In Peru, major disasters like the 2007 Pisco earthquake have produced high rates of post-traumatic stress. However, evidence is still needed to strengthen interventions. In 2021, a major earthquake struck Piura, in northern Peru. In this context, we aimed to assess the prevalence of PTSD and its associated factors. A cross-sectional study was conducted during August–September 2021 in people who experienced the 6.1 Piura earthquake on 30 July 2021. The questionnaire included the PCL-C, CD-RISC, ISI, HFIAS, and additional demographic data. Generalized linear models were used. The prevalence of PTSD was 20.3%. Household income was between PEN 2001 and 3000 , smoking , experience of a nervous breakdown , moderate food insecurity , and severe insomnia  increased the prevalence of PTSD. One out of five individuals experienced post-traumatic stress symptoms after the 2021 earthquake in Piura, which varies depending on socioeconomic, psychosocial, and individual factors. Further research should strengthen these findings to ensure a fair and early mental health intervention against new seismic events in this and other Peruvian regions. Post-traumatic stress disorder (PTSD) is a weakening condition caused by past life-threatening events that manifests as symptoms of re-experiencing, blunting, avoidance, and hyperarousal . This diPeru’s location within the ‘‘Pacific Ring of Fire’’, a geographical area characterized by the most important seismic events in the world, is associated with a higher risk of experiencing major earthquakes . NonethePost-earthquake PTSD is generally attributed to high levels of chronic stress due to uncertainty about the immediate future in terms of material, social, and family possessions . This coA cross-sectional study was conducted during August–September 2021 in people from Piura who experienced a seismic event of magnitude 6.1 according to the Richter scale on 30 July 2021.®. A Facebook page was created to share survey invitation posts. To this end, ads were promoted using Facebook’s advertising services to reach a larger number of people in Piura. The survey was also disseminated on social networks of local health institutions, universities, and press media , that agreed to share the survey free of charge.An online survey was designed using REDCapThe population consisted of residents of the department of Piura, Peru, who suffered the earthquake of 30 July 2021, and who lived in 1 of the 38 districts of Piura, declared in a state of emergency after the seismic event.Individuals over 18 years of age, who experienced the earthquake and resided in Piura, were included. People who did not respond to the variables of interest in the survey were excluded. Also excluded were those who self-reported residing in Piura but were not present during the earthquake.The estimated sample size was 179, which was based on an expected prevalence of 12%, a confidence level of 95%, a margin of error of 5%, and a refusal rate of 10%. The final sample included a total of 177 participants. Snowball sampling was applied by initially recruiting individuals living in urban and rural areas from the most affected cities of Piura , and then asking participants to share the survey to contacts in their and other locations. Internet coverage in this Peruvian region is approximately 53% of individuals over 14 years of age. We used this approach to increase the probability of obtaining the minimally required sample size.PTSD symptoms were assessed using the PTSD Checklist—Civilian Version (PCL-C). This questionnaire assesses the general traumatic experience, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and in accordance with the National Center for PTSD . The PCLResilience was assessed with the Connor–Davidson Resilience Scale (CD-RISC). The questionnaire has 10 items rated on a 5-point Likert scale . The CD-Insomnia was assessed using the Insomnia Severity Index (ISI). This questionnaire consists of seven items rated on a 5-point Likert scale . The ISIFood security was measured using the Household Food Insecurity Access Scale (HFIAS). The questionnaire consists of 9 items rated on a 3-point Likert scale. The HFIAS has three domains: anxiety and uncertainty about household food supply, food quality/insufficient quality food intake, and physical consequences . The oveSociodemographic and work-related variables were age (years), sex , marital status , educational level , type of work , monthly household income in Peruvian currency , religion , and number of family members in the household. Variables related to personal and family medical history were frequent consumption of alcohol and tobacco and comorbidities . Variables related to stressors before, during, and after the earthquake were personal and family history of mental disorders, nervous breakdown immediately after the earthquake, physical injury due to the earthquake, family member with physical injury due to the earthquake, housing damage due to the earthquake , and job loss due to the earthquake. The variable related to social support was social/material support from family, relatives, neighbors, friends, religious members, politicians, government, or non-governmental organizations.n, %) or the median value and 25–75th percentile.Sample characteristics were described with frequencies  when jX = 0.β1: coefficient of jX, equal to ln (jλ+1/jλ) when j increases by one unit.jX: variable with value j.Variables associated with the outcome in the unadjusted model were included in the adjusted analysis, based on the following equation:jλ: probability of occurrence of the event given a j value.β0: intercept, equal to ln (jλ) when jkX = 0.iβ: coefficient of jkX, equal to ln (jλ+1/jλ) when j increases by one unit and the other i − 1 variables remain constant.jkX: variable k  with value j.p-values < 0.05 were considered statistically significant. Collinearity was evaluated between the variables of interest. The analyses were performed with Stata v. 17 .Prevalence ratios (PRs) with 95% confidence intervals were reported. n = 98) were female, 64% (n = 113) reported having a higher level of education, and 55% (n = 98) were currently studying. Seventy six percent (n = 134) were at home at the time of the earthquake, and 19% (n = 34) reported that their houses had suffered minor damage due to the seismic event. Six percent (n = 10) had moderate food insecurity and 7% (n = 12) experienced moderate insomnia. Forty one percent (n = 71) scored high resilience and 20% (n = 36) experienced PTSD symptoms due to the earthquake. The frequency of each PTSD symptom is shown in Participant characteristics are presented in p = 0.021). Severe insomnia was associated with a higher prevalence of PTSD symptoms . Severe food insecurity was associated with a higher frequency of PTSD symptoms .p-value < 0.05 in the simple regression model (unadjusted) was included for the adjusted analysis. A household income between PEN 2001 and 3000 was found to be associated with a higher prevalence of PTSD symptoms . Smoking  and severe insomnia  were associated with a higher frequency of PTSD symptoms. Having suffered a nervous breakdown immediately after the earthquake , moderate food insecurity , and social/material support from non-governmental organizations  were also associated with PTSD symptoms. A high level of resilience  and having experienced the earthquake in a public place  were associated with a lower prevalence of PTSD symptoms. More details in To identify potential factors associated with PTSD symptoms, a Poisson regression analysis was performed. All exposures that showed a In total, 5 out of 10 participants were found to experience PTSD symptoms. Factors associated with a higher prevalence of PTSD symptoms were an income between PEN 1001 and 2000, smoking, a nervous breakdown immediately after the earthquake, a family member with physical injury due to the earthquake, social/material support from non-governmental organizations, moderate food insecurity, and severe insomnia. Conversely, high resilience and having experienced the earthquake in a public place were associated with a lower frequency of PTSD symptoms.Approximately 2 out of 10 participants experienced PTSD symptoms due to the 6.1 seismic event. Previous studies in Europe, Asia, and Latin America have documented a prevalence of PTSD ranging from 5 to 60% as a consequence of natural disasters, including earthquakes . In PeruLower family income was found to be associated with a higher prevalence of PTSD symptoms. The economic impact of large-scale natural disasters tends to occur long after the immediate aftermath . The notSmoking was also found to be associated with a higher frequency of PTSD symptoms. This behavior can contribute to the development of several conditions that impair the ability to work and interact with the environment . The freInterestingly, having experienced the earthquake in a public place was found to be associated with a lower prevalence of PTSD. A previous study conducted in Peru four years after the 2007 Pisco earthquake showed no association between PTSD and the location of the earthquake . The expHaving suffered a nervous breakdown immediately after the earthquake was associated with a higher prevalence of PTSD symptoms. Nervous breakdown is associated with temporary inability to react physically and mentally to stressful situations . It may Participants who had a family member with physical injuries due to the earthquake experienced a higher frequency of PTSD symptoms. This result supports an earlier Peruvian study  that fouUnexpectedly, participants who received social/material support from non-governmental organizations experienced a higher prevalence of PTSD. This is different from one study  showing Severe insomnia was found to be associated with a higher prevalence of PTSD symptoms. This is consistent with a cohort study reporting that adolescent earthquake survivors diagnosed with PTSD were 50% more likely to have insomnia . AnotherFinally, high resilience was found to be associated with a lower frequency of PTSD. This is similar to a study after the 2011 earthquake in Japan that found a 50% lower prevalence of PTSD in people with high resilience . SimilarThe present study is the first to explore factors influencing the development of post-traumatic stress after the Piura earthquake in 2021. Although our results add to previous Peruvian and Latin American evidence on post-disaster mental disorders ,37,58,59The study has important limitations. First, the sample size was smaller than estimated and regression analysis was therefore underpowered. Second, the cross-sectional design of the study does not allow us to establish a causal relationship between the study variables. Third, the non-probabilistic sampling limits the inference of results to the entire population of Piura. Fourth, the data collection strategy may have biased the selection of participants, as young people frequently use social media and the internet. Fifth, common survey-related biases, such as recall or social acceptability bias, may have affected the accuracy of all responses. Sixth, some included variables  may have acted as either exposure to or outcome of PTSD due to assessment at one point in time. Seventh, we used a version of PCL-C based on the DSM-IV criteria, so the prevalence of PTSD may have been different compared to the updated DSM-V version. Despite these limitations, the questionnaire was administered within the first two months after the earthquake; therefore, the mental health variables were measured in a period near to the traumatic exposure. Additionally, the instruments were previously validated and showed high internal consistency.We conducted an online survey study in the general population of Piura after the 6.1 magnitude earthquake in 2021. Our findings indicate that one out of five individuals have experienced post-traumatic stress symptoms, and those with more vulnerable characteristics, such as low family income, food insecurity, smoking, and insomnia, were more likely to experience PTSD. The prevalence of post-disaster PTSD found in this study is in line with the current global evidence. Notably, it was very similar to that found in an earlier study following one of Peru’s most devastating earthquakes during the 2007 in Pisco [It is important to note that data collection was carried out mainly in the most affected cities through snowball sampling and using validated instruments . In addition, generalized linear modeling helped to identify variables independently associated with PTSD. Future research should confirm our findings by overcoming current limitations, but also by focusing on testing the effectiveness of interventions to reduce PTSD in higher-risk groups. The timely management of this condition would ensure fair mental health care in the face of new seismic events in this and other regions of Peru.


Achieving the best possible outcome for the therapy is the main goal of a medicine. Therefore, nanocarriers and co-delivery strategies were invented to meet this need, as they can benefit many diseases. This approach was applied specifically for cancer treatment, with some success. However, these strategies may benefit many other clinical issues. Skin is the largest and most exposed organ of the human body, with physiological and psychological properties. Due to its exposition and importance, it is not difficult to understand how many skin diseases may impact on patients’ lives, representing an important burden for society. Thus, this review aims to summarize the state of the art in research concerning nanocarriers and co-delivery strategies for topical agents’ applications targeting skin diseases. The challenge for the medicine of the future is to deliver the drug with spatial and temporal control. Therefore, the co-encapsulation of drugs and the appropriate form of administration for them are so important and remain as unmet needs. It is well known that skin is the largest and the most exposed organ of the human body, acting mainly as a barrier to the environment, and preventing the entrance of harmful microorganisms and substances and the loss of water ,2. Skin’Combination therapy involves the simultaneous use of two or more therapeutic agents, with different toxicities and acting through different mechanisms. Even though combination therapy gained prominence when better outcomes in cancer therapy were achieved ,7,8, it Another way to enhance treatment options of various diseases is the use of nanostructures as drug delivery systems. Nanocarriers can improve drugs’ bioavailability, solubility, and permeability, increase drugs’ half-lives in the organism, and decrease the toxicity, as well as promote targeted or controlled release ,19,20. EStudies have already reported the association of co-delivery and nanostructured systems for cancer treatment ,21,22, aSkin is considered as a key site for local and systemic drug delivery. Its advantage is that it is easily accessible, which allows products from a wide range of formulations to be easily applied and then removed as needed. Skin is also relatively impermeable, which makes it a natural barrier. Thus, topical delivery systems have evolved from simple solutions and ointments to sophisticated nanotechnologies. The key factors for topical delivery products are to meet market requirements, including safety and sensory requirements, efficacy, and design . stratum corneum and on cell membranes. The main barrier that hinders the penetration of the active substance of the cosmetic through the skin is the stratum corneum, made of flat and keratinized cells [stratum corneum, which is lipid in nature with a low water content, effectively regulates the degree to which the active substances penetrate the deeper layers of the skin. Considering the properties of the stratum corneum, lipophilic compounds with an admixture of hydrophilic properties are preferred [Penetration of active substances through the skin is a very important issue in research on the effectiveness of compounds used in cosmetics and pharmacy. Obtaining the proper degree of penetration of active substances as well as confirming their clinical effectiveness are two of the key challenges for the modern cosmetics and pharmaceutical industry . The effed cells . It is treferred . Application directly at the site of action. No first-pass effect and thus no reduction in the dose of the drug substance taken. The first-pass effect is defined as the metabolism of a part of an orally taken drug dose in the liver ; because of which, the total amount of the active substance entering the bloodstream is lower.Reducing the risk of systemic effects and the possibility of side effects from the cardiovascular system, digestive system, or kidneys.Possibility of administration in people intolerant to oral doses for various reasons.Avoiding drug–drug interactions, for example with drugs that lower blood pressure or cardiological doses of acetylsalicylic acid.Possibility of reducing the oral dose ,27.As shown in To enable the effective transportation of biologically active substances into the skin, various types of innovative nanocarriers were created and used, in which small amounts of the active substance were enclosed. Depending on the structure and composition, the nanocarriers have a different penetration capacity and transfer the active substance to the target site, where it is then released . NanocarThe biggest challenge for making nanocarriers for topical delivery is to make them biocompatible and nonirritant , and at Polymeric nanoparticles are solid colloidal particles, which can be nanospheres, nanocapsules, dendrimers, polymeric micelles, and nanogels with a size ranging from 1 to 1000 nm ,33,34. TConventional techniques for establishing polymeric nanoparticles include nanoprecipitation, solvent evaporation, supercritical fluid technology, dialysis, reverse salting out, and polymerization ,35,37. Tstratum corneum than emulsion-type nanosystems. This allows the drugs to be released gradually and provides a satisfying period of retention in inflamed skin [The pharmacokinetic characteristics of polymeric nanoparticles, such as drug loading, controlled drug release, and structural stability in vitro and in vivo, are satisfactory . Polymermed skin ,40. ThisYang et al.  created Co-loaded nanoparticles of hydroxytyrosol and hydrocortisone were prepared to minimize the adverse effects of hydrocortisone and provide additional anti-inflammatory and antioxidant benefits to atopic dermatitis treatment . The autShah et al.  developeOn the other hand, nanocapsules have also been produced aiming at co-delivery of topical agents. Lipid-core nanocapsules (LCNs) resemble vesicular carriers, formed by an oily inner core surrounded by a polymeric membrane ,47, whicCoradini et al.  developeA US patent US10850246B2 describes a new method for preparing ultra-small polymeric-lipid nanoparticles (USDNs). These nanoparticles are prepared via nanoprecipitation followed by layer-by-layer nanodeposition. The USDNs in the patent are pH sensitive with a pH-controlled release profile with their size ranging from 5–25 nm with loading capacity between 300–500 µg/mg. Efalizumab and ustekinumab were 22–72% released at pH 5.0 while no release was observed at pH 7.4 or above. Skin-penetrating properties were also evaluated, and after 2 h treatment, FITC-labeled USDNs were found in the epidermis diffused to dermal tissues. The authors believed that the small sizes of the USDNs made them effective in penetrating all of the skin strata and made them effective in delivering the payload topically .Lipid nanoparticles play an important role as topical drug delivery systems mainly to treat skin disorders. Both solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs) are colloidal lipid nanoparticles produced with lipids recognized as safe, tolerable, biodegradable, and having low skin irritability ,50. TheyJain et al.  encapsulAnother strategy was proposed by Gupta et al.  to treatAndrade et al.  efficienTacrolimus was also applied by Viegas et al. , giving Moreover, focusing on psoriasis treatment, betamethasone dipropionate and calcipotriol were incorporated into SLNs with the purpose of decreasing drugs’ limitations; betamethasone is common in psoriasis treatment as an effective antiproliferative agent, but it offers a risk of cutaneous atrophy and the rebound of psoriasis. Calcipotriol is a vitamin D derivative and has severe skin irritation potential. They found SLNs with size < 200 nm, low polydispersity (around 0.172), and high EE . SLNs were non-irritant and presented a better distribution onto the skin layers when compared to the commercial product. From in vitro and in vivo assays of skin permeation and pharmacokinetic and skin irritation, the formulation also showed higher antipsoriatic efficacy than the commercial product . Emphasizing the NLC ingredients approach, Ott et al.  co-encapVenturini et al.  studied Costa-Fernandez et al.  producedPalliyage et al.  extensivLacatusu et al.  producedGiving a different approach to lipid nanoparticles, Sakellari et al.  interestLiposomes are drug delivery systems that gained popularity over the past decades, reaching the market with liposomal anticancer and antifungal drugs . LiposomCaddeo et al.  combinedIn another study, Eroğlu et al.  created Aiming for a novel combination therapy for psoriasis, Boakye et al.  developeIn a similar approach, Jose et al.  used catKohane et al.  developew/v/v ratio) which were used for the entrapment of benzoyl peroxide (BPO) and chloramphenicol (CAM). Co-encapsulation of around 50% for BPO and 60% for CAM, respectively, was obtained and the size of the obtained liposomes ranged from 130 to 150 nm mean diameter, with a polydispersity index below 0.2. Liposomal formulation was less cytotoxic than the corresponding drug solutions used as references, hence demonstrating that DAC is a fast, easy, and suitable method for the encapsulation of more than one drug within the same liposomes.Ingebrigtsen et al.  created stratum corneum more easily or penetrate the deeper layers of the skin, and so are considered more suitable for topical and transdermal delivery [As seen, liposomes presented advantages as carriers to co-loading drugs. However, they are often referred to as having a rigid structure, meaning they are less likely to permeate the skin. Therefore, several studies are dedicated to studying modifications in liposomes’ structures that can ameliorate this drawback. In the co-loading for topical and transdermal delivery, the trend is to create ultra-deformable liposomes, also known as transferosomes or elastic liposomes. These modified vesicles can be created by modifying the composition with edge activators such as surfactants  that can interweave into phospholipid bilayers and make them more flexible . This gadelivery .In fact, Lei et al.  demonstrDoppalapudi et al.  preparedIn another study, Cosco et al.  prepared50 of amastigotes when compared to amphotericin B and miltefosine solutions, respectively. The dual approach presented a synergistic effect in vivo, leading to full lesion healing and a reduced number of parasites in the infected mice.Dar et al.  developeMicroemulsions (MEs) and nanoemulsions (NEs) are lipid-based drug delivery systems composed of two immiscible phases, that are stabilized by surfactants and co-surfactants . Micro/nCarvalho et al.  directlyMEs and NEs are prepared via emulsification with a mixture of water, oil, surfactant, and co-surfactants, often selected by solubility studies, to determine which components better solubilize the drug of interest. After this selection, a pseudo-ternary diagram is usually constructed to determine the component combinations that yield micro- and nanoemulsions . HoweverIn this scenario, Khatoon et al.  developeThe authors often incorporate NEs and MEs into gels to make their rheological properties more favorable for topical application, such as better spreadability and adhesion . The comEvodia rutaecarpa, the traditional Chinese medicinal plant Wu-Zhu-Yu. EVO- and RUT-loaded MEs presented an averaged droplet size of 71 nm, a mean PDI of 0.17, and ζ potential of −3 mV. The encapsulation efficiency of both bioactive compounds was near 100% (99% for EVO and 96% for RUT). MEs improved the transdermal drug permeation of both drugs by 2-fold, when compared to the drugs dispersed in a gel and the ME gel. The authors concluded that the gel network structures made the diffusion of drugs difficult and reduced the contact between the lipids from MEs and the lipids from the skin. ME gels with both drugs did not show irritation in vivo and reduced mice’s pain when compared to free drugs dispersed in the gel, by reducing inflammatory cytokine serum levels.For example, Zhang et al.  created A study realized for Chattopadhyay et al.  developeOverall, ME and NE may be an effective way to enhance the delivery of drugs through the skin and enhance the stability of the formulation. Still, they can be challenging to formulate and may need additional incorporation into gels for topical delivery, which can lead to drug delivery retardancy.Niosomes (NIOs) are vesicular nanocarriers with lamellar structures composed of amphiphilic molecules surrounded by an aqueous compartment. These amphiphilic molecules, known as surfactants, contain hydrophilic groups (heads) and hydrophobic groups (tails), since in an aqueous environment they exhibit self-assembly properties, being able to co-encapsulate hydrophilic and hydrophobic drugs ,97. ThesYang et al.  develope−7 and 5.83 × 10−7 mol, respectively, while the co-encapsulation of RES and CUR was 4.08 × 10−7 and 4.18 × 10−7 mol, respectively. The permeation through the skin in the period of 12 h for samples containing CUR and RES was 93 and 19%, respectively. In the samples containing α-TOC and CUR, the permeation was 94 and 12%, respectively. The results showed synergistic activity between the co-encapsulated antioxidants. The nanoformulation containing RES/CUR showed a percentage of inhibition of free radicals of 40%, while in the formulation containing α-TOC/CUR, the inhibition reached 100%. However, the RES/CUR samples ensured an optimal performance in terms of the cumulative number of antioxidants permeated across the skin. The authors concluded that both nanoformulations showed a promising transdermal delivery of antioxidant molecules.In another interesting study, Tavano et al.  preparedPolymer micelles (PMs) are DDS, usually between 10 and 100 nm, composed of amphiphilic block copolymers with hydrophilic and hydrophobic blocks self-assembled in aqueous solution, usually with a spherical structure, and characterized by a core hydrophobic inner shell and a hydrophilic outer shell . PMs havTM (9.1%). The same behavior was also observed for ITR deposition in the skin, as follows: ITR/CLIN-loaded PM gel (13.5%) > free ITR drug dispersion (10.4%) > marketed isotretinoin formulation SotretgelTM (6.2%). The nanoformulation not only decreased the minimum inhibitory concentration (MIC) of the ITR but also helped to retain the drug in the desired location in the skin layers, in addition to demonstrating the antimicrobial activity of the ITR against Propionibacterium acnes.In this context, Sharma et al.  developeIn another interesting study, Xu et al.  prepared100–PPA5 was 196 nm, and for PLL100–PPA5 it was 173 nm, with a mean of PDI of 1.23 for PLL100–PPA5 and 1.15 for PGA100–PPA5. The ζ potential was −68 for PLL100–PPA5 and −63 for PGA100–PPA5. Concerning drug encapsulation, the EE showed values of 76.5% and 87.4% for PLL–PPA and PGA–PPA, respectively. The drug release from the micelle-hydrogel was evaluated in various pH conditions  and demonstrated that the drug-loaded composite was sensitive to pH changes. At pH 11, the cationic PLL-PPA micelles displayed a hastened release of Cur; at lower pH levels, the release was more gradual. PGA-PPA micelles, however, demonstrated the reverse pattern, exhibiting a burst release at pH 3 and a protracted release profile at a higher pH. Micelle hydrogel composites with a high surface charge (both positive and negative) exhibited rapid Amp B release, while a low net charge displayed sustainable release. This burst release of antibiotic and/or antifungal drugs in the first phase of wound healing may be advantageous for preventing sepsis in the exposed wound, whereas sustained release may facilitate wound closure. These findings suggest that the micelle–hydrogel composite could be used as a dual drug release technology due to its outstanding adjustable characteristics and regulated multidrug release.Patel et al.  preparedstratum corneum is the first and main obstacle for the topical delivery route, which can be bypassed by microneedles (MNs). MNs were first described in a United States patent and defined as a drug delivery device with a drug reservoir and multiple projections, that can penetrate the stratum corneum, used in percutaneous administration of drugs for local or systemic therapy [The  therapy . Since t therapy ,108,109. therapy . The mosA core-shell MN was developed by Yang et al.  to effecBletilla striata polysaccharide used in MN fabrication. MNs were completely dissolved in 40 min, delivering a model drug at the same time, meeting the rapid dissolving requirements for hypertrophic scar application. Its efficacy was also tested using the rabbit hypertrophic scar model, showing a decrease in scar thickness and the expression of hydroxyproline and TGF-β1 [Triamcinolone acetonide and verapamil were co-loaded in dissolving microneedles to treat hypertrophic scars. Due to its hydrophobic nature, triamcinolone was previously complexed with hydroxypropyl β-cyclodextrin to improve its solubility in the mixture of carboxymethyl chitosan and d TGF-β1 .More recently, MNs have been used to mediate the delivery of drug-loaded nanoparticles, helping them to transpose the upper skin layer . For exaAn international patent WO2022119985A1 describes dissolvable microneedle arrays loaded with curcumin–albumin extracellular vesicles for the control of skin inflammation. Curcumin stability increased after co-incorporation with albumin in the extracellular vesicle, keeping 90% and 45% of curcumin initial content when kept in PBS at 37 °C for 3 h and 7 days, respectively. MNs dissolved within 5 min after application into rat skin, and thus can be considered as a burst release system. After incorporation into MNs, the cellular uptake and anti-inflammatory activity of curcumin–albumin extracellular vesicles did not change, and bioactivity was maintained after 12 months when stored at room temperature ,116.As already mentioned, skin diseases are a heterogenous group and can be caused by many conditions, such as genetic conditions, microorganisms’ infections, wounds and burns, inflammation, and cancer ,3,4. AmoPsoriasis is an immuno-mediated inflammatory skin disease, which is prevalent and incident worldwide, and related with a high patient burden ,121,122.Cancer burden and prevalence worldwide is well known and established. In 2020, 19.3 million new cancer cases occurred worldwide, leading to almost 10 million deaths . Skin caThe increased popularity of topical medications in recent years is impressive. This is mainly because this form has proven to have more advantages than disadvantages. After all, the skin is ideal for drug delivery because it can produce both systemic and local effects. Local drug delivery systems have certainly changed the way we look at drugs. More and more medical institutions and healthcare professionals are adopting this form of treatment to improve their services to patients. This breakthrough in medicine provides a future of healthcare that is more effective and enjoyable for patients. To achieve this goal, the co-encapsulation of two or more active substances is one of the ways. Co-encapsulation is not only the art of combining molecules, but also the craft of achieving synergism through reciprocity. The term reciprocity in the case of co-encapsulated molecules means cohabitation within nanocarriers that is not compromised by molecular interactions, at least those that negatively affect their therapeutic effect or give rise to any cross-resistance, while maintaining adequate molecular integrity through synchronized release with the possibility of synergy. In other words, the goal of co-encapsulation is not just to achieve co-delivery, but rather to deliver it to the right place, at the right dose, and at the right time. This is where the greatest challenge for future medicine lies. Thus, there is a need to characterize the co-encapsulated molecules very precisely and find the right dosage form for them.


Different forms of full coverage policy of essential medicines (FCPEMs) have been adopted worldwide to lower medication expenditure and improve adherence. This study aims to analyse the effect of FCPEMs on patients' medication adherence in Taizhou city, China.This study was a quasi-experimental study and set treatment and control groups. We extracted Electronic Health Records (EHRs) for hypertension and diabetes 1 year before and after FCPEMs implementation and their medication adherence level assessed by physicians. We applied the propensity score matching (PSM) method to balance the bias between the two groups. Then, the descriptive analysis was used to compare the differences in the reported medication adherence. Using the Difference-In-Differences (DIDs) method, the fixed-effect model with the logistic regression was built to analyse the effects of FCPEMs.P < 0.001) and that in the control group increased by 2.6% . The regression results showed that FCPEMs significantly increased patients' medication adherence .225,081 eligible patients were identified from the original database. In the baseline year, FCPEM covered 39,251 patients. After PSM, 6,587 patients in the treatment group and 10,672 patients in the control group remained. We found that the proportion of patients with high adherence in the treatment group increased by 9.1% (60.8 to 69.9%, FCPEMs significantly improved medication adherence. Socially disadvantaged individuals might benefit more from continuing FCPEM efforts. Expanding the coverage of FCPEMs to other medicines commonly used in patients with chronic diseases may be a promising strategy to manage chronic diseases and promote patient outcomes. Medicine cost is one of the leading causes of suboptimal medication adherence and underutilization, aggravating disease burden, especially for chronic diseases. Reducing out-of-pocket expenses for evidence-based therapies proved an effective strategy for promoting rational use of medicines and lower rates of preventable complications –3. The fThough FCPEMs implementation varied across countries and regions, many FCPEM programs prioritized vulnerable populations such as children and/or the elderly, patients from lower-income groups, and those with chronic diseases. For instance, Burkina Faso eliminates fees for healthcare utilization for children under five . SimilarChina bears a heavy burden from cardiovascular and kidney diseases due to complications of hypertension and diabetes , 23. Thu2 in Zhejiang Province, located in the central area of the Yangtze River Delta in China. The city administers three urban districts , three county-level cities  and three counties . In 2011, Taizhou had a population of 5.8 million, of which 9.1% were aged over 65 years, 19.3% were aged 45–64 years, and the per capita GDP was 7,287.4 dollars. There were 3,061 health institutions, 156 hospitals and health centers, 29,890 health professionals, 12,606 licensed physicians and 17,536 hospital beds  were to reimburse in full , 28. In −6 to reduce the matching tolerance and allowed equally qualified objects to retain in this step.This study was a quasi-experimental study, which set treatment and control groups and used the longitudinal EHRs data to examine the effect of FCPEMs policy on patients' medication adherence. We controlled for confounding factors between two groups using the difference-in-differences (DIDs) method  and analWe conducted analysis on both the whole and the matched samples to ensure the stability of the results.We extracted EHR data from Taizhou's database for chronic disease management. Due to a system upgrade, data from six districts were inaccessible and thus excluded from our study. Therefore, only Linhai and Wenling were altogether taken as the control group. We defined records collected from Huangyan, Wenling and Linhai between June 2011 and June 2012 as the baseline data. As Wenling and Linhai announced the FCPEMs in February and October 2013, we defined follow-up data as records from June 2012 to June 2013 in Huangyan and Linhai, and from June 2012 to February 2013 in Wenling. We subsequently established a 2-year cohort dataset. According to the requirements and regulations of the Chronic Disease Management Services of China, family physicians should administer follow-up surveys regularly and file follow-up records into EHRs. The EHRs system categorizes adherence indicators into “regular medicine use,” “interrupted medicine use,” or “taking no medicine” at each follow-up. In this analysis, “regular medicine use” was identified as high adherence (=1) while “irregular medicine use” and “taking no medicine” were regarded as poor adherence (=0).Besides the primary variable of concern, categorical variables, including the patient's characteristics, socioeconomic status, and health behaviors, were identified as controls and used for PSM . These iT Test for continuous variables and Chi-square Test for categorical variables. We constructed a fixed-effect model with logistic regression would be constructed to ascertain the statistical significance of the findings, ensuring the scientific and rigorous interpretation of our study results. The DIDs method is incorporated into the fixed-effect model to control for heterogeneity. The analytic model was constructed as:The study conducted a descriptive analysis to indicate the impacts of the FCPEMs on medication adherence, with Student's Yit denoted medicine adherence of every individual at different times, Group represented the individual's participation category , Time indicated the stage of policy implementation , β0 was the regression intercept, and εit denoted an idiosyncratic error that changed across individuals and time. Xit captured other individual and household characteristics for control. The coefficient of interest β1 gave the estimate of the average treatment effect of FCPEMs on medication adherence. The coefficients were interpreted in terms of odds ratio (OR).Where All analyses were programmed in STATA 14.0.P = 0.043), residence (P = 0.005), and employment status (P = 0.006).225,081 patients and their respective records were included in the baseline year. Among them, 39,251 patients were covered by FCPEMs. P < 0.001) among the control group and 18.5%  among the treatment group. After matching, the proportion of patients with high adherence in the control group increased by 2.6%  and that in the treatment group increased by 9.1% . The results showed that FCPEMs could promote medication adherence.As indicated in P < 0.001) and the sample after PSM . That means the treatment group had 2.825 times more likely to be high adherence than the control group in the original sample and 2.546 times in the sample after PSM. Patients' medication adherence experienced a natural increase with the progression of time in samples without PSM  and with PSM . Moreover, results from the unmatched sample indicated that the patient's BMI level had a significant positive association with adherence . Other factors present no statistically significant effects on the outcome.As the fixed-effect model omitted all time-invariant covariates, only Group × Time (policy indicator), Time, Age, BMI, Smoking and Drinking were retained in the results. This study found that FCPEMs could significantly promote medication adherence based on patient-level data. The proportion of patients with high level of medication adherence increased by 13.2% (18.5–5.3%) in the unmatched population and by 6.5% (9.1–2.6%) after matching. The fixed-effect model further suggested that the policy effect was statistically significant, which aligns with results from previous literature –21, 32. Furthermore, many policy beneficiaries in our cohort sample were vulnerable populations, which have implications for studies in disadvantaged settings. Studies have revealed that socially disadvantaged groups demonstrated a lower adherence to medicine due to costs , 12, 25.Our study, however, is subject to several limitations. First, though randomized controlled study design remains the golden standard in examining the effect of the interventions, the assignment to FCPEM in this study was not rigorously randomized. We controlled for the bias with PSM and the fixed-effect model constructed with the DIDs method and subsequently formed a quasi-randomized controlled study design. Still, there were likely other influential factors of medication beyond our scope , 37. SecThis study found that FCPEMs is an effective strategy to improve adherence to medicines for chronic diseases, with PSM controlling for baseline biases and the fixed-effect model eliminating time-invariant unobservable factors. For patients with hypertension and diabetes, FCPEMs in Taizhou resulted in a substantial increase in the level of adherence to antidiabetic and antihypertensive medicines. Meanwhile, as our treatment group was mostly vulnerable populations, FCPEMs could be a promising strategy to protect socially disadvantaged groups. Policymakers should consider reducing or removing cost-sharing for essential medicines for chronic diseases.guanxiaodong@pku.edu.cn.The data analyzed in this study is subject to the following licenses/restrictions: The data used in the study are non-public electronic health records belonging to the health department of Taizhou city, Zhejiang. The data contains patients' personal information, so other researchers need permission from Taizhou city's health department to access the data. Some detailed statistical data underlying this article will be shared on reasonable request to the corresponding author. Requests to access these datasets should be directed to The studies involving human participants were reviewed and approved by Peking University Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.ZG, XG, and LS conceptualized and designed the study and contributed to data collection. ZG and LZ participated in data analysis. ZG, ZH, and XG conducted the final analyses and contributed to the interpretation of the results. ZG, ZH, XG, and LS drafted the initial manuscript. All authors have read and agreed to the published version of the manuscript.This study was supported by the National Natural Science Foundation of China (72104011 and 71774005). The Foundations had no role in the study design, data collection, data analysis and interpretation, writing of the manuscript, and the decision to publish.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. The reviewer DZ declared a shared affiliation with the authors to the handling editor at the time of the review.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.


CI) = 0.115–0.463). A positive association was found among participants from junior and senior school , and the SR score was positively associated with sexism among participants from the university/college . The most potentially obvious trauma that contributed to SR in junior and senior school adolescents might be cyberbullying. Family neglect or abuse might be a detrimental factor in SR for adolescents whether those in junior school or those in university school in China. More interventions, like education related to cyberbullying and family abuse, should be prioritized to reduce the risk of suicide.This study aimed to examine the current suicidal risk and whether the suicidal risk was associated with a wide range of trauma. The self-administered online questionnaire was adopted to collect suicide risk (SR) such as suicidal ideation, self-harm, suicide attempts, and different trauma information of the adolescents by cluster sampling in Chongqing, China. Multivariable linear regression was presented to assess the association between different risks of trauma and SR scores. Approximately 14.7% of adolescents enrolled reported suicide ideation and more than 10% of adolescents have experienced one kind of trauma during the Coronavirus disease 2019 (COVID-19) pandemic period. After adjusting for confounding variables, adolescents who suffered family hurt had a higher risk score of SR (beta coefficients (β) = 0.289, 95% confidence interval ( The Coronavirus disease 2019 (COVID-19) has profoundly caused the global public health crisis around the world since it broke out. The threat is continuing to ferment with the virus of COVID-19 constantly mutating, the virus Omicron strain has been recurring all over the world . The menSuicide is a serious global public health issue, especially in adolescents. The report of the World Health Organization (WHO) shows that close to 800,000 people die by suicide every year, which become among the top twenty leading causes of death worldwide and was the second leading cause of death between 15 and 29 years of age . AlthougTrauma is a complex emotional response to a stressful event that overwhelms the individual's capacity to cope. All traumas or stresses that can upset the psychophysical well-being of an individual, such as economic problems, diseases associated with chronic pain, war, sexual violence, grief, bullying, family conflicts, and other violence, are risk factors , 12. TheThe suicide risk (SR) assessment is the process of assessing and analyzing individuals who may have suicidal tendencies and risks, and then screening out the high-risk individuals, which can prevent suicide to a certain extent . TherefoChina Statistical Yearbook, China's adolescents (15–24 years old) population accounts for 10.48% of the total population  and university/college students. A stratified sampling frame was used according to the development of socio-economic, regional differences, urban and rural types, and other factors. Two districts and two counties were selected from Chongqing city through a convenience sampling method. In each district or county, one middle school or one university was selected using a random number table. In each school, one class was selected from each grade using a random number table. All students in selected classes were recruited through a questionnaire survey.Due to the COVID-19 epidemic, this survey was conducted by online questionnaire during September 2020. The questionnaires were completed online through WeChat and website link, and a total of 1,800 valid questionnaires were collected, due to the number of primary school students being small, they were excluded. Finally, the number of valid questionnaires included in this study is 1,248. Also, this study was approved by the Ethics Committee Review Committee of Chongqing Collaborative Innovation Center for Functional Food in Chongqing University of Education (202009HS01). The written informed consent to participate in this study was provided by the participant's legal guardian.The Chinese Youth Health-Related Behavior Questionnaire that was corrupted by the Chinese Center for Disease Control and Prevention (CDC) . was useBeyond suicidal thoughts and suicide plans, there are several behaviors in which there is an intention to die, such as depression emotion, SA, interrupted attempts, aborted attempts, and other suicidal preparatory acts. Suicidal behaviors require, not only the self-harm act but also there must be suicidal intent. By contrast, when individuals engage in self-injurious behaviors for reasons other than ending their lives, this behavior is termed as non-suicidal self-injury. Deliberate self-harm behaviors comprise self-injurious behaviors regardless of intentionality. Thus, the suicidal risk (SR) was measured by the following seven questions in this study: ‘During the past 2 weeks or more time, did you feel sad and desperate to be unable to carry out daily activities?' (yes/no); ‘did you approve of the behavior of suicide?' (yes/no); During the past 12 months, did you hurt yourself?'(yes/no); ‘During the past 12 months, did you seriously consider suicide?'(yes/no); ‘During the past 12 months, did you make a suicide plan?' (yes/no); and ‘During the past 12 months, did you attempt suicide?' (yes/no), if the answer to this question is yes, the participants would be asked to answer ‘how many times did you attempt suicide or did you make a suicide plan?' (none/once/2–3 times/4–5 times/≥6 times). As for the first five questions, if the answer is yes, the suicidal risk score gets 1 point. otherwise, 0 points were counted. The answer to the sixth question was got 0 to 4 points. When the sixth question answer is yes, none = 0, once = 1, 2–3 times =2, 4–5 times = 3, ≥5 times = 4; and the sixth question answer is no, the score is also 0. The score of suicidal risk is higher, the suicidal risk was higher.To adjust for potential confounders, the gender, nationality, grade, regions, living conditions, and family support were set as socio-demographic characteristics variables. The nationality was categorized as ‘Han' and ‘minority'; the grade was categorized as the junior school, the senior school, and the university/college; the regions were classified into two levels, urban and rural. The living conditions of participants included whether they were stay-at-home or migrant adolescents. The family support was scored by assessing the relationships of participants with their parents.The lifestyle consists of a history of smoking, drinking, and exercise status. The health status variables include a history of the diseases, which were dichotomized and defined by doctors, such as loneliness, sleep quality, and physical status. Loneliness was a subjective feeling; wand classified it into three levels, such as low, medium, and high level. The sleep quality was categorized into three levels, such as low, medium, and high level by assessing the participants' problems when they were sleeping. The physical status was measured by the following questions ‘Did you have the following physical problems in the last 2 weeks? headache/stomachache/back pain/depressed/irascibility/nervous/difficulty of fall asleep/dizzy)'?The trauma risk (TR) in this study was categorized into six facets, family abuse or neglect, bullying at school, sexual assault, sexism, economic discrimination, and cyberbullying. The ignorance of parents, the cures and injury by parents, the violence between parents were concluded in the family abuse or neglect. The bullying at school was measured by asking the participants whether they used to be given a nickname, or be teased, or be sidelined, or be disrespectful, or be bullied by teachers or their schoolmates/classmates. Sexual assault was an incident that involves sexual contact or language violation that is forced by somebody, and the sexism and economic discrimination were scored by asking percipients whether they used to get sexism or economic discrimination by anybody. Participants who received any trauma in one specific aspect, are considered to have trauma of this specific aspect. Otherwise, it is regarded as no trauma in this specific respect.t-tests in Stata statistical software . Considering the adolescents in university/college and junior and senior school youths may be at different physiological stages and may face different social pain, we analyzed the grade as the subgroup. The ANOVA test was used for the continuous variables and the chi-square analysis was used to estimate the different trauma among adolescents experiencing SI and those with a history of SAs. Multivariable linear regression was presented to assess the association between different risks of trauma and SR scores. To adjust for potential confounders, the following three models were used. Model 1 adjusted for variables of the different trauma, bullying at school, sexual assaults violence, sexism, economic discrimination, and cyberbullying. Model 2 further adjusted for socio-demographic characteristics variables which included gender, nationality, regions, living conditions, and family support. Model 3 further adjusted for variables of lifestyle and health status. The positive regression coefficient indicates an increase in suicidal risk scores. Results are reported for beta coefficients (β), and 95% confidence interval (95% CI).All statistical data were analyzed using two-sided p < 0.05). As for the health status, the participants in the junior and senior schools have higher aloneness than the adolescents in university/college . Besides, the participants in junior and senior school may have lower physical health .The characteristics of the 1,248 participants in the study population were presented in p < 0.05) ( < 0.05) .CI = 0.454–8.08), and the associations remained significant after adjusting for confounding variables in model 2 and the model3 . The same results were found among participants in junior and senior school, with beta coefficients ranging from 0.29  for family neglect or abuse to 0.415  for cyberbullying. The SR score was positively associated with cyberbullying in all three models (p < 0.05). In fully adjusted models (model 3), there was no evidence that the SR was associated with bullying at school (p = 0.19), sexual assault (p = 0.399), sexism (p = 0.161), and economic discrimination (p = 0.755). However, we found that the SR score of the participants from the university/college was positive with sexism. Additionally, the SR score was not significantly associated with cyberbullying among participants from the university/college (p > 0.05) while a positive association was found among participants from the junior and senior schools.Multivariable adjusted the associations between SR scores and different traumas were shown in During the COVID-19 pandemic, isolation, contact restrictions, and economic shutdown impose a complete change to the psychosocial environment of affected countries , and higAdolescents those suffered family neglect or abuse had a high score of SR, and the associations remained significant after adjusting for socio-demographic variables, whether those in college/university or those in middle school. During the COVID-19 pandemic period, adolescents were isolated in homes and spent more time with their families than before. Families will not only provide adolescents with financial and material resources, but also provide them with social support and social integration, which will have an important impact on their physical and mental health . The socThe association between SR and bullying at school, sex violence, and economic discrimination was not found among adolescents whether those in college/university or those in Middle School, after adjusting the confounding variables in this study. The school closures and social contacts are strongly limited, and out-of-home and leisure time activities are canceled during the COVID-19 pandemic , which mLife events before suicidal behavior are usually academic stressors (such as exam stress or bullying), family conflicts, disturbance, and other stressful life events . In thisFurthermore, a significant association between sexism and SR score was only found in the group of adolescents in college/university. This finding was similar to the previous study in Pakistan . Sexism The study was conducted within one province of China the samples may not represent all Chinese adolescents. As with all cross-sectional study designs, the causal nature of associations between different trauma and SR in this study cannot be determined. A longitudinal, multi-center sampling and multi-method design should be used in further study. Thus, the results should be interpreted with caution. Although anonymity, privacy, and confidentiality were assured, the self-report data may be impacted by social acceptability bias, particularly concerning sensitive questions such as a history of sexual assault. The COVID-19 is also a kind of trauma, and the community environment, sexual orientation, and other possible confounding variables may have impacted the SR, the interaction of COVID-19 and other different traumas should be considered in further studies.The findings highlight the different effects of sub-types of traumas on SR. The most potentially obvious trauma that contributed to SR in junior and senior school adolescents might be cyberbullying, and sexism contributed to the SR in those university students might be still serious during the COVID-19 pandemic period. Family neglect or abuse might be a detrimental factor in SR for adolescents whether those in junior school or those in university school. More attention should be paid to family education to decrease neglect or abuse and the SR during the COVID-19 prevention and control period. Intervention on cyberbullying and efforts should be prior conducted in adolescents in junior and senior school and the concept of gender equality should be traded for everyone from an early age to anti-sexism and suicide prevention.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Ethics Committee Review Committee of Chongqing Collaborative Innovation Center for Functional Food in Chongqing University of Education (202009HS01). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.YY and TW conducted statistical analyses of the data and prepared the draft manuscript. SW edited the manuscript. XZ and WL provide critical comments to the manuscript. All authors checked and proofread the final version of the manuscript.Chongqing Municipal Education Commission, Humanities and Social Sciences Research Project 2021 (21SKGH284).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The aim of this study was to compare the anthropometric, biochemical, and hormonal characteristics and the presence of genetic polymorphisms of leptin, adiponectin, and tumor necrosis factor alpha (TNF-α) between eutrophic and obese children and adolescents.This is a case–control study involving 104 children and adolescents. All subjects were assessed for anthropometric characteristics and clinical, laboratory, and genetic polymorphism parameters. The sample was selected from the pediatric endocrinology outpatient clinic specialized in the treatment of obesity in children and adolescents according to the Centers for Disease Control and Prevention (CDC) classification, and controls were selected from the same location in the general pediatric outpatient clinic.As a result, the parameters, such as black color, obese parents, hypertensive parents, and early weaning, were found to be associated with obesity. Increased levels of insulin, triglyceride, total cholesterol, LDL cholesterol, CRP-U, AST, ALT, GGT, free T4, IGF-1, and uric acid and low levels of HDL cholesterol are found to be associated with a higher chance of obesity. The presence of AG/AA polymorphisms in the leptin is associated with a 290% (OR 3.9) higher chance of obesity, and for adiponectin genes, the chances are 740% (OR 8.4) higher. In these obese children and adolescents with AG/AA haplotypes, serum leptin levels were increased and adiponectin levels were decreased in eutrophic individuals, whereas serum TNF-α levels did not change.The AG/AA polymorphisms in the leptin and adiponectin genes alter the serum levels of these adipokines and predispose them to obesity, and many anthropometric, biochemical, and hormonal markers are altered, demonstrating early consequences for the health of these obese children and adolescents. According to the World Health Organization (WHO), there was an estimated 1.9 billion (39%) overweight and obese adults. Overweight children and adolescents between the ages of 5 and 19 years are 340 million. By 2025, it is expected that there will be an increase in the overweight people by 2.3 billion.Obesity is determined by a combination of genetics, environment, and lifestyle. It is known that obesity initiates during childhood or adolescence, followed by increased rates of dyslipidemia, hypertension, coronary diseases, diabetes, and depression before adult age.LEP) gene has the function of informing the brain about energy supply, in addition to the modulation of glucose and lipid metabolism, angiogenesis, immunity, and homeostasis of blood pressure. Serum leptin production and concentration are proportional to adipose tissue mass.Adipose tissue and regulation of leptin, adiponectin, and tumor necrosis factor alpha (TNF-α) are linked to endocrine and molecular mechanisms, which play a physiological role in energy balance and body weight. In this sense, the human leptin  aged 6–18 years, with a mean age of 10±2 years. The subjects were obese patients who visited at the Preventive Medicine Service, Aracaju, Sergipe, Brazil, in the period May–November 2019. The patients were divided into case group and control group. The case group included those who had body mass index (BMI) above the 97th percentile or Z-score greater than +2, according to the Centers for Disease Control and Prevention (CDC) classification. The patients were excluded if they have taken anti-obesity or anti-anxiolytic medication and those with bulimia. The control group consisted of patients selected from the same location in the general pediatric clinic, who considered themselves healthy, were eutrophic with a BMI of the 50th percentile or a Z-score of 0, and age similar to the case group.All subjects were evaluated for anthropometric characteristics, sex color, obese father, obese mother, hypertensive father, hypertensive mother, type of birth, early weaning, and food behavior; and in clinical parameters, birth weight, BMI, and abdominal circumference were assessed.The laboratory evaluation was performed in a certified laboratory from the serum sample taken after 12 h of fasting. The sample included concentration of 21 biochemical, hormonal, and cytokine parameters, such as insulin, glucose, homeostatic model assessment for insulin resistance (HOMA-IR), triglyceride (TRI), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), ultrasensitive C-reactive protein (CRP-U), homocysteine, interleukin 10 (IL-10), IL-6, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), thyroid-stimulating hormone (TSH), free T4 (T4L), insulin-like growth factor 1 (IGF-1), cortisol, uric acid, leptin, adiponectin, and tumor necrosis factor alpha (TNF-α).www.allsnps.com). This program illustrates a panel of human chromosomes representing the location of more than 150,000 SNPs validated in the haplotypic blocks and respective SNP tags for each population evaluated in the HapMap Project , in addition to prioritizing the selection of SNPs based on the model’s connection imbalance.Single-nucleotide polymorphisms (SNPs) were selected using the SNP browser TM software version 4.0  greater than 5%, and the presence of at least one marker in each haplotypic block of the genes. Therefore, we studied the SNPs and compared the association of genetic polymorphisms of leptin , adiponectin , and TNF-α .After extraction of the genomic DNA by the Flexi Gene® kit (Qiagen), SNP analyses on the adiponectin rs17300539 (11931G/A) and leptin rs7799039 (2548G/A) genes were performed using the real-time polymerase chain reaction (PCR). From the isolated DNA, the DNA fragments were amplified by the commercial TaqMan system, using primers and probes corresponding to each SNP made by Applied Biosystems®.The specific primers used for the genes in question are as follows: SNP rs7799039 (leptin) (5’-TTGTTTTGTTTTGCGACAGGGTTGC [A/G] CTGATCCTCCCGCCTCAGTCTCCCT-3’) and SNP rs17300539 (adiponectagA) [TipGTTAA] GCTCAGATCCTGCCCTTCAAAAACA-3’).Reactions were performed in CFX96 real-time thermal cycler (Bio-Rad®). A final reaction volume of 20 μL containing 50 ng of DNA diluted in water, 10 μL of 2× master mix (TaqMan), and 1 pmol/μL of primer were used. The analyses were performed using the CFX 96 (Bio-Rad®) thermocycler program.To identify the SNP in the TNF-α rs1800629 (−308G/A) gene, PCR-RFLP was performed using specific primers to amplify the polymorphism region, with primer forward (5’’AGGCAATAGGTTTTGAGGGCCAT-3’) and reverse (5’’TCCTCCCTGCTCCGATTCCG-3’) as previously described.The enzymatic restriction reaction with the Ncol enzyme was standardized at 37°C for 2 h. The electrophoretic run was performed on a 2% agarose gel at 125 V for 1 h and 20 min to analyze the products of the PCR-RFLP reaction with Syber green intercalating dye.The bands were visualized by an image capture system coupled to a transilluminator. A 107 bp band, without the restriction of the Ncol enzyme, corresponds to the wild-type homozygote genotype (GG), and the presence of two 87 and 20 bp bands corresponds to the cut by the enzyme, due to the presence of the allele (A), polymorphic homozygote (AA), and the presence of three bands, 107, 87, and 20 bp, corresponding to the heterozygote (GA).The analyses were performed using STATA Analysis and Statistical software version 12 .To evaluate the normality of the laboratory parameters, a graph of diagnosis for quantile–quantile (Q-Q) residues was used in a regression model, and the significance value (p) of the Shapiro–Wilk test for the diagnosis of normality was considered as a deciding factor.The nonparametric study variables were presented as frequency and median and dispersion measures as the interquartile range (25th percentile–75th percentile).To compare the quantitative results between the eutrophic and obese classification, the data were compared with the Mann–Whitney U test, considering the level of significance (α) as 5% (0.05).Odds Ratio (OR) statistics with 95% confidence intervals (95% CI) to estimate the associated risk.To compare the qualitative results between the eutrophic and obese classification, homogeneity tests were performed using the chi-square test and In this study, 60 patients met the inclusion criteria, and 58 agreed to participate in the study. Among the 60 (eutrophic), 14 were dropped out during the survey. Considering a 95% CI, the cases have a sampling error of 2.3% and the controls 7.0%.The ethical and methodological aspects of this study were approved by the local Ethics Committee (protocol 04065412.600005526) according to the National Health Council (Resolutions 466/12). All participants were informed about the objectives and procedures of the study, and written informed consent was obtained from the participants.The eutrophic group was composed of 46 children and adolescents with a mean age (SD) of 10 (±2.7) years and had a BMI with a mean (SD) of 17.3 (±2.1), and the obese group was composed of 58 children and adolescents with age mean (SD) of 11 (±2.9) years and presented BMI with mean (SD) 28.1 (±5.3).Anthropometric characteristics were compared between eutrophic and obese children and adolescents. The parameters such as skin color (black), having an obese father or mother, having a hypertensive father, and having been weaned early, that is, before 6 months of life were found to be associated with obesity .The HOMA-IR index values in the eutrophic and obese groups were 1.6 and 2.6, respectively (p<0.001), with birth weights of 3,000 and 3,285 kg (p=0.010) and abdominal circumferences of 65 and 88 cm (p<0.001), and these clinical and laboratory parameters were associated with higher statistical significance in the group of children and adolescents with obesity when compared to eutrophic individuals.The levels of insulin, TRIs, total cholesterol, LDL, CRP-U, AST, ALT, GGT, and uric acid were elevated and HDL levels were decreased among obese patients when compared with eutrophic patients. Although the levels of T4L, IGF-1, and cortisol are high in the obese group compared with controls, these parameters do not meet the criteria of hormonal pathologies that are performed for diagnostic screening .A greater chance of obesity was observed in patients who had leptin AA/AG haplotypes (rs7799039)  and adiponectin (rs17300539)  when compared to GG haplotypes, but not significant for patients’ TNF-α haplotypes .Patients with leptin AA/AG haplotypes had higher serum leptin concentrations when compared to the GG haplotype, whereas patients with AA/AG adiponectin haplotype had lower serum adiponectin concentration when compared to the GG haplotype. No difference was found in serum TNF-α concentration between the TNF-α haplotypes of the study patients .The Kernel density graph shows a predominance of low results for leptin in patients with GG haplotypes, while the adiponectin graph shows a predominance of high results for GG haplotypes .Several etiological causes may contribute to the onset of children and adolescents’ obesity. The obese children are at higher risk of becoming obese adults and of suffering more serious complications of illness in the short term. In our sample of children and adolescents, we also found this association. Studies demonstrate that the allele A is a protective factor against obesity in adults. In our study, we can evidence this protection in eutrophic children and adolescents. The relationship between these genetic factors of leptin in the regulation of leptin synthesis is evident, which may be important for therapeutic interventions in obese children and adolescents.In our study, we found higher serum leptin levels in patients with AA/AG haplotype of this gene, which is similar with previous studies in adults. Jiménez-Osorio et al. demonstrated that the presence of AA/AG polymorphism in the leptin gene is associated with obesity in adult patients.The polymorphism in the leptin gene rs7799039 is located at the 5’ end of the promoter region and close to a transcription factor binding site that regulates leptin transcription. Leptin is an adipokine that regulates food intake by suppressing appetite, and increased serum levels are associated with inflammation, oxidative stress, and the development of insulin resistance. In our study, this decrease was also observed in obese children and adolescents. Adiponectin participates in energy homeostasis and acts on adipose tissue, and reduction in adiponectin concentrations promotes sluggish lipid and carbohydrate metabolism, thereby stimulating the consumption of food for energy supply. The allele A of this gene appears to increase adiponectin levels due to increased transcription, suggesting an influence of this allele on characteristics related to obesity.The rs17300539 adiponectin gene, an adipokine abundantly produced by adipose tissue, was associated with a decrease in the serum expression of adiponectin in adults. However, the understanding of the genetic mechanisms involved in the genesis of obesity is necessary for the development of interventions even in childhood and adolescence that can prevent future health problems, which in some cases are irreversible, but which can be mitigated by a team of interdisciplinary health professionals.The role of the environment cannot be ignored, although the genetic variants in the adiponectin and leptin genes have effects on energy consumption and weight gain. This conformed to the children and adolescents in our study. However, our result differs from a study published in 2016 with 885 elderly Brazilians in which obesity was not associated with self-declared black color, but with socioeconomic variables such as education and family income, which may be related to color.Furthermore, it has been reported that obesity has a hereditary factor and that black adults are more likely to be obese.Our study demonstrated that babies who started solid feeding before 6 months of age, characterized by early weaning, had a higher chance of obesity in childhood and adolescence, which corroborates with the WHO recommendations of breastfeeding for 6 months, followed by the gradual introduction of nutritionally adequate and safe complementary foods along with the maintenance of breastfeeding for up to 2 years. Other epidemiological studies have also shown that babies who started feeding solids before the age of 6 months have a higher risk of obesity compared to those who started after. It also receives a flow of chemical mediators, which inform about the mother’s nutritional status and possibly the quality of the postnatal environment. This information contributes to shaping the composition and size of the body, as well as to the structuring of the individual’s endocrine and metabolic systems.In our study, we observed a higher birth weight in obese patients. The fetus reflects, depending on nutrition, growth, and body composition, the supplies and energy it receives from the mother and also expresses its dependence on the placental function.Obesity is accompanied by an increase in waist circumference, which was also observed in this present study. Higher waist circumference represents a higher risk for the development of diabetes, dyslipidemia, cardiovascular disease, and metabolic syndrome. This measure has been suggested to be better than BMI to estimate these risks.Assessing the relationship between diabetes and obesity, in our study, it is possible to observe that in childhood and adolescence, β-pancreatic cells increase their production of insulin as a compensatory mechanism, while glucose tolerance remains normal.Insulin resistance in obese patients can be explained due to the inflammatory response with alteration of substances that act systemically, participating in several metabolic processes, such as leptin, adiponectin, and TNF-α, which play a fundamental role in insulin resistance.In this situation, there is a decrease in the insulin capacity to stimulate the use of glucose by the muscle and fat tissue, causing damage to the suppression of lipolysis, a condition that increases the circulation of free fatty acids and further alters the transport of glucose to the target tissues inhibiting the action of insulin. Insulin resistance leads to increased oxidation of fatty acids, providing a substrate for the synthesis of TRIs and increasing the release of LDL cholesterol by decreasing HDL cholesterol. This lipid profile is related to an increased risk of developing cardiovascular disease, hepatic steatosis, and insulin resistance.In our study, we identified the change in the levels of the components of the lipid profile, which is explained by the accumulation of adipose tissue and the release of free fatty acids, which are in greater proportion directed to the liver for greater production of TRIs and LDLs, contributing to the increase in total cholesterol and decrease in HDL cholesterol. Although PCR-U is not specific for cardiovascular risk, compared to the control group, the highest risk of coronary disorders associated with obese children and adolescents is evident.The PCR-U parameter has already been associated with obesity in adults. In our study, PCR-U increase was associated with obese children and adolescents. PCR-U has been described as an important marker of future coronary disorders. The normal levels of a population are below 0.5 mg/dL. The eutrophics in this present study had a median of 0.02 mg/dL, while the obese group had 1.52 mg/dL. Studies show that a small increase is considered a cardiovascular risk factor, independent of other factors already known.The liver parameters such as AST, ALT, and GGT were elevated and compared between obese patients and eutrophic patients, despite not being above the reference value. Obesity is associated with several changes in the liver resulting from the release of fatty acids from adipose tissue for the production of TRIs in the liver, which leads to liver steatosis and increased liver enzymes and, in some cases, may progress to hepatomegaly, fibrosis, and cirrhosis. However, in our study, we found higher T4L levels in obese individuals, and this elevation does not meet the criteria for thyroid hormone pathologies. This fact has not been described in the literature.It is known that childhood obesity is multifactorial, with the majority of cases being exogenous in nature; however, it can be associated with other causes, especially when accompanied by identifiable changes in growth monitoring. It has been described that hypothyroidism is not a cause of obesity, just as obesity is not a cause of hypothyroidism. Our obese patients had higher levels of IGF-1 when compared to eutrophic individuals.It is known that hyperinsulinemia, a characteristic that was observed in our sample, induces a higher production of IGF-1 and lower production of IGFBP-1 (Insulin-like growth factor-binding protein 1) by the liver. IGFBP-1 is an IGF-1 binding protein that inhibits its activity. These insulin-induced changes would result in a greater amount of free IGF-1 capable of exerting negative feedback on the pituitary for GH secretion.Uric acid is an organic compound, produced endogenously in the liver of humans. It acts as a metabolite of purines. It is formed by adenosine, inosine, hypoxanthine, adenine, and guanine. It is considered as one of the main hydrophilic antioxidants in the body. Uric acid inhibits the action of free radicals on organic molecules, such as those that make up the cell membrane and genetic material. In our study, obese patients had higher levels of uric acid, and this chronic increase is associated with the risk of metabolic syndrome; however, the acute increase in its concentration seems to be a protective factor against oxidative stress.Although the sample is considered small for polymorphism studies in chronic metabolic diseases, the population of our study was a multiracial heterogeneous group of children and adolescents with obesity in the Northeast region of Brazil. Further studies should be carried out with children and adolescents with obesity in other regions of Brazil with a larger sample.We conclude that the AG/AA polymorphisms in the leptin and adiponectin genes alter the serum levels of these adipokines and predispose to obesity. Furthermore, there are changes in anthropometric, biochemical, and hormonal markers, showing early consequences for the health of these children and adolescents.


This study aims to predict the lymphatic metastasis in Ewing's sarcoma (ES) patients by nomogram. The risk of lymphatic metastasis in patients with ES was predicted by the built model, which provided guidance for the clinical diagnosis and treatment planning.n = 51). Receiver operating characteristics (ROC) curves and calibration plots were used to evaluate the prediction accuracy of the nomogram. Decision curve analysis (DCA) was implemented to illustrate the practicability of the nomogram clinical application. Based on the nomogram, we established a web calculator to visualize the risk of lymphatic metastases. We further plotted Kaplan-Meier overall survival (OS) curves to compare the survival time of patients with and without lymphatic metastasis.A total of 929 patients diagnosed with ES were enrolled from the year of 2010 to 2016 in the Surveillance, Epidemiology, and End Results (SEER) database. The nomogram was established to determine predictive factors of lymphatic metastasis according to univariate and multivariate logistic regression analysis. The validation of the model performed using multicenter data , which were identified for lymphatic metastasis in ES patients. The model showed significant diagnostic accuracy with the value of the area under the curve (AUC) was 0.743 (95%CI: 0.714–0.771) for SEER internal validation and 0.763 (95%CI: 0.623–0.871) for multicenter data external validation. The calibration plot and DCA indicated that the model had vital clinical application value.P < 0.01), M stage  and survival time  were important independent factors for lymphatic metastasis in ES patients. Furthermore, survival time in patients with lymphatic metastasis or unclear situation (P < 0.0001) was significantly lower. It can help clinicians make better decisions to provide more accurate prognosis and treatment for ES patients.In this study, we constructed and developed a nomogram with risk factors to predict lymphatic metastasis in ES patients and validated accuracy of itself. We found T stage (Tx OR = 2.540, 95%CI = 1.433–4.503,  It is characterized by young onset age, non-specific clinical features, strong invasion ability and poor clinical prognosis (Ewing's sarcoma (ES) is the secondly common malignant bone and soft tissue tumor in children and adolescents, with an incidence of 1 in 1.5 million. It is a small round cell malignant tumor originating from bone marrow mesenchymal stem cells. Eighty-five to ninety percent of ES patients have typical chromosomal translocations [rognosis .Patients with ES have poor long-term prognosis in spite of the variety of treatments and the progress made in surgery, radiotherapy and chemotherapy , 9, 10. Few previous studies have involved combining multiple independent factors to predict lymphatic metastasis in patients with ES , 14. TheIn this study, the patients' data was extracted from the SEER database in order to establish a nomogram. Furthermore, we validated it externally via multi-center clinical data of patients. To provide patients with more accurate medical services, we also designed a web calculator that could help clinicians quickly and accurately assess the risk of lymphatic metastasis in various ES patients.The Surveillance, Epidemiology, and End Results (SEER) database was used for data collection and analysis. The database is the most detailed and authoritative one which provide evidence of evidence-based medicine, covering more than 30% of the total population in the United States from 1973 to 2016. The patients in this study were selected from the SEER database for diagnosis of ES from 2010 to 2016.* STAT (version 8.3.5) software. 929 patients were selected as training cohort according to inclusion/exclusion criteria: (1) ES confirmed according to morphological code 60 of ICD-O-3/WHO 2008; (2) The patients who did not lose follow-up; (3) A clear description of tumor invasion; (4) Complete baseline information; (5) Clear treatment information; (6) Survival time is >0.Patients diagnosed with ES from 2010 to 2016 in the SEER database were screened by SEER The information on sex, age, race, survival time, primary site, laterality, T stage, N stage, surgery, radiotherapy, chemotherapy, and distant metastasis were collected. External verification using data of 51 ES patients via clinical and pathological diagnosis from four medical institutions . Three investigators were responsible for data acquisition and processing at each center. Two of them were in charge of extracting the data while the third person was responsible for further verification. Data was further checked by using Microsoft Excel .T-test and Chi-square test. Then we evaluated several potential factors to predict lymphatic metastasis in ES patients by univariate logistic regression analysis. Multivariate logistic regression was utilized to further analyze the independent factors associated with lymphatic metastasis in ES patients. From this, we constructed a nomogram, plotted the receiver operating characteristic (ROC) curve, and calculated the area under the curve (AUC) to evaluate the accuracy of nomogram. The proximity between the actual probability and the predicted probability was verified by the calibration plot. Decision curve analysis (DCA) was used to evaluate the clinical utility.We compared the baseline information of 980 patients using the T-test, Chi-square test, Kaplan-Meier, univariate and multivariate logistic regression analysis. Nomogram, ROC curve, calibration plot, and DCA curve were prepared by R language (version 4.0.5). P < 0.05 was considered statistically significant.Quantitative data were calculated in the form of Mean ± standard deviation (SD), and qualitative data were expressed as counts and percentages. SPSS 26.0 software  was used for T-test and Chi-square test with baseline information of patients showed that no significant differences existed between the training group and the validation group in survival time, age, sex, primary site, laterality, M stage, surgery, chemotherapy and lung metastasis (P > 0.05), however, differences were statistically significant in the race, radiotherapy and T stage statistically (P < 0.05). Among the 980 patients, 139 of them had lymphatic metastasis, while 841 didn't have or the status of lymphatic metastasis could not be assessed. There were statistically significant differences between the two groups in survival time, race T stage, M stage, surgery and lung metastasis (P < 0.05).A total of 980 patients were included, among which 929 patients were screened from the SEER database for a training cohort and the other 51 patients were from four clinical centers for validation. The results of the P < 0.01), M stage  and survival time  were important independent factors for lymphatic metastasis in ES patients  in order to assess the risk of lymphatic metastases. We found that Tx had the greatest impact on lymphatic metastasis while surgery had the least impact  was significantly lower. At the same time, DCA plots were drawn to evaluate the clinical utility of the model, and we observed that the model had good clinical utility in predicting lymphatic metastasis in ES patients  curves for patients with and without lymphatic metastasis . Comparepatients .Ewing's sarcoma (ES), first reported by James Ewing in 1921, is an aggressive bone and soft-tissue tumor , 23. ThaLogistic regression analysis indicated that T stage, M stage and survival time were independent factors for lymphatic metastasis in ES patients. Several consistent prognostic factors were identified in North America and Europe. Multiple studies showed that in addition to stage, poor prognostic factors included tumor size and metastasis at diagnosis –32, whicTumor size was considered to be an important prognostic factor. Large initial tumor size has been repeatedly identified as negatively affecting survival in ES patients . The cor18F-fluorodeoxyglucose(FDG)PET-CT scan.The current study also showed that most patients began with micro-metastases . FurtherBased on previous studies, ES was more commonly found in men than in women (sex ratio of 3:2), and the prevalence was over seven times higher in whites than in blacks , 5, 35. Although this model provided theoretical support for clinical diagnosis and treatment, some shortcomings remained in our study: (1) first of all, although we established the lymphatic metastasis in patients with clinical prediction model which was verified by external cohort, external validation group of small number of cases might be a problem such as selective bias; (2) due to incomplete data entry in SEER database, we were unable to analyze all factors that might be associated with lymphatic metastasis. For instance, it was lack of some laboratory indicators, such as serum lactate dehydrogenase (LDH) levels. Based on this, we could avoid bias by further increasing the number of cases in the external cohort. In addition, we could use the case data of Asian people to establish a more suitable prediction model for Asian people so that we can make a comparison of this model.Our study established the associated nomogram by using data from the SEER database and comprehensively evaluated predictors of lymphatic metastasis in ES patients via external validation. The prediction of the risk of lymphatic metastasis could guide clinicians to carry out individualized and precise treatment for patients, and help to formulate follow-up treatment measures and plans for patients.The original contributions presented in the study are included in the article/All participants signed written informed consents following the recommendations of the Institutional Review Board of the Xianyang Central Hospital. The ethical approval certificate is 20210022.CY and ZL designed the study. WeL and ZH performed the study and analyzed the data. WeL and CX wrote the manuscript. SD, HW, QL, and Z-RT provided the expert consultations and clinical suggestions. WaL participated in its design and coordination. BW helped to draft the manuscript. All authors reviewed the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.