83% during the stages of digestion.Only twelve phenolic compounds were identified in the is (AvL) . The vanAvL was also able to significantly increase (p < 0.05) the content of aloin in the juice, as for the AvF. Although its content had dropped 19% at the oral phase, afterward it remained constant. At the end of digestion, an amount of 15.59 ± 0.69 g/L was still quantified in the AvL, which was similar to the initial amount present in the Av and the AvF. Nevertheless, for Av and AvF, a high biotransformation or degradation occurred during digestion, decreasing up to 76% of its initial amount. The fermentation process of the AvF. The content of hesperidin, resveratrol, and kaempferol also increased after digestion by 91%, 101%, and 473%, respectively. These phenolics also increased during the digestion of the AvF. This positive behavior was not observed in the digestion of the Av. Therefore, fermentation of Av with the LAB may promote the production of these compounds during digestion. Ellagic acid also increased from 15.39 ± 0.89 to 61.31 ± 3.71, similar as occurred for p < 0.05), and then, at the intestinal phase, was not detected. Apparently, ferulic acid was maintained during the stages of digestion. p-Coumaric and 3,4-dihydroxybenzoic acid was only detected in trace amount. Naringenin and taxifolin were decreasing in each phase of digestion, as shown in Quercetin increased during the gastric phase , followed by ellagic acid (195%), quercetin (160%), and resveratrol (72%). Meanwhile, epicatechin, p-coumaric acid, naringenin, hesperidin, ferulic acid, taxifolin, and aloin were found in the range of 55–3%. Vanillic acid, catechin, and 3,4-dihydroxybenzoic acid are more unstable compounds and therefore were degraded or biotransformed between the oral and the gastric phases of digestion.The bioaccessibility of individual phenolic compounds of AvF, the highest percentage of bioaccessibility was also determined for kaempferol (699%), followed by ellagic acid (411%), resveratrol (252%), taxifolin (137%), hesperidin (112%), and ferulic acid (83%). Epicatechin, p-coumaric acid, naringenin, and aloin were found in the range of 57–29%. It was clearly observed that fermentation enhanced the bioaccessibility of phenolic compounds. The bioaccessibility determined for AvL had a similar trend as for AvF. The highest percentage of bioaccessibility was also determined for kaempferol (575%), followed by ellagic acid (398%), resveratrol (201%), hesperidin (194%), ferulic acid (99%), and aloin (76%), although taxifolin, naringenin, and epicatechin were found in the range of 62–17%. The actions of both human digestive and gut microbial enzymes represent an essential mechanism to metabolize polyphenols from components of the food matrix, which allows for the accessibility of the compounds [p-coumaric acid, quercetin, and 3,4-dihydroxybenzoic acid did not resist the low pH of the gastric phase or any of the above-mentioned hypotheses.Regarding the digestion of ompounds . VanilliAloe vera juices , the determined antioxidant activity was even higher.Three methods  were used to evaluate the antioxidant capacity of the undigested and digested a juices , since eAvF and AvL) along the digestion steps were similar. Interestingly, a significant increase in antioxidant activity was observed for all juices during digestion, except for Av, whose antioxidant activity did not vary significantly during digestion when analyzed by FRAP. The most noticeable changes were observed for AvF.Results obtained by FRAP and ABTS for fermented samples  of Av and of AvL with TPC  was insignificant. Nevertheless, the antioxidant activity of AvF increased after digestion. It is noteworthy that there was an increase in antioxidant activity, which could be associated with a specific phenolic compound such as epicatechin, which was found to be twice as high in the AvF juices as compared to the AvL.For Aloe vera samples there was no correlation among TPC and antioxidant activity using the DPPH method. This analysis suggests that the results of antioxidant activity by DPPH were independent of TPC, since one variable increases as the other decreases. This supports the results on the antioxidant activity obtained by DPPH assay of the three digested Aloe vera samples. The opposite behavior was observed in comparison with FRAP and ABTS, as the activity increased after digestion. This may be related with the differences in the methods applied for measuring antioxidant capacity.The correlation analysis also showed that in the three Polyphenols present in foods or beverages have been described as potential health promoters, although these benefits depend on their bioaccessibility in the gastrointestinal tract. To provide health benefits, compounds of interest must be released from the food matrix extraction and become bioaccessible in the gastrointestinal tract. These compounds must then be metabolized to reach the target tissue for action . HoweverAloe vera beverage.In this sense, results gathered in this work suggest a transformation of high-molecular compounds or bound compounds into free compounds with lower molecular weight. These resulting polyphenol derivatives release reactive functional groups into a complex with the Folin–Ciocâlteu reagent, giving a visible increase in the TPC value. On the other hand, it has been reported that many phenolic compounds can be metabolized during digestion and absorbed in the intestine. This may be due to the fact that many polyphenols may not be free in the raw material and, after chemical extraction and further digestion, can be released into the small intestine, such as covalently bound or occluded . MoreoveAloe vera juice takes place during or after the gastric phase. The differences in the amounts released of these active ingredients are related to differences in the compositions and bioactive properties among the different fruit/vegetable products [Aloe vera juice, several changes could have occurred in the phenolic compounds such as (i) modification of the chemical structure, (ii) increase or decrease of solubility, or (iii) interaction with other compounds, which influenced their bioaccessibility [Several studies showed that the release of phenolics begins in the oral or gastric phase ,43,44. Tproducts . In addisibility .However, these results were consistent with those reported by Qin et al.  since thPhenolics are considered the most important bioactive compounds, and their presence in foods is beneficial for consumers due to their health properties such as antioxidant, antimutagenic, and/or anticarcinogenic activities, anti-inflammatory action, and others . In factAloe vera juice, the content of identified/quantified phenolic compounds decreased  in a synthetic substrate (MRS) using an LC–MS/MS apparatus [No studies were found concerning the biotransformation of phenolic compounds from entation . These apparatus .Av. The behavior of ellagic acid during digestion was similar for AvF and AvL. The increase of this acid during fermentation may be related to the pH, with the presence of pancreatic enzymes, and with bile salts, factors that could promote the transformation of α- and β-punicalagins into ellagic acid. These results were consistent with results reported by Valero-Cases et al. [As reported before, fermentation with LAB increased the ellagic acid content in s et al.  for ferms et al. .Ellagic acid and its derivatives are generated by hydrolysis of ellagitannins with acids or bases, when ester bonds are hydrolyzed, and the hexahydroxydiphenoyl group spontaneously rearranges into ellagic acid. Numerous derivatives of ellagic acid exist in plants, formed through methylation, glycosylation, and methoxylation of its hydroxyl groups. Furthermore, during food processing, ellagitannins are changed to free ellagic acid and ellagic acid derivatives . This phBifidobacterium.Epicatechin decreased during the stages of digestion. This fact may suggest that the bacterial metabolism of epicatechin occurs during all steps of digestion, predominantly during the intestinal phase. The results agree with the work of Valero-Cases et al. , who obsAloe vera samples. The results obtained for Av and AvF, where aloin decreased up to 76% after digestion, agree with those reported by Shim and Kwon [Aloe-emodin, and aloenin A. Aloenin A and Aloe-emodin were stable and entirely recovered during simulated digestion, but 50% of aloin was lost. On the other hand, for AvL, aloin decreased in the oral phase but then its amount was stable. The differences in the reduction of aloin in the Aloe vera juice when fermented either by E. faecium or L. lactis may be related to the metabolism of each bacterium. However, the reduction of aloin during the stages of digestion may be related to aloin-proteins binding and/or to its lower stability as compared to other bioactive components of Aloe vera [Aloe-emodin, which is responsible for purgative activity and exhibits anti-cancer properties, its lower biodegradation in the upper gastrointestinal passage might be quite relevant [Aloin decreased in the three and Kwon . They usloe vera . Since arelevant .The efficacy of functional foods in providing therapeutic or physiological benefits depends largely on the maintenance of their bioavailability, defined as the fraction of an ingested compound that is absorbed and available for physiological functions, i.e., that reaches the systemic circulation in an active form. Therefore, to exert their bioactivity, the active molecules have first to be bioaccessible, i.e., released from the food matrix and solubilized ,60.Aloe vera, there is limited information regarding the bioavailability and intestinal transport mechanism of these compounds. However, some studies simulate the digestion along the gastrointestinal tract, allowing the evaluation of their bioactivity. Existing static in vitro models simulate the digestion environment from the mouth to the intestinal phase. This model allows for the evaluation of changes in the bioaccessibility of phenolic compounds [Contrary to numerous studies on medicinal properties of phenolic compounds in ompounds .Aloe vera showed that the bioaccessibility of phenolic compounds increased considerably, mainly in the samples that were fermented with E. faecium and L. lactis. Ellagic acid, hesperidin, resveratrol, ferulic acid, aloin, and kaempferol are compounds that were mainly favored with respect to bioaccessibility, which can be attributed mainly to the fermentation process of the samples. These results agree with the study by Campos-Vega et al. [Results obtained in this work for a et al. , which iE. faecium and L. lactis could produce health benefits due to the fact that fermentation enhances the bioavailability of Aloe vera juices.The relationship observed in fermented juices between the phenolic compounds and microbial presence suggests the possible prebiotic effect of phenolic compounds on the LAB. The metabolites excreted by the Antioxidant compounds released from the food matrix, formed or transformed during the biological processes, or its synergistic activity, may have distinct behavior against different antioxidant assays, namely FRAP, ABTS, and DPPH.Aloe vera juices, as observed in the intestinal phase with the methods used in this work. The greatest antioxidant activity determined by FRAP and ABTS in the intestinal phase was observed for AvF, which in turn improved the bioaccessibility of compounds. The increase in antioxidant activity after the intestinal phase could be explained by the additional time of reaction of the gastrointestinal simulation method (plus 2 h 45 min) and/or the effect of intestinal digestive enzymes (pancreatin and protease activity) on the complex food matrix, facilitating the release of compounds with antioxidant activity bound to the matrix [The results obtained by ABTS are related to those obtained by FRAP and TPC analyses, since the intestinal phase is where there is the greater antioxidant activity after ingestion of e matrix . In addie matrix .Some authors have suggested that the probiotic fermentation process facilitates cleavage/dissociation of the bonds between phenolic compounds and other constituents, leading to the release of phenolic compounds-monomers, which increases antioxidant capacity ,64.The behavior for DPPH showed results contrary to those obtained by FRAP and ABTS, since in the oral and gastric phases, antioxidant activity increases, while in the intestinal phase, antioxidant activity decreases. This may be due to several factors, such as the molecular changes of some phenolics ,65, the Oxalis pes-caprae extract was opposite the phenolic content [However, this contradiction among phenolic content and antioxidant activity was also found by other authors in other plant materials that were subjected to in vitro digestion. It has been reported in some works, such as a study by Ma et al. , that th content . Further•+ radical [The difference among the antioxidant capacity behaviors of the studied samples could be related to differences in the mechanisms accessed by these techniques. In the FRAP assay, antioxidant capacity is based on the antioxidant ability to reduce the ion iron III to iron II . The ABT radical . The DPP radical . Therefo radical ,49,69.Aloe vera demonstrated that the phenolics released during gastrointestinal digestion were able to reduce free radicals either by hydrogen donation (assessed by the ABTS test), or by electron donation (assessed by the FRAP test)  generation. The results obtained herein for AP test) A,B, possAloe vera with E. faecium and L. lactis enhances the bioactivity of the Aloe vera active compounds, since the total phenolics increased more in the fermented Aloe vera than in the non-fermented juice during gastrointestinal digestion. The individual phenolic compounds, mainly ellagic acid, resveratrol, hesperidin, and kaempferol, increased after in vitro digestion and were more bioaccessible in the fermented Aloe vera juice. The antioxidant activities of the digested Aloe vera samples changed almost as a function of their TPC, and there were strong correlations among them (TPC and FRAP/ABTS) in Aloe vera fermented with L. lactis. This is reflected in the bioaccessibility, suggesting that Aloe vera fermented with LAB enhances health benefits, thereby justifying their valorization.Overall, the present study demonstrated that fermentation of Aloe vera phenolic compounds by the gut microbiota and their impact and absorption by intestinal cells.Further studies will, however, be necessary to understand the metabolization of the Aloe vera juice with E. faecium and L. lactis promoted the bioavailability of the compounds, transforming the non-fermented juice into a healthier beverage, with added nutrition and functionality.In conclusion, the fermentation of


Esophageal cancer is a common and aggressive cancer, with a five-year survival rate of approximately 20%. Therefore, identifying safe and effective medications that can reduce the risk of esophageal cancer is of great importance. Objective: To examine the association between H1-antihistamines (AHs) use and the incidence of esophageal squamous cell carcinoma (ESCC) in a head-to-head propensity score matching (PSM) comparative study. Design: Retrospective cohort study. Setting: Nationwide population-based study in Taiwan. Participants: 1289,526 adults from the National Health Insurance Research Database from 2008 to 2018. Exposures: AH use. Main Outcomes and Measures: Incidence rates (IRs), incidence rate ratios (IRRs), and adjusted hazard ratios (aHRs) of ESCC in AH users compared with nonusers. Results: AH users had a significantly higher IR of ESCC than nonusers . The IRR (95% CI) for ESCC was 1.18 (1.08–1.28) in AH users compared with nonusers. After adjustment for age, sex, income levels, urbanization, cigarettes smoking, alcoholic related diseases, comorbidities, medication use, and Charlson Comorbidity Index scores, the aHR (95% CI) for ESCC was 1.22 (1.12–1.33) in AH users compared with nonusers. A dose–response relationship was also observed, with aHRs for AH use at 28–182, 183–488, 489–1043, and >1043 cumulative defined daily doses (cDDDs) of 1.12, 1.20, 1.25, and 1.37, respectively, compared with <28 cDDDs. Conclusions and Relevance: Our study found a significant association between AH use and the increased risk of ESCC, with a dose–response relationship. This study suggests that AH use may increase the risk of ESCC, especially at high doses, and highlights the importance of caution when prescribing AHs. Esophageal cancer is a major global health concern, ranking as the eighth most common cancer and the sixth most common cause of death worldwide ,2,3. SquAntihistamines targeting the histamine receptor H1 are promising candidates for repurposing as cancer therapies due to their safety, minimal side effects, and widespread tolerance among patients . There iTo better understand the association between AH use and the risk of ESCC, as well as the potential dose–response relationship, we conducted a long-term follow-up head-to-head propensity score matching (PSM) comparative national cohort study. This is the first clinical study of its kind to investigate the relationship between AH use and ESCC risk, and it provides valuable information that can be used to guide future research on ESCC risk.We conducted a population-based cohort study using data from the Taiwan National Health Insurance (NHI) Research Database (NHIRD) from 2008 to 2020. The NHIRD contains comprehensive medical claims data for all NHI beneficiaries, including diagnoses, procedures, drug prescriptions, demographics, and enrollment profiles, all of which are encrypted using unique patient identifiers ,31,32,33Our study included patients aged 40 or older who were enrolled in the NHIRD and excluded patients with missing age data. AH use was defined as the use of at least 28 cumulative defined daily doses (cDDDs) of an AH. The index date was the date when a patient began using at least 28 cDDDs of an AH. The observation period for each patient began on the index date and continued until the patient was diagnosed with ESCC, died, or the end of the study period (31 December 2021), whichever occurred first. Patients who were prescribed at least 28 cDDDs of an AH during the follow-up period formed the case group (AH users), while those who were prescribed less than 28 cDDDs of an AH during the follow-up period formed the control group (AH nonusers). The follow-up duration was defined as one year after the initial AH use or cohort entry date. This study is the first to investigate the association between AH use and ESCC risk, and aims to provide valuable information for understanding the risk of ESCC in the general population.We excluded patients from our cohort who met any of the following criteria: (1) they were diagnosed with ESCC within 1 year of the index date, (2) they had missing data on their sex or age or were younger than 40 years old, (3) they had a follow-up duration of less than 1 year, or (4) they were diagnosed with any other type of cancer within 1 year before the cohort entry date (to prevent the influence of ESCC-related metastases). This was carried out to ensure that our results accurately reflected the association between AH use and ESCC risk.The study protocols were reviewed and approved by the Institutional Review Board of Tzu-Chi Medical Foundation (IRB number: IRB109-015-B).To control for potential confounding factors, we included various covariates in our analysis. The study participants were divided into four age groups based on their age at the index date: 40–50, 51–60, 61–70, and 71 or older. The index date for AH users was defined as the date when they started using AHs at a dose of at least 28 cDDDs. For matched AH nonusers, we used variables collected at the index date. To prevent repeated adjustment in multivariate analysis, we excluded repeat comorbidities from the CCI calculations. We identified comorbidity onset within one year before the index date using International Classification of Diseases codes from either the main inpatient diagnosis or at least two outpatient visits within one year. These codes were from either the Ninth Revision, Clinical Modification (ICD-9-CM) or the Tenth Revision, Clinical Modification (ICD-10-CM).AH use was defined as the use of at least 28 cDDDs of an AH ,15. AHs To further investigate the potential relationship between AH use and ESCC risk, we conducted a sensitivity analysis to examine the intensity of AH use. We calculated the average daily dose of AHs by dividing the DDD by the total number of prescription days. AH use intensity was then divided into two categories: average DDDs of >1 or ≤1. This allowed us to evaluate the frequency of daily AH use and its potential effect on ESCC risk.We used a time-varying Cox proportional hazards model to analyze the relationship between AH use and the onset of ESCC after controlling for potential confounders. To minimize the impact of confounding factors when comparing the risk of ESCC in AH users and nonusers, we matched the patients based on their propensity scores. The variables used for matching included age, sex, income level, urbanization, cigarette smoking, alcoholic related diseases, and comorbidities such as diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, gastroesophageal reflux disease, Barrett’s esophagus, obesity, achalasia, Tylosis (Howel–Evans syndrome), Plummer–Vinson syndrome, and medication use . Comorbidities were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision, Clinical Modification codes from one inpatient visit or two or more outpatient visits within 1 year for the main diagnosis. We excluded repeat comorbidities from the CCI calculations to prevent repetitive adjustment in the multivariate analysis.Here, the continuous variables are presented as means with standard deviations or medians with first and third quartiles, as appropriate. To minimize differences between the patient groups, we used a matching technique called greedy method: PSM with a caliper width of 0.2 to match the patients at a ratio of 1:1 . This meThe primary outcome of this study was the occurrence of ESCC, which was confirmed through the certification record in the Registry for Catastrophic Illness Patients .To further explore the relationship between AH use and ESCC risk, we conducted sensitivity analyses. We examined the risk of ESCC in patients with different levels of AH use intensity by dividing the patients into two subgroups based on the average daily DDD: >1 or ≤1. This allowed us to evaluate the effect of the frequency of daily AH use on ESCC risk. We also conducted stratified analyses by age, sex, cigarette smoking, alcohol-related diseases, and medication use  to assess the potential effect modification of these factors on the association between AH use and ESCC risk.We collected information on patient characteristics including age, sex, comorbidities, and AH dosage. Age was divided into 10-year intervals and the baseline characteristics of AH users and nonusers were compared using chi-squared test for categorical variables, t-test for continuous variables, and Wilcoxon rank-sum test for median values. The cohort entry date was set as the baseline. To assess the association between AH use and risk of ESCC, we calculated incidence rates (IRs) and incidence rate ratios (IRRs) and estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) using Cox regression models, adjusting for age, sex, income levels, urbanization, cigarettes smoking, alcoholic related diseases, comorbidities, medication use, and Charlson Comorbidity Index (CCI) scores. The cumulative incidence of ESCC was estimated using the Kaplan–Meier method and compared using the log-rank test.p < 0.05 was considered to indicate statistical significance.All statistical analyses were performed in SAS for Windows , and a two-sided In this study, we analyzed data from 1,289,526 individuals who were enrolled between 2008 and 2018. The final follow-up date was 31 December 2020. To compare the AH user and nonuser groups, we performed individual 1:1 matching and each group included 644,763 patients. The age distribution was similar between the two groups (as shown in p = 0.001). Even after stratifying the patients by AH cDDDs, a similar trend was observed (p = 0.001).We also observed a dose–response relationship between AH use and ESCC risk: compared with AH nonuse (<28 cDDDs), the aHRs for AH use at 28–182, 183–488, 489–1043, and >1043 cDDDs were 1.12, 1.20, 1.25, and 1.37, respectively. Our Kaplan–Meier analysis showed that ESCC risk was higher in AH users than in AH nonusers  on the incidence of ESCC in individuals with and without AH use are shown in The results of our study were surprising, as we found a positive association between AH use and the incidence of ESCC, with a dose–response relationship between the two. This contradicts previous findings linking AH use to a decrease in the risk of HCC ,15,36. IH1-antihistamines are classified into two categories: first generation and second generation. First generation H1-antihistamines have poor selectivity for H1 receptors and can cross the blood–brain barrier. These drugs have been associated with a range of adverse events, including antimuscarinic, anti-alpha-adrenergic, anti-serotonin, and sedative effects. Despite these risks, the potential dangers of first-generation H1-antihistamines have been largely underestimated . Until nOur study found that several factors are associated with an increased risk of ESCC, including older age (>50 years), the male sex, cigarette smoking, and alcohol-related diseases see . These rThere are several strengths to this study, including its large sample size, large validation cohort, long-term follow-up time, homogenous covariates between cases and controls after PSM, and long-term verification of medication data. However, there are also some limitations to consider. First, although the National Health Insurance Administration routinely reviews patient charts to ensure the quality of claims from medical institutions, there is still the possibility of data miscoding or misclassification. Second, there are several unmeasured confounders related to ESCC (such as body mass index and use of other over-the-counter drugs) that were not included in our database. Third, the analysis of different H1-antihistamines is difficult because the crossover use of H1-antihistamines is very common in the AH users group. Unfortunately, it is difficult to separate the effects of different H1-antihistamines, as crossover use of these drugs is prevalent in the antihistamine user group. In our study, we faced the challenge of differentiating between individual use of specific H1-antihistamines. This is because, in practice, the choice of H1-antihistamines often depends on the availability and convenience of the drug at the hospital where it is prescribed. This leads to frequent crossover use of different H1-antihistamines. As a result, it is difficult to identify the exact antihistamine used by each individual, i.e., as crossover use is common. Fourth, we were unable to contact patients directly to confirm their AH use because their data were anonymized. We assumed that all patients adhered to their prescribed medication regimens, but the actual ingested dosage may have been overestimated due to nonadherence. One question that remains unanswered in this study is the duration of AH use. Our study showed that AH usage ≥28 cDDDs was a risk factor for ESCC. We also found that patients who were prescribed AH at a dosage of ≥28 cDDDs had a significantly increased risk of ESCC with a dose–response relationship see . HoweverThe use of AHs may increase the risk of ESCC in the general population in a dose-dependent manner. Further research is needed to confirm these findings and to understand the mechanisms behind this association. It is important for healthcare providers to consider the potential risks and benefits of AH use, especially in individuals at high risk for ESCC. Patients who are considering using AHs should discuss the potential risks and benefits with their healthcare providers.


Objective: This paper assesses the relationship between demographics, health parameters, and functional limitations among older adults in Korea, including limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).Methods: We analyzed data from the Korean Longitudinal Study of Aging survey in 2020 and included only participants aged 65 and older. Multinomial logistic regression models were conducted to evaluate the factors that predicted functional limitations.Results: The prevalence of at least one ADL and IADL limitations were 6.14% (severe 1.94% and moderate 4.20%) and 15.49% (severe 3.11% and moderate 12.38%), respectively. People aged 85 and older had high rates of severe disability with 7.37% for ADLs and 12.06% for IADLs. High rates also occurred among people with low education, underweight, physical inactivity, depression, and three or more chronic diseases.Conclusion: Factors associated with functional limitations were age, educational status, body mass index, physical activity, depression, and chronic diseases. To prevent and improve functional limitations in the older populations, active and applicable interventions should be considered for modifiable factors such as physical activity, depression, and abnormal weight. The concept of aging in place, living independently or with some assistance from the community, has been well-acknowledged and promoted by the Korean government for people aged 65 years and older (older adults), including older adults with dementia , and it The most common indicators of functional limitations in older adults are changes in the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) . ADLs arSeveral studies found that the progression of disability in older adults differed by sociodemographic and health-related parameters such as age, sex, education status, living arrangement, physical activity, and body mass index (BMI) –16. The Our purposes in this study are to show the prevalence of ADL/IADL disability levels the distribution of ADL/IADL disability level according to age group by sex, and to determine the relating factors of the ADL/IADL disability levels according to demographics and health parameters in older Korean adults.In this study, the data from the Korean Longitudinal Study of Aging survey in 2020 (KLOSA 2020)  were appFollowing the KLOSA 2020 survey, the ADL scale considered seven indicators: 1) dressing, 2) washing face, hair, and brushing teeth, 3) bathing or showering, 4) eating food that has been prepared, 5) getting in/out of bed, 6) toileting, and 7) managing bladder/bowel . For eacThe IADL scale contained ten instrumental activities: 1) grooming, 2) household chores, 3) preparing meals, 4) laundry, 5) going out a short distance, 6) using public transportation, 7) shopping, 8) managing money, 9) making or taking a phone call, and 10) taking medicine at the right dose and time. The IADL index had a total of 10 possible scores, calculated based on the sum of scores from ten indicators. With the same meaning as ADL disability, an IADL disability was also defined with three levels: “none,” “moderate,” and “severe,” corresponding to participants scoring 0, 1-9, and 10 on the IADL index, respectively. This classification of ADL disability and IADL disability into different levels is similar to that of previous studies [2; normal, 18.5–23 kg/m2; overweight, 23–25 kg/m2; and obesity, >25 kg/m2, based on the Asia-Pacific classification of BMI [The covariates were taken from the KLOSA 2020 data and included demographic factors of sex , age , living arrangement , and educational status ; and health parameters of BMI , physicp-values for differences across ADL/IADL disability levels.The data were analyzed by using R software version 4.1.3. Bivariate statistics was used to identify participant characteristics and estimate differences in ADL/IADL disability levels for research purposes. The prevalence of ADL/IADL disability levels was specified. The Chi-square test  was usedp-values less than 0.05 in the two-sided Wald test were considered statistically significant. An OR represented a relative risk ratio for the change of the dependent variable in a particular category (relative to the reference category) associated with a one-level change in the respective predictor [Multinomial logistic regression models  were useredictor .We analyzed 4,337 participants aged 65 and older, and 2,509 (57.85%) of them were female. People aged 65–74 accounted for the highest proportion (47.06%), whereas those aged 85 and older made up only 13.77% of the study population. People with an elementary school or lower education accounted for the highest proportion (approximately 50%), whereas those with a college degree or higher accounted for a relatively small proportion (8.72%). Up to 24.9% of participants reported being obese whereas only 3.76% of them were underweight. More than 60% of participants responded did not exercise at least once a week, and 4.45% of those living in a depressive state. Those with at least one chronic disease accounted for about 81%; three or more chronic diseases accounted for 26.59%. The proportion of people with at least one ADL limitation was 6.14%, of which severe disability was 1.94%. For the IADL limitation, these numbers were 15.49% and 3.11%, respectively. The demographic and health parameter characteristics of the participants are shown in The prevalence of ADL/IADL disability among older adults is shown in The distributions of ADL/IADL disability levels by age and sex are visualized in p-values in the Goodness-of-fit test (around 2.2 × 10−16) indicated that the models were appropriate and consistent.The results of multinomial logistic regression analyses are shown in As shown in People with severe functional limitations often experience particular difficulties with daily activities, which place a burden on the healthcare system –16. TherThis study analyzed the prevalence of functional limitations in older Korean adults. For the entire population discussed in this study, the proportion of people who reported at least one ADL limitation was 6.14%, of which severe ADL disability was 1.94%. These numbers for IADL disability were 15.49% and 3.11%, respectively. The ADL/IADL disability increased significantly with age. For people aged 85 years or older, approximately 21.6% reported at least one ADL limitation, and 44.6% reported at least one IADL limitation. The results are similar to those of a survey of older adults residing in the community in Korea ; those rThe average human lifespan in Korea has been increasing in recent years, and the number of older adults increased significantly. Around 16% of the Korean population was age 65 or older in 2020, according to the South Korea Age structure . Among tIn this study, we verified that advanced age, low education, being underweight, physical inactivity, and chronic diseases were factors strongly associated with functional limitations in older adults. These findings were consistent with those of previous studies , 7, 11. We found that the prevalence of ADL/IADL disability was higher in underweight individuals than in normal-weight individuals, while it was lower in groups with overweight and obesity. This finding differs from the studies from Korea in that BMI did not significantly affect the prevalence of ADL/IADL disability in Korean older adults , 19. PreThe rates of severe ADL/IADL disability were exceptionally high in physically inactive individuals (a 9.85-fold increase for ADL and a 6.10-fold increase for IADL as shown in this study) compared with physically active individuals. A previous study reported a high prevalence of ADL (OR = 15.23) and IADL (OR = 4.98) disability in older adults without physical activity . LimitatChronic disease has been consistently reported as a risk factor for disability, and it may lead to disability due to limitations on physical and social activities , 38. TheWe also found that factors such as age, physical activity, depression, and chronic diseases influenced the risk for severe disability much more strongly than that for moderate disability at both ADL and IADL while there was almost no more difference in the influence of BMI on risk for severe as well as moderate disability. With the factor of educational status, the risk of ADL disability was significantly higher than that of IADL disability at both severe and moderate levels. This finding is interesting and has not been shown in previous studies related to older adults in Korea. This can be explained by the nature of limitations. ADL disability involves basic activities of daily living while the IADL disability includes more complex activities, so the prevalence of IADL disability was often higher than that of ADL disability and it is often more evident in the later stages of the disability .This study had some limitations. First, several parameters, such as the place of residence and income, were not included in this study to avoid the presence of missing data. Second, as this was a secondary data analysis study, we were unable to include the variables known as significantly associated factors  as in previous studies. Third, our study was based on cross-sectional data and did not include time-varying trends in ADL/IADL disability. It is necessary to confirm the causal relationship between the associated factors according to the level of ADL/IADL disability in a future longitudinal study. Despite several limitations, our findings have importance in formulating social policies and improving the healthcare system to properly accommodate the development of physical disabilities among older people in Korea. In particular, active policy support and intervention approaches for severe disability groups will be needed.In summary, this study specified the risk factors associated with ADL/IADL disability among older adults in Korea using bivariate analyses and multinomial logistic regression analyses of KLOSA data. Significantly, severe ADL/IADL disability tended to be closely associated with age, educational status, BMI, physical activity, depression status, and chronic diseases. In particular, modifiable factors were identified as major related factors of ADL/IADL disability, and it is necessary to prevent the occurrence of disability in the older population by improving modifiable factors through active intervention.


This review presents an update on nanotube functionalization, including an investigation of their methods and applications. The review starts with the discussion of microscopy and spectroscopy investigations of functionalized carbon nanotubes (CNTs). The results of transmission electron microscopy and scanning tunnelling microscopy, X-ray photoelectron spectroscopy, infrared spectroscopy, Raman spectroscopy and resistivity measurements are summarized. The update on the methods of the functionalization of CNTs, such as covalent and non-covalent modification or the substitution of carbon atoms, is presented. The demonstrated applications of functionalized CNTs in nanoelectronics, composites, electrochemical energy storage, electrode materials, sensors and biomedicine are discussed. The carbon nanotubes (CNTs) are modified by different routes, such as covalent and non-covalent modification of the outer surface, the substitution of atoms or the filling of CNT channels ,2,3,4.2 carbon of CNT. The main advantage of the covalent functionalization of CNTs is that it is stronger than non-covalent interactions, however, it requires damage to the sidewalls. Unlike non-covalent functionalization, it changes the electronic structure, resulting in the irreversible loss of double bonds. These changes can affect conductivity properties and therefore, some applications [Covalent functionalization (adsorption) requires reactive species that can form covalent adducts with the spications ,7,8,9,10Surface modifications of SWCNTs are not only achievable by covalent functionalization, but also by non-covalent methods. Known examples of molecules spontaneously assembling into micelles around SWCNTs are polymers , polycycCovalent incorporation of foreign atoms within the CNT lattice is proposed for the effective engineering of CNT properties by consequent doping. Numerous materials have been used for SWCNTs’ substitution, such as N, B, P, Si, Cl or Ar. The important parameter in this case is the controlled concentration of the embedded atoms. Substitutional doping introduces strongly localized electronic features in the valence or conduction bands of CNTs, which makes it different from doping. Different methods can be utilized for the substitution of atoms: arc-discharge, laser-ablation, CVD, chemical reactions and plasma treatment .This review is dedicated to the methods of nanotube functionalization. (a)exterior covalently attached functional groups,(b)exterior physisorbed moieties,(c)2 mesh,heteroatoms directly incorporated into the sp(d)endohedral filling of SWCNTs.There are several methods of the functionalization of carbon nanotubes:Each of these distinct techniques is a well-established research area with a distinct origin and history. To which extent the different techniques are applicable depends greatly on the intended modification and the requirements of a specific application. They were all tailored toward specific aims in accordance with their unique weaknesses and strengths. In this context there cannot be a meaningful classification according to general advantages and disadvantages. Yet, for a novel use case, the features of the existing techniques can be evaluated according to the current goals and requirements.In this section we discuss the microscopy and spectroscopy of fluorinated CNTs. Attaching various functional groups  constitutes exterior chemical modification of the walls of SWCNTs . The inc4 and SF6 plasmas. 6 at −200 V bias and CF4 at −200 V bias. The SWCNTs’ network was similarly functionalized in all of the shown samples, forming bundles due to van der Waals interactions. Meanwhile, the CNTs appeared to be unharmed.In Ref. , SWCNTs 2 carbon at 284.3 eV [3 carbon. Upon fluorination at increasing reaction temperatures, the sp2 peak becomes less intense as new peaks at higher binding energies arise and grow in intensity. The C 1s spectral range undergoes well visible changes. Each fluorination temperature has a clearly distinct fingerprint due to different chemical shifts. 2 (A), sp3 (B), various oxygenation states (C–E) and also multiple fluorination states (F–H). The peaks, F, G and H at 291.2 eV, 292.9 eV and 294.6 eV, are ascribed to C-F, C-F2 and C-F3 bonds, respectively. The F 1s XPS spectra in CNTs were fluorinated at different temperatures ranging from 150 to 300 °C. The C 1s X-ray photoelectron spectra (XPS) of the pristine SWCNT in 284.3 eV . The tai−1 and an increase in the peak at 1230 cm−1 with increasing fluorination temperature. The first shrinking peak signifies the loss of ionic fluorine while the second growing peak confirms a gain of covalent C-F bonds. The broad bands around 2350 cm−1 and 3400 cm−1 belong to CO2 and OH groups.The Fourier-transformed infrared (FTIR) spectra in −1, which corresponds to the SWCNTs’ distinctive breathing mode. It was shown that the breathing mode is suppressed due to doping. Broadband spectra consist of distinctive 1580 cm−1 and 1360 cm−1  peaks. As the fluorination temperature rises, the intensity ratios (IG/ID) decrease. This demonstrates the alteration in the bulk structural characteristics of CNTs after fluorination [rination .4 gaseous plasma treatment on SWCNTs was investigated. In particular, Raman spectroscopy showed that CNTs had more disordered sp3 bonds, associated with functionalization, as gas flow rates in the plasma and exposure duration in the plasma were increased  in addition to the shear force effect. This causes the formation of the structural defects and eventually, their breakage. After defect introduction, the sidewalls are expected to be chemically active, thus improving the reactivity of the CNTs.3, H2SO4 or KMnO4, which leave holes functionalized with oxygenated functional groups as well as open CNT caps [3 results in defect formation in addition to the opening of the ends of the nanotubes. Besides that, it stimulates the formation of the aromatic polycyclic compounds , which can be removed by an alkali and then reversibly reabsorbed. This consequently results in the improvement of the dispersion of CNTs in the aqueous solution.Oxygenated sites can also be considered defects. Chemical oxidation of nanotubes is mainly achieved by using either wet chemistry or gaseous oxidants. One way of creating defects and functional groups is oxidative damage to the nanotube framework via strong acids or oxidants, such as HNOCNT caps ,51,52. TCNT caps ,54, hydrCNT caps , potassiCNT caps , oxidatiCNT caps  and hypoCNT caps . In Ref.The gas phase functionalization of CNTs, including oxidation, was carried out. Here, carbon dioxide ,59, wateMoreover, some functionalization methods are combined together. For example, in , the effIt was also shown that the oxidation processes strongly depend on the curvature of the CNT’s wall and consequently, the diameter dependence ,72,73. UCNT silanization is the interaction of oxidized CNTs with organosilanes. The silanization after oxidation usually takes place in a few steps. Firstly, the hydrolysis of silanes into silanols is performed. The creation of hydrogen bonds between oligomers and the surface hydroxyl groups of carbon nanofillers as well as the condensation of silanols into oligomers occurs in the next phase. Finally, Si-O-C bonds are created through the interaction of Si-OH groups with OH groups on CNTs. The 3-aminopropyltriethoxysi-lane has been widely used as a silane agent ,82,83,84Access to numerous CNT surface functionalizations is made possible by adding carboxylic and hydroxyl groups to CNTs. CNTs can be functionalized via esterification or amidation. Typically, carboxylic groups are activated to acyl chlorides by thionyl chloride, and then amidation and esterification reactions convert them to carboxamides (or carboxyesters) to introduce a variety of functional groups as nucleophiles, such as aliphatic or aryl amines, amino acid derivatives, ensims, peptides, or amino-group-substituted dendrimers ,78,79. T2 at temperatures between 150 and 400 °C [The chemical manipulation of carbon nanotube sidewalls via fluorination and then defluorination is well developed ,49,87. Id 400 °C . The intd 400 °C . These md 400 °C ,91,92,93d 400 °C ,95.The most common approach to hydrogenation is wet chemistry which includes the dispersion of a mixture of lithium and CNT in diaminoethane . The proCNTs functionalized with fluorescein or a fluorescent bioactive peptide can also effectively cross the cell membrane without significant damage of the membrane ,103. For2 to sp3 hybridization. This consequently leads to changes in mechanical, optical and electrical properties. On the other hand, the covalently functionalized CNTs open the road to many applications, which require the change in optical and electrical properties [In general, the covalently functionalized CNTs are soluble in many organic solvents due to the attachment of polar or nonpolar groups. The main difficulty in developing covalent functionalization arises from spoperties ,112.The first commonly used non-covalent functionalization is surfactant based. These types of molecules result in the dispersion of the CNTs via physical adsorption. Both ionic and non-ionic surfactants have been used. The known surface charge of CNTs can be used to predict the colloidal stability of CNT solutions and the interaction (adsorption) mechanism with ionic surfactants. A larger negative surface charge and steric repulsion, for instance, are produced when CNTs and SDS interact through hydrophobic components, which increases the stability of the dispersion. Therefore, the purification procedure and tube wall functionalization, which influences its surface charge, may be used to regulate the adsorption mechanism of ionic surfactants . While tThrough π-π interfaces, aromatic compounds like anthracene, phenanthrene, pentacene, porphyrin, pyrene and fullerene interact with one another. Under mild sonication, the strong bonding of functional molecules and large systems allows for debundling and produces hydrophilicity. A CNT@Pyrene hybrid was developed, aimed at improvement heat transport due to the anion addition . The BioThe interaction of polymers with the CNT surface via wrapping was used to improve the dispersion of CNT in water and organic solvent and to further enable the separation of CNTs by metallicity and chirality and the separation of CNTs from carbonaceous and metal impurities ,132,133.Dispersions of MWCNT with the pluronic surfactant F-127 were made with the intention of examining the interactions of CNT with biological tissues . A waterFinally, we would like to discuss the mechanical interlocking of SWCNT as a possible route for non-covalent functionalization. In particular, in , the macNitrogen has one more electron than C, which it can easily substitute for C atoms. There are two types of C–N bonds that occur: pyridine-type in which each N atom is bonded to two carbon atoms and a type in which the N atom is bonded to three carbon atoms. The first type results in either a p- or n-type doping depending on the concentration of N atoms; meanwhile, the second type leads to n-type conducting behavior. In situ doping techniques include high temperature arc-discharge ,154, che0.43. The heating resulted NTs under He with temperatures ranging from 100 to 400 °C desorbed the fluorine [The halogens, such as fluorine, chloride and bromide, can also be attached to the sidewall of CNTs. As mentioned in fluorine . Hydrazifluorine ,170.2. The removal of metal catalysts and amorphous carbon residues from CNT has been reported to be accomplished using Cl2 gas and Cl2 aqueous solution treatments. Simultaneously, this protocol introduces chlorine but with a relatively low amount [2 under a high temperature and pressure with prolonged reaction times of up to 14 days [The commonly used alternative method for CNT functionalization via substitution is chlorination. Usually, the source of chlorine comes from liquid precursors such as thionyl chloride, chloroform, trichloromethane, tetrachloroethylene or hydrochloric acid or solids such as dichlorocarbene or gaseous precursors such as Clw amount . The chlw amount . A simil 14 days . Recentl 14 days . Chlorin4, carbon tetrachloride. The perpendicular arrangement of bromine atoms in relation to the CNT surface was readily seen using TEM. Br atom conjugation was made possible in the graphite structure of CNTs (2.8 % weight) by electrochemical oxidation of inorganic salts such as KBr [17Br stoichiometry. The covalent bromination process with a total weight of 4.9% in CCl4 solution at microwave irradiation and a cool CH3Br plasma were described in [4NO3/NBS and Br2 were used in an electrophilic addition and radical reaction with UV light or conventional heating to archive the effective bromination [A method of purification for CNT polluted by carbon impurities was used because of the low sensitivity of CNTs to bromination. However, the C−Br bond is more reactive than the comparable iodinated fluoro- or chloro-derivatives. The bromination of CNTs required relatively difficult to achieve conditions as compared to other carbon nanostructures. With bromine in the liquid, gas or plasma phases, it can only be done by electrochemical, electrothermal or microwave processes at a higher temperature. Despite the improvement that has been shown, bromination causes a small amount of CNT degradation and fragmentation . Bromineh as KBr . Additioh as KBr . Elementribed in . N-bromomination . In compmination .The literature has covered a lot of various substitution methods, including the substitution by I, S, Si, Se, P-N and Ar. Another technique for changing the graphitic structure of CNTs is iodination. First, a modified Hunsdiecker reaction was used to carry it out . It was The functionalized CNTs have been used in numerous applications. Here, we focus on some in which functionalization is the key to achieve a certain application. In particular, surfactant, used for functionalization, helped to sort SWCNTs by chirality and electronic types. First of all, the complete separation can be achieved if SWCNTs are present in the suspension as individual nanotubes. Secondly, the micelles created by the surfactant help to control the density and therefore, are useful in density gradient centrifugation (DGC), chromatography and two-phase separation. In , it was CNTs have further been utilized as a polymer matrix filler material. In the polymer matrix, the functionalized CNTs produce improved homogeneity and dispersion. It was demonstrated that interactions between CNTs and a polymer matrix are necessary for efficient CNT integration ,192. The2. For instance, SnO2-functionalized CNT derived from CNT functionalized with sulfonic acid was employed in lithium-ion battery anodes without the usage of a binder, conductive agent or current collector [2@CNTF’s lithium storage capacity was determined using galvanostatic charge/discharge under the circumstances of a 100, 200, 500 and 1000 mA/g rate . Different concentrations of butanone and 3-octanone were found using the electrochemical sensor in the N2 matrix . As can 2 matrix . The det2 matrix .Additionally, the functionality can lower the toxicity and improve the biocapability. Reduced blood circulation time, reticuloendothelial system uptake and other effects are caused by PEGylated CNTs . It was The encapsulation of materials in CNTs has attracted interest. Metals and compounds have been placed into CNTs and can be manipulated using magnetic fields to target cells . FurtherHigh water transport rates, supported by functionalized carbon nanotube pores, closely resemble the structure of aquaporin channels, making them excellent candidates for the creation of artificial water channels and high-performance membranes ,216,217.The chemistry of carbon nanotubes represents a serious topic in science and technology. Modification of the outer surface is performed by covalent attachment of functional groups. Here, it is considered with transmission electron microscopy, scanning tunnelling microscopy, Raman spectroscopy and X-ray photoelectron spectroscopy. Modification of the outer surface of carbon nanotubes by the wrapping and adsorption of molecules is an important technique. The substitution of atoms into carbon nanotubes via other atoms is a way to tailor the physical properties of nanotubes. The filling of carbon nanotubes opens up a way to study the chemistry and physics of carbon nanotubes. The demonstrated applications of functionalized CNTs are presented.