With improvements in treatments for primary tumor and brain metastases (BM), the life expectancy of patients with advanced cancers is increasing; thus, helping patients with BM maintain quality of life is becoming increasingly important. Sense of coherence (SOC) has been found to be closely related to health-related quality of life (HRQoL) in patients with chronic diseases, however, this relationship has not been validated in patients with BM. This study first examined the relationship between SOC and HRQoL in patients with BM, and further identified factors associated with SOC in these patients. Patients with BM reported lower scores for most of the functioning subscales and for the general rating of quality of life, and higher scores for most of the symptom subscales, compared with a normative sample. SOC was significantly correlated with most aspects of HRQoL in patients with BM. Further, SOC in the patients was associated with awareness of the disease, possession of religious belief, and type of primary cancer. These results validate the close relationship between SOC and HRQoL in patients with BM, and indicate that SOC is associated with awareness of illness and religious belief. Metastatic brain tumors occur when primary tumor cells from other parts of the body metastasize to the brain. It is estimated that 20–40% of patients with cancer will develop brain metastases (BM), and the incidence of BM is 4–5 times more common than that of primary brain tumors . The repThe occurrence of metastases may induce a high level of psychological distress in cancer patients. Some cancer survivors show successful psychosocial adjustment to the illness . Such adA few studies have indicated that in patients with chronic illnesses, SOC is positively associated with quality of life . A meta-Research suggests that in adulthood, SOC remains relatively stable, and even after radical life events, only temporary fluctuations occur. It has been shown that SOC is unaffected by age, gender, education, and place of residence . Other rCurrently, studies are lacking of the association between HRQoL and SOC; nor have investigations considered the factors related to SOC in patients with BM. Accordingly, the first aim of this study was to investigate the relationship between SOC and HRQoL in patients with BM. Such knowledge would contribute to the growing body of research highlighting the close association between HRQoL and SOC in patients with chronic diseases. Further, we investigated the relationship between sociodemographic/psychological/disease-related characteristics and the level of SOC in patients with BM.This cross-sectional study was conducted at the Department of Functional Neurosurgery of Ruijin Hospital and the Gamma Knife Treatment Center of Shandong Provincial Hospital from January 2017 to July 2019. The inclusion criteria were (a) 18 years of age or older, (b) a diagnosis of BM, and (c) physically able to participate. Patients were excluded from the study if they exhibited disturbed consciousness or if they were diagnosed with a psychiatric disorder, as indicated by their clinical records. The patients were enrolled during appointments either after consultation or before hospitalization. Each patient recruited was fully informed of the purpose of the study and gave their written consent to participate. Sociodemographic information and treatment histories were recorded. In addition, the patients were asked to complete questionnaires measuring SOC and HRQoL at the clinic or during the intake process for hospitalization. The patients were instructed to complete the questionnaires based on their experiences of cancer, rather than previous experiences of psychological disorders, other chronic illnesses, or previous trauma. In total, 170 patients consented to participate in the study, all of whom answered the questionnaires before gamma knife treatment. The 162 patients (95.3%) who completed the questionnaires formed the sample. This study was approved by Ruijin Hospital Ethics Committee .The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 Version 3.0 (QLQ-C30) is a self-rated questionnaire that assesses multiple dimensions of quality of life among cancer patients. It is composed of multi-item functional scales , multi-item scales, or single-item measures of common symptoms reported by patients with cancer patients , financial difficulties, and two questions assessing global quality of life. An example item from the functioning subscale is “Do you have trouble taking a long walk?” and an example from the symptom subscales is “Have you had pain during the past week?” The raw score of each subscale/item in the QLQ-C30 is linearly transformed into a score ranging from 0 to 100. Higher scores on functional or global quality of life scales indicate better functioning or quality of life, while higher scores on symptom scales indicate the presence of more severe symptoms . The totThe Sense of Coherence 13-item scale (SOC-13) is a short version of Antonovsky’s Sense of Coherence Scale, which evaluates a person’s capacity to cope with stressors. The items are rated on a 7-point Likert scale, and ratings of all items are summed to generate a total score. Besides the total scale, the SOC-13 has three subscales: Meaningfulness (4 items), Comprehensibility (5 items), and Manageability (4 items). Higher scores indicate stronger SOC. Higher scores indicate stronger SOC. An example item from the Meaningfulness subscale is “How often do you have the feeling that there’s little meaning in the things you do in your daily life,” an example item from the Comprehensibility subscale is “Has it happened in the past that you were surprised by the behavior of people whom you thought you knew well?” and an example item from the Manageability subscale is “Has it happened that people whom you counted on disappointed you?” The SOC-13 has been shown to have sufficient validity and reliability . The Chit-tests or one-way ANOVAs. Associations between scale scores were examined using Pearson’s correlation coefficients. The significance level was set at p < 0.05 (two-tailed). Post hoc statistical power was calculated based on the actual effect size, α error probability (0.05) and actual sample sizes using G∗Power software, version 3.1.9  were calculated to profile the sociodemographic and disease-related characteristics of the sample. Harman’s single factor test was performed to examine the existence of common method bias, i.e., such bias was considered to exist if the 1st principal component explained more than 50% of the variance. Differences in SOC and HRQoL between subgroups of patients were tested using two-sample on 3.1.9 .SD = 10.95, range: 27–83 years). Among the patients, 81 finished elementary or secondary school education, 47 completed high school or college education, and 22 received undergraduate or graduate education. Most (93.2%) patients were married, 83.3% had medical insurance, 92.6% did not report any religious affiliation, and 16.0% were not aware of the situation of BM. The mean time interval between diagnosis of primary cancer and brain metastasis was 22.66 months . The average number of BM was 2.49 . Forty-one (25.3%) patients had extracranial metastatic lesions. The patients’ functional impairment, as indicated by the Karnofsky Performance Scale (KPS) score (SD = 20.02), which corresponded to being able to care for oneself, but unable to conduct normal activities or engage in active work.The sociodemographic characteristics of the patients are presented in S) score , which wps < 0.001, p = 0.491). The rating of general quality of life also decreased in patients with BM . The post hoc statistical power values were larger than 0.996 for the significant differences.Scores on the QLQ-C30 subscales indicated specific aspects of the quality of life of patients with BM. The Cronbach’s alpha coefficient of the QLQ-C30 scores of the patients was 0.914, indicating high internal consistency reliability. Compared with a large normative sample of 15,386 healthy subjects , the patSD = 11.66). The mean subscale scores were 25.30 (SD = 5.64) for Comprehensibility, 20.04 (SD = 4.21) for Meaningfulness, and 20.68 (SD = 4.30) for Manageability. The Cronbach’s alpha coefficient of the SOC scores of the patients was 0.833, indicating high internal consistency reliability. The SOC total and subscale scores were positively correlated with the global health status according to the QLQ-C30 and the four subscales measuring physical, role, emotional, and social functioning , while the other variables, including gender, age, education level, marital status, possession of medical insurance, possession of religious belief, type of primary cancer, existence of extracranial metastatic lesions, interval between diagnosis of primary cancer and BM, and awareness of BM were not significantly associated with QLQ-C30 total scores (ps > 0.088).To examine whether SOC was the key variable associated with HRQoL, and whether there exist some other variables closely related to HRQoL, an analysis was conducted to test the association between the sociodemographic/clinical/psychological variables and QLQ-C30 scores . The rest = 2.122, p = 0.035, Hedges’ g = 0.635), whereby those who expressed religious affiliation  reported higher scores on the Comprehensibility subscale of the SOC than those who did not express religious affiliation . Compared with patients who were not aware of the BM, patients who knew the extent of their disease reported significantly lower SOC total scores  and scores for the two subscale of Comprehensibility  and Meaningfulness . Comprehensibility scores of the SOC were also associated with the type of primary cancer ; post hoc comparisons indicated that the patients with primary gastrointestinal cancer produced higher SOC Comprehensibility ratings than did patients with primary breast cancer and other types of primary cancer . The other sociodemographic and clinical variables were not significantly associated with SOC scores, including gender, age, education level, marital status, possession of medical insurance, presence of extracranial metastatic lesions, and the amount of time between diagnosis of primary cancer and brain metastasis (ps > 0.072). The post hoc statistical power values were 0.557, 0.590, and 0.951, respectively, for religious belief, awareness of BM, and type of primary cancer.To examine whether SOC was associated with sociodemographic or clinical characteristics in patients with BM, a comparison was performed among subgroups and correlations between variables were assessed . There wIn the present study, we first examined HRQoL in patients with BM. We then determined that there was a significant positive relationship between SOC and HRQoL in the patients with BM, which has been observed for other types of chronic illness . In addiCompared with the normative sample of a previous study , the patIndividuals with a strong SOC maintain and enhance health by coping with stressors effectively and flexibly . PreviouThe experience of cancer is generally considered a low-control situation. In facing cancer, it is better for patients if they have a strong SOC, so they may perceive their life as meaningful despite the adversities they face . SOC hasOur study was subject to several limitations. First, the study only involved patients who were admitted before receiving treatment for BM. A long-term follow-up would be informative for the analysis of SOC and its impact on HRQoL alterations over time in patients with BM. Second, the study population was heterogeneous in that it included several types of primary tumors. Thus, this sample might only be representative of patients with metastatic brain cancer before stereotactic radiosurgery. In future studies, other treatments, such as surgery and whole-brain radiotherapy, should be included in addition to including more hospitals and cancer centers to gather additional information about the effect of treatments on patients’ SOC and HRQoL. The lowest statistical power value for the significant results was 0.557, which is not sufficiently high. This may have resulted from the relatively small number of patients within certain subgroups . Studies with larger sample sizes are needed to increase statistical power.In summary, the results of the present study indicate that high SOC levels are associated with high HRQoL in most aspects, with the exception of diarrhea symptoms. The SOC of patients with BM was associated with having religious beliefs, awareness of the illness, and the type of primary cancer. Our study validated the close association between SOC and HRQoL in patients with BM, and identified the sociodemographic, clinical, and psychological characteristics associated with SOC. These results highlight the close relationship between SOC and HRQoL, and that SOC in patients with BM is associated with awareness of the illness and possessing religious beliefs.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Ruijin Hospital Ethics Committee (2017), clinical ethics approval No. (28). The patients/participants provided their written informed consent to participate in this study.XQ and B-WW: conceptualization, writing – review, and editing. XQ and NZ: data curation, analysis, and writing the original draft. XQ, S-JP, and PZ: investigation and resources. B-WW: supervision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study explores how well the World Health Organization Disability Assessment Schedule (WHODAS 2.0) assesses problems with psychosocial functioning in patients with severe mental illness (SMI). Further, we assessed the relationships between psychosocial functioning and psychopathology, medication side effects, treatment setting, and quality of life.We performed an observational, cross-sectional study on the island of Curaçao to assess psychosocial functioning in 77 patients with SMI; they mainly had psychotic disorders. We interviewed their healthcare providers using the proxy version of the WHODAS 2.0. In addition, patients were examined for psychiatric symptoms, medication side effects (including drug-induced movement disorders), and quality of life. Associations were examined with Spearman's rank correlation (ρ).versus M=23.2, SD=14.1, p=0.03). A positive correlation was observed between drug-induced parkinsonism and the WHODAS 2.0 total score , as well as with various subscales, getting around, and household activities.Difficulties in psychosocial functioning were reported by patients with SMI in the WHODAS 2.0 domains of understanding and communicating . Notably, outpatients had more problems participating in society than inpatients (M=33.6, SD=18.5 The proxy version of the WHODAS 2.0 is clinically useful for patients with severe mental illness. The highest scores on the WHODAS 2.0 were found in domains related to interactions with other people and to participation in society. Inpatient status appeared to aid participation in society; this might be due to living in the sheltered clinic environment and its associated daily activities. We further found that drug-induced parkinsonism was associated with a broad spectrum of psychosocial disabilities.ClinicalTrials.gov, identifier: NCT02713672; retrospectively registered in February 2016 The term “severe mental illness” (SMI) was introduced by the USA Substance Abuse and Mental Health Services Administration to differentiate between psychiatric patients with and without problems in daily functioning. Criteria for SMI include excessive disturbance and clinically significant distress or impairment in social, occupational, or other important areas of functioning. Although, potentially, all Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), diagnoses can be involved, most of the patients who qualify as severely mentally ill have been diagnosed with schizophrenia, or another psychotic or major mood disorder. The prevalence of severe mental illness in the USA is about 5% in adults .In the aim of treatment of patients with SMI, there is currently a shift in focus from care to recovery. Recovery is a process in which the most important goal is to regain a meaningful life in the community, including participation in valued activities and fulfillment of social roles –5. PartiIn DSM-5, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) was introduced as a better measure of psychosocial functioning in individuals with psychiatric disorders  than theversus in-hospital treatment in patients with SMI , and treatment setting (in- or outpatient) may influence functional recovery –13. For with SMI –14.The WHODAS 2.0 offered valuable insight into patients' experiences, had acceptable validity and psychometric properties, but it was challenging to use with patients with long-term psychotic disorders and several limitations were reported , 16, e.gOur study explored the use of the proxy version of the WHODAS 2.0 for assessing psychosocial functioning in a population with SMI. Further, we assessed the relationships between functioning and psychopathology, medication side effects, treatment setting, and quality of life.Our study was performed in the well-defined geographical area of Curaçao, an island in the Caribbean and part of the former Dutch Antilles. The study was also part of a clinical trial on CYP2D6 and CYP2C19 genotyping in patients with SMI . Our stuOur participants were inpatients recruited in November–December 2014 from the Klinika Capriles  and from the psychiatric ward of the prison, and outpatients recruited from the psychiatric outpatient clinic (Psychiaters Maatschap Antillen).Inclusion criteria for the study were: 1) Antillean ethnicity, defined according to the Dutch Central Bureau of Statistics as born on the former Netherlands Antilles, with at least one parent also born on the former Netherlands Antilles; 2) aged 18 years or older, and 3) meeting SMI criteria, defined as having a mental disorder causing functional impairment as shown by the need for intensive psychiatric care in or out of hospital. Exclusion criteria were: 1) refusal to give written informed consent, or 2) no family member or healthcare professional available and willing to participate in the study.We approached 86 patients, of whom 77  met our inclusion criteria. Eight patients were excluded because they had no healthcare professional or family member available for interview; one patient died before inclusion. After being informed about the study procedures, all patients signed an informed consent form.Of the 77 proxy questionnaires, two were completed by family members and 75 by healthcare professionals. The healthcare professionals were all nurses, with patient contact at least once a week.Each patient had a thorough assessment of psychopathology, subjective experience, extrapyramidal symptoms, quality of life, and global functioning. Demographic information was registered. In line with a previous study on SMI patients on Curaçao , diagnosFunctioning was measured using the official Dutch translation of the proxy interview version of the WHODAS 2.0 (32 items), which was used with well-informed healthcare professionals or family members . IdeallyThe questionnaire measures patients' functioning in six domains: 1) understanding and communicating (six items), 2) getting around (five items), 3) self-care (four items), 4) getting along with people (five items), 5) work and household activities (each four items), and 6) participation in society (eight items). Four items on work were not included in our study because almost none of the participants had a job—this is in line with the instructions in the Manual for WHO Disability Assessment Schedule WHODAS 2.0 .Standardized summary scores range from 0 to 100, with higher scores indicating greater levels of disability in functioning .The patient interview version of WHODAS has a robust factor structure that is replicated across countries and populations, has high internal consistency , good concurrent validity with other quality of life and handicap scales (correlation coefficients 0.45–0.65), and a reasonable sensitivity to change (effect sizes 0.44–1.38) , 32. In The interviewer, a resident-in-psychiatry (AK), was trained by experts (DH and HH) in scoring the WHODAS 2.0.The severity of patients' psychopathology was assessed with the Brief Psychiatric Rating Scale . This rating scale has five subscales: affect ; positive symptoms ; negative symptoms ; resistance ; and activation  –35. ExtrFor all the above scales, higher scores indicate more severe symptoms. AK, a resident-in-psychiatry, was the interviewer for all the scales; she was trained by experts in scoring the SHRS and BARS (PH and HH), and this included a training course with 10 Antillean patients with SMI on Curaçao.Patient experience of psychopharmacological medication side effects was measured with the Subjective Well-Being Under Neuroleptics Scale . This is a self-rating scale that assesses subjective experience over the preceding seven days . For patQuality of life was assessed with the EQol 5D , a widely-used scale that measures health status on five dimensions: 1) mobility, 2) self-care, 3) daily activities, 4) pain/discomfort, and 5) anxiety/depression , 41. HigAll analyses were performed with IBM SPSS Statistics Version 25. Normality of the data distribution for all measurements was assessed by inspecting Q-Q plots. We conducted multiple regression analyses to identify how much age and gender contributed independently to the WHODAS 2.0 outcomes. The Mann-Whitney U test was used to compare outcomes between in- and outpatients. Correlations between the WHODAS 2.0 and the other measures were examined using Spearman's rank correlation (ρ), with the significance level set at p < 0.05.Eighteen (23.4%) patients were outpatients and 59 (76.6%) were inpatients. The inpatients lived in housing on the clinic site and had been there for at least 2.5 years. Of those included in the study, 95% had a diagnosis of a psychotic disorder. Other diagnoses included depression, bipolar disorder, substance abuse, and intellectual disability. All patients were using antipsychotic medication . Antidepressant medication was prescribed for 7 (9%) of the patients, while 8 (10%) were using anti-epileptic medication and 33 (42%) were using cardiovascular medication.th percentile of overall disability in functioning according to general population data for the WHODAS 2.0 interview version , whereas patients with fewer mental health problems reported better scores for recovery , 18, 42.In contrast to our expectations, outpatients reported more problems with participation in society than inpatients. This contrasts with results from a previous validation study of patients with schizophrenia, in which outpatients demonstrated better social functioning than inpatients, as rated by independent assessors . There aThe third, and in our opinion the most plausible, explanation is that participation is easier in the sheltered environment of an inpatient setting, in which co-citizens also have severe mental disorders, and where social activities are organized, patients are encouraged to participate in activities, basic life needs are taken care of, and barriers and problems are partly resolved by caregivers.There was a significant correlation between drug-induced parkinsonism and problems in getting around and performing household activities. This could be related to the symptoms of drug-induced parkinsonism such as tremor, bradykinesia, rigidity, and postural instability . These mWe studied a difficult-to-examine population of severely ill psychiatric patients who were recruited from all three psychiatric institutions on Curaçao. There was no selection regarding the type of psychiatric care or medication, presence of side effects, or treatment response when the participants were recruited. This resulted in a group of patients who are representative of the general population with SMI on Curaçao. Although nearly half of our participants were unable to communicate in Dutch, we were able to use the official Dutch translation of the WHODAS 2.0, as all the healthcare professionals are educated in Dutch. So far, no local-language versions of the WHODAS 2.0 are available for populations in the Caribbean who do not speak English or Dutch. Although it would have been valuable to interview a relative, most of the patients did not have an engaged relative. A personal healthcare provider who was engaged with all the patient's personal activities was interviewed instead. In a previous study assessing patient functioning, it was found that high-contact clinicians generated ratings of everyday functioning that were more closely linked to patients' ability scores than those from friends or relatives .Not all patients were able to read the Dutch language. To be able to administer the SWN-20 self-report questionnaire to these patients, it was translated by a bilingual (Papiamentu-Dutch) resident-in-psychiatry. No back translation was performed and we did not formally ensure whether the validity and reliability of the questionnaire were still intact. Failure to complete back translation of the SWN-20 might have affected the reliability and validity of the data from the questionnaire and its subsequent correlation with the WHODAS 2.0 and its domains. Our examination of the correlation between the WHODAS 2.0 and its domains and the SWN-20 in the subset of patients who completed the Dutch version of the scale (n=38) showed similar results to those on the subset that completed the translated version of the SWN-20 (n=39). This indicates that the negative impact of the failure to back translate was minimal.Problems with using questionnaires on functioning with patients with poor insight and cognitive deficits, as reported in earlier studies and confirmed in a pilot study, were parried by using the proxy-version with well-informed third parties. A limitation of this study is that we did not interview the patients themselves using the WHODAS 2.0, because a pilot study with the patient version of the questionnaire showed that patients' concentration problems negatively affected the reliability of their answers. Therefore we could not compare the information given by patients with that from their proxies.vs. outpatients) could not be ruled out, however, the results indicate that useful information on psychosocial functioning can be retrieved from proxies.Responder bias  have less statistical power than their parametrical equivalents. As our main purpose was to explore relationships between different measures, we chose to show all individual results of our small sample size study. Thus, together with the fact that the study has a cross-sectional design, the results need to be treated with caution. Future studies, using larger sample sizes are needed to confirm our findings.In this exploratory study, we show that the proxy version of the WHODAS 2.0 is a clinically useful instrument for patients with severe mental illness and that it provides good insight into the psychosocial functioning of these patients. In patients with lack of insight into their disease or severe cognitive deficits, this proxy questionnaire version can be used to determine useful information about patients' problems in psychosocial functioning. The highest scores on the WHODAS 2.0  were found in domains related to interactions with other people and participation in society. Inpatients were reported to experience fewer problems with participation in society than outpatients, which could be due to the adapted circumstances and sheltered environment of the clinic. We found drug-induced parkinsonism is associated with a broad spectrum of social disabilities. Before any practice or policy recommendations can be made, our results need to be replicated, preferably with larger samples. Wherever possible, researchers should include the patient interview version of the WHODAS 2.0 in order to compare the outcomes of the two versions of the questionnaire.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.http://www.clinicaltrials.gov (NCT02713672).The study protocol was approved by the Institutional Review Board of Maastricht University, the Netherlands. The procedures were in accordance with the ethical standards of the Helsinki Declaration of 1975 (as revised in 1983). All patients signed written informed consent forms after being informed about the study procedures. The study was registered in an international trial registry at Study conception and design: AK, DV, DH, DC, PH, HH. Acquisition of data: AK. Analysis and interpretation of data: AK, DV, DC, DH. Drafting of manuscript: AK. Critical revision: AK, DC, DH, DV, PH, HH. All authors read and approved the manuscript.This study was funded by the Netherlands Organization for Health Research and Development . ZonMW provided financial support only and had no role in the analysis or interpretation of the data, nor in the preparation, review, or approval 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.


Q4 vs. Q1: 0.70, 95%CI: 0.56–0.89, Ptrend = 0.001), the consumption of hydroxybenzaldehydes  and hydroxycoumarins  were also inversely associated. The intake of stilbenes, hydroxybenzaldehydes and hydroxycoumarins can contribute to BC reduction risk on all menopausal and receptor statuses.There is limited evidence of phenolic compounds acting as protective agents on several cancer types, including breast cancer (BC). Nevertheless, some polyphenol classes have not been investigated and there is a lack of studies assessing the effect on menopausal status and hormone receptor status as influenced by these compounds. The objective of this study is to evaluate the association between the intake of all polyphenol classes in relation to the BC risk by menopausal and hormone receptor status. We used data from a population-based multi-case-control study (MCC-Spain) including 1472 BC cases and 1577 controls from 12 different regions of Spain. The odds ratios (ORs) with 95% CI were calculated using logistic regression of mixed effects by quartiles and log2 of polyphenol intakes  of overall BC, menopausal and receptor status. No associations were found between total intake of polyphenols and BC risk. However, inverse associations were found between stilbenes and all BC risk (OR Vegetables and fruits contain plant secondary metabolites called polyphenols, which can be classified in more than 24 subclasses based on their chemical structure, comprising more than 5000 different individual compounds. Polyphenols can have diverse bioactive effects .Polyphenol consumption could reduce the risk of cancer development through various mechanisms ,3,4,5, pBreast cancer (BC) is the leading cause of cancer death among women in the world, responsible for 25% of the total new cancer cases and 627,000 deaths in 2018 . IncidenAccording to the continuous update project, early menarche (before the age of 12), late menopause (after the age of 55) and not bearing children increase time exposure to estrogen and progesterone and the risk of BC . This reSeveral epidemiological studies, focused on lignans and flavonoids, have detected a protective association with BC risk ,18,19, bThe aim of this study was to evaluate the effect of dietary intake of all polyphenol classes  on total BC and by and hormone receptor status in the Multi-Case-Control (MCC)-Spain study.MCC-Spain  is a popData on sociodemographic factors, lifestyle and personal/family medical history were collected with a structured computerized epidemiological questionnaire that was administered by trained personnel in a face-to-face interview . HabituaSimilarly to other studies, if a given food was a mixture of several others  the recipe was calculated (sum of ingredients). Total energy intake and nutrients were also estimated. Moreover, some questions about general dietary habits were included in the questionnaire and were used to adjust the responses to the FFQ according to Calvert et al. methodology .In this study, the daily intake of four classes and 22 subclasses of polyphenols was estimated using both Phenol-Explorer food-composition database  and USDAPolyphenol intake was calculated in mg per day, using the food consumption data from the FFQ and the polyphenol content (expressed as aglycones) of each food included in the Phenol-Explorer database . Data pr2-transformed to correct right-skewedness [Polyphenol intake was positively correlated with total energy intake. For this reason, the contents of polyphenols were adjusted for total energy using the residuals method , and posewedness  and to fOdds ratios (ORs) and 95% confidence interval (CI) of BC risk were calculated according to the polyphenol consumption quartiles using mixed effects logistic regression adjusted by known BC risk factors and by menopausal status and receptor status ,31. Adju2), physical activity , age of menarche , number of children , oral contraception consumption , hormone replacement therapy  and energy intake  as fixed effects and province of residence as a random effect term. In a sensitivity analysis, we further adjusted the previous model for fibre (mg/d) and vitamin C (mg/d) to account for potential interactions with other bioactive nutrients also present in some polyphenol-rich foods. The age at first child and lactation were included in the first models that we carried out as in other studies, but did not generate any change in the results.Age (y), family history of cancer , smoking status , consumption of nonsteroidal anti-inflammatory drugs , consumption of alcohol , socioeconomic status , BMI   test through the Benjamini–Hochberg procedure was made (.05) see .Stata statistical software   was usedCharacteristics of the study population and sociodemographic factors by case-control status and by menopausal status are shown in Q4 vs. Q1 = 1.06; 95% CI = 0.86–1.30). The intake behavior of the various families is heterogeneous, ranging from the clear protective association with stilbenes  to the probable higher risk with phenolic acids  and without noticeable effect in the case of flavonoids, lignans and other polyphenols. As with families, a heterogeneous behavior with the various compounds is observed, highlighting the protective and statistically significant association with dihydroflavonols , hydroxibenzaldehydes  and hydroxicoumarins . We also observed a possible higher risk associated with high metoxyphenol intake . In the sensitivity analysis, almost identical values were observed after additionally adjusting the multivariable model for fiber and vitamin C.Q4 vs. Q1 = 1.62; 95% CI = 1.00–1.62) while no association was observed among postmenopausal .In Q4 vs. Q1 = 0.78; 95% CI = 0.61–0.99), flavonols as a risk factor against TNBC  and protective against ERB (+), hydroxybenzoic acids as a possible protective association in the case of ERB (+), the higher risk of hydroxicinnamic acids for ERB (+)  and metoxyphenols .Regarding hormonal receptors, we highlighted only polyphenols with differences in the results ; the resOur results suggest that the intake of total polyphenols, flavonoids, and lignans was not associated with BC risk. However, a significantly lower risk was found with stilbenes and, a probable higher risk with phenolic acid intake. Our results indicate an inverse significant association between all BC cases with dihydroflavonols, hydroxybenzaldehydes and hydroxycoumarins. Regarding the results by menopausal status, it is important to take into account the variability of the associations with dihydrochalcones, flavanones, flavonols, hydroxybenzoic acids, isoflavones with menopausal status. Moreover, polyphenol subclasses showed a protective association with hydroxycoumarins and a higher risk with isoflavonoids only for postmenopausal women. In relation to receptor status, our results showed that the intake of polyphenol subclasses such as chalcones, dihydroflavonols, hydroxybenzoic acids, stilbenes, and hydroxycoumarins could act as a protective factor in the development of BC. We found protective associations for hormonal receptor (+) BC with chalcones, dihydroflavonols, flavan-3-ols, and stilbenes. Meanwhile, chalcones, dihydroflavonols, flavonols, stilbenes, hydroxybenzaldehydes, and hydroxycoumarins were inversely associated with the risk of the Erb2 subtype, while alkylmethoxyphenols and methoxyphenols subclasses are directly associated. Finally, dihydroflavonols, stilbenes, hydroxybenzaldehydes and hydroxycoumarins were associated with a lower risk of developing TNBC.These results are in line with those obtained by the study of Zamora-Ros et al. , in whicIn contrast, there is controversy about our results with other published studies as Feng et al.  and GardIn relation to the different subclasses of polyphenols in all categories performed  and the risk of developing BC, the heterogeneity found must be taken into account. Contrary to these results, the Fink et al. study  found a Case-control studies carried out in USA , Mexico This protective associations could be explained by the ability of some polyphenol subclasses to generate similar responses to estrogen (phytoestrogens), as their structure resembles the most important type of estrogen in humans and possesses hydroxyl groups and phenolic rings, necessary for binding to estrogen receptors . In addiIn our study, polyphenol classes showing a protective association against BC risk  seem to be mainly related to grape-wine consumption. Even though high alcohol consumption is related to an increase of BC risk, in our database, 85.6% of controls and 84.6% of cases were distributed in 0 and 0–12 g/day of alcohol consumption. The protective association for low dose wine consumption with BC risk could be explained by several mechanisms, as wine contains high concentrations of many polyphenols, among them resveratrol, the most well-known stilbene. An in vitro study has proved the antiproliferative activity of these compounds on different BC cell lines, indicating that at nM or even at pM plasma concentrations, obtained after moderate stilbene ingestion, stilbenes have a protective effect against BC risk . However, our results must be interpreted with caution, given that they are not exempt from limitations. Since the present study is based on a case-control study design, therefore results are prone to selection and recall bias. The MCC recruited the controls from the general population (population-based case-control study), so selection bias was reduced. BC patients did not usually change their diet before diagnosis; although, recall bias is difficult to control in retrospective studies. Moreover, it is possible that cases applied as a lower consumption of alcohol than the reality, and as a consequence these flavonoids appear as protective features . The difThis is the first study to carry out an analysis including all polyphenol classes and subclasses by menopausal and receptor status. Several reviews ,3,4,5 suThe present study suggests that there might be a high variability in the results obtained when exploring the effect of polyphenols on BC risk if classes and subclasses of polyphenols or menopausal and hormonal receptor status are taken into account. Therefore, it is important that future studies on this topic include such information.


Background: Traditional statistical models often are based on certain presuppositions and limitationsthat may not presence in actual data and lead to turbulence in estimation or prediction. In thesesituations, artificial neural networks (ANNs) could be suitable alternative rather than classical statisticalmethods.Study design: A prospective cohort study.Methods: The study was conducted in Shahrekord Blood Transfusion Center, Shahrekord, centralIran, on blood donors from 2008-2009. The accuracy of the proposed model to prediction of numberof return to blood donations was compared with classical statistical models. A number of 864 donorswho had a first-time successful donation were followed for five years. Number of return for blooddonation was considered as response variable. Poisson regression (PR), negative binomialregression (NBR), zero-inflated Poisson regression (ZIPR) and zero-inflated negative binomialregression (ZINBR) as well as ANN model were fitted to data. MSE criterion was used to comparemodels. To fitting the models, STATISTICA 10 and, R 3.2.2 was usedResults: The MSE of PR, NBR, ZIPR, ZINBR and ANN models was obtained 2.71, 1.01, 1.54, 0.094and 0.056 for the training and 4.05, 9.89, 3.99, 2.53 and 0.27 for the test data, respectively.Conclusions: The ANN model had the least MSE in both training, and test data set and has a betterperformance than classic models. ANN could be a suitable alternative for modeling such data becauseof fewer restrictions. Poisson distribution is used if the mean and variance of the data on response variable are equal and negative binomial distribution is suitable if the variance is larger than the mean (count variable is largely dispersed) 3. In real situations, during modeling count outcomes, we frequently face two issues namely overdispersion and excess zeroes in outcome values. Because of excess zeroes in response variable, mean and variance of response variable are not equal. Therefore, Poisson is not a suitable model for this type of data. In these specific situations, models such as zero-inflated Poisson regression (ZIPR), zero-inflated negative binomial regression (ZINBR), hurdle model, and generalized Poisson model have been recommended7.In regression models, when outcome is a count variable, Poisson Regression (PR) or negative binomial regression (NBR) is used for modeling8.Generally, classical statistical models have some presuppositions and limitations, such as equal variances of errors, considering a default distribution for the response variables, and linear relationship between dependent as well as independent variables that in actual data may not be available. In addition, most of these approaches have not the capability of modeling sophisticated, non-linear relationships and high degree interactions. Sensitivity to missing values and outliers is another limitation of these models9. Generalizability of ANNs allows the model to provide an appropriate answer related to a new observation. Since the precise and accurate prediction is very important in medicine, so, using models with highest confidence is a priority and ANN model seems to be a suitable method for this purpose8.A potential approach that able to overcome the limitations of classical models could be artificial neural networks (ANNs). Multi-layer perceptron (MLP) is the most popular architecture in ANNs. Usually, back-propagation (BP) algorithm is used to learn MLP based on minimizing sum of squared errors10.Blood, as a mysterious liquid, is part of the body’s vital system with special characteristics enabling it to save life of a patient or an individual in need through being donated. This issue is more important than one might think, as one per three individuals' needs transfusion of blood and its products10.Despite all advances made in different medical fields, no artificial substitute has been yet found for blood to satisfy the needs of different patients and the only route to meeting the need for this vital substance is the blood donated or bought12. Therefore, predicting the number of blood donations has a particular status and hence we should seek for an appropriate, highly accurate approach to predicting this number.A human can donate blood several times during lifetime. Donors who donate blood at least once per six months are classified as constant donors. The number of blood donations by these donors is definite and their blood health is certain, therefore it is more suitable for health system to enhance index of constancy as much as possible. Women can donate blood at most three times per year and men can do it once per three monthsIn this study, we proposed a new method with fewer restrictions based on ANN to model zero-inflated count responses, then, the accuracy of the proposed model was compared with common statistical and zero-inflated models to prediction of a number of returns to blood donations.10. The number of return to blood donation until 20 Mar 2013 were extracted as response variable and sex, age, weight, marital status, education, job, blood group and Rh were considered as independent variables. To compare ANN with classic models data from a longitudinal study was used. The study was designed as a follow-up study with a maximum of five years conducted in Shahrekord Blood Transfusion Center, Shahrekord, central Iran. At the beginning of the study, a list of registered donors in Negareh software system used by the Shahrekord Blood Transfusion Center who had blood donations for the first time from 21 Mar 2008 until 20 Mar 2009 was prepared. The sampling method was systematic sampling and the sample size was calculated using previous information about percentage of donors return to blood donation for at least five times7. The probability density function for zero-inflated cunt data can be formulated as follows:As discussed above, for count regression, models in the case of excess of zeroes in response variable, Poisson, and negative binomial models are inadequate and zero-inflated model is alternative way to model datai is proportion of extra zeroes than original Poisson or negative binomial in response variable and Pr(Yi=yi) is probability of Yi=yi in Poisson or negative binomial distribution. By replacing μβTxi=eTxiβ in above formula, ZIPR model defined as:That pAnd ZINBR model can be written as:5.That r is overdispersion parameteri, and compute outputs yi, using a specified number of layers. The architecture of ANN model can be written as:For fitting of ANN model, MLP with one hidden layer was used. ANN adopts a set of input observations, xjs is the weight for input xis at the hidden node j. In addition, βj is the weight dependent to the hidden node j, and wj0 and β0 are the biases for the hidden and the output nodes respectively. In addition, p and M are number of covariates and number of nodes in hidden layer respectively. The function Ψh is activation functions of hidden layer and the function Ψo is activation functions of output layer8.where wThe BP algorithm was used to learning MLP based on minimizing sum of squared errors. The BP algorithm has two computational paths; Forward path and backward path. For the k-th input, the equations on the forward path were as follows:In forward path, the network parameters do not change during computing, and the activation functions applied on each neuron:In backward path, the sensitivity matrices from the last layer were returned to the first layer:Finally, the weights and biases matrix were regulated by the following relationships:12.In recent formulas, L, f, nl , α, δl, t(k) and ek were referred to number of network layers, activation function, output in hidden layer, network learning rate, transformation gradient in l-th layer, the actual output value of k-th sample and Estimated error for k-th sample respectively13. To fitting the models, STATISTICA 10 and, R 3.0.1 was used.Accuracy of statistical count regression models, including PR, NBR, ZIPR, and ZINBR were compared with ANN model to prediction number of return to blood donation via MSE criterion. We fitted MLP with one hidden layer, including 11-18 nodes. Batch Gradient Descent (BGD), Conjugate Gradient (CG) and Broyden Fletcher Goldfarb Shanno (BFGS) learning algorithms were used for training. All these algorithms are from BP algorithm familyFrom 864 donors, 801(92.7%) donors were male and 623(72.1%) were married. Overall, 710(82.2%) of donors lived in the city and 154(17.8%) in the country. Mean ± standard deviation of age in donors at the first donation was 36.6±10.7 yr and the mean of body weight at the first donation was 77.8±11.7 kg. Number of return to blood donation was from 0 to 12 . Mean anFor Akaike information criterion (AIC), NBR and ZINBR models have a similar performance, but MSE criterion is 0.96 for NBR and 1.03 for ZINBR .To find the best structure of ANN model, CG, BGD and BFGS training algorithms were compared and BFGS selected . For BFGHealthy blood supply is one of the most important issues in blood transfusion organizations around the world. On the other hand, it is very important to recognize who is able to donate healthy blood continuously. Therefore, providing models that can accurately predict the number of return to blood donation(s) is very valuable.In this study, response variable was the number of return to blood donation that was a zero-inflated count variable. To model such variables, the use of common methods for analyzing count data in classical statistics will be associated with errors. It is very important to know the methods predicted with high precision.14.In this study, we presented different approaches for modeling zero-inflated count outcomes. ANN and count statistical models such as PR, NBR, ZIPR, and ZINBR were compared and more accurate model for predicting the number of return to donations was determined. ZINBR was the best model among classical statistical models to predicting a number of return to blood donation, while, comparison between these approaches and ANN in view of MSE values indicated that ANN could be a more appropriate approach to prediction. In a longitudinal study investigating the performance of Poisson regression of neural networks in predicting main cognitive changes compared artificial neural network and Poisson regression for cognitive changes in the elderly within a five-year follow-up through MSE, ANN with any structure had a better performance than Poisson regression15.NBR and ANN analyzed the frequency of accidents in freeways in some highways in Taiwan. Artificial neural network had better performance compared with statistical models for prediction8.In zero-inflated count data, the common methods in classic statistics suffer from some shortcomings. Their performances depend on the distribution of variables, size, and quality of data, etc. When relation between predictors and response variable is nonlinear, predictions will be confusing and will lack confidence. ANN can be considered as alternative techniques to overcome this problems8.Despite the advantages of ANN models, they have some limitations. They are neither capable to inference on the parameters nor to assess significance of relationship between the variablesANN model had the best performance of prediction of number of return to blood donation in both training and test data set compared with PR, NBR, ZIPR and ZINBR models. Therefore, considering the importance of precise prediction in medical studies and due to the restrictions of traditional statistical methods, the use of ANN model is a suitable alternative for analyzing such data.The authors declare that there is no conflict of interest.The present study was extracted from MSc thesis supported by a grant number 1632 from the Research and Technology Deputy of Shahrekord University of Medical Sciences.ZINBR was the best model among classical statistical models to predicting number of return to blood donationThe ANN model had the least MSE in both training and test data set ANN model had the best performance of prediction of number of return to blood donation in both training and test data set compared with PR, NBR, ZIPR and ZINBR models


The aim of this study was to assess the associations of serum and bone zinc (Zn) and cuprum (Cu) with bone mineral density (BMD) and content (BMC), markers of bone turnover, and sex hormones. The study group comprised 144 men treated with total hip replacement due to hip osteoarthritis. We measured total, free, and bioavailable testosterone, estradiol, and sex-hormone-binding globulin (sex hormones), as well as parathyroid hormone, osteocalcin, carboxy terminal collagen crosslinks, and N-terminal propeptide of type I procollagen (markers of bone turnover). Total body BMD, BMC, total and visceral fat, and appendicular skeletal mass (ASM) were measured using dual-energy X-ray absorptiometry. ASM index, and total and visceral fat were positively correlated with BMD. Bone Zn correlated neither with sex hormones nor with bone turnover markers; however, it was positively associated both with BMD and with BMC, while bone Cu (as opposed to serum Cu) was not. In multiple regression, the ASM index, Zn/Cu ratio (in both the serum and the bone), and serum Cu concentration were significantly associated with BMD and BMC after adjustment for age and body mass index (BMI). Our results suggest that the Zn/Cu ratio in both the serum and the bone may exert a significant positive effect on total BMD and BMC. Bone mass and quality are determined by many genetic, hormonal, and environmental factors. Among hormonal factors, it is well established that sex hormones play a key role in maintaining lifelong skeletal integrity and bone health through a complex variety of endocrine, paracrine, and autocrine actions ,2. It isZn is a cofactor in metalloenzymes and an important contributor to bone health ,5. The sThe aim of this study was to assess the associations of Zn and Cu status with total BMD, bone mineral content (BMC), markers of bone turnover, and the sex-hormone milieu. To this end, we measured Zn and Cu content in the bone tissue of the hip joint removed during total hip replacement in patients with hip osteoarthritis.The study included 144 men treated at the Orthopedics Clinic of the Pomeranian Medical University due to osteoarthritis of the hip joints using the total hip replacement method. Exclusion criteria were diabetes, history of cancer, alcohol abuse, liver or kidney failure, heart failure of class III or IV according to the New York Heart Association (NYHA), and taking drugs that affect bone metabolism, such as mineral supplements, neuroleptics, chemotherapeutic agents, immunosuppressive drugs, corticosteroids, or antidepressants. The study complied with all applicable institutional regulations regarding the ethical use of human volunteers in research and the terms of the Declaration of Helsinki. The Pomeranian Medical University Ethics Committee approved the study protocol, and all participants gave their written consent.All venous blood samples were obtained after an overnight fast (between 07:00 a.m. and 09:00 a.m.) and stored at −20 °C until processed. The concentrations of total testosterone , estradiol , sex-hormone-binding globulin , and dehydroepiandrosterone sulfate  were determined by ELISA . The free testosterone  level was calculated using the following formula developed by Vermeulen: tion + 1 . The biotion + 1 . The senThe following markers of bone turnover were measured: osteocalcin , parathyroid hormone , carboxy-terminal collagen I crosslinks , and human procollagen I aminoterminal propeptide .2O2 was added. Then, the samples were placed in special Teflon vessels and heated in a microwaved digestion system for 35 min in 180 °C. At the end of the digestion, all samples were removed from the microwave and allowed to cool to room temperature. Blank samples were prepared by adding concentrated nitric acid to tubes without sample and subsequently diluted in the same manner. Multi-element calibration standards  were prepared with different concentrations of inorganic elements in the same manner as the blanks and samples. Deionized water  was used for the preparation of all solutions. For the calibration of bone samples, we used Merck, Darmstadt, Germany), which consists of steamed bone meal that was sieved and blended to a high degree of homogeneity . Quality control for determination of both trace elements in serum was applied by analyzing the SRM  using Instrumental Neutron Activation Analysis. The accuracy of the measurements (expressed as % recovery) and precision (% coefficient of variance) were in the range of 93–103% and 92–112%, whereas the % coefficient of variation was 3.62% and 5.17% for Zn and Cu, respectively. The wavelengths were 213.856 nm and 324.754 nm for Zn and Cu, respectively.Extracted serum samples and bone samples were frozen at −80 °C until processed. Serum and bone Zn and Cu were analyzed using inductively coupled plasma optical emission spectrometry , which is an established and powerful technique for the analysis and quantitation of trace elements in both liquid and solid samples. Analysis was performed in radial and axial mode. Serum samples were thawed at room temperature and digested using the oven digestion system CEM MARS 5. Bone samples also were thawed at room temperature and then dried overnight at 80 °C to constant weight after cleaning all the adherent tissues. The bones were ground into powder in a porcelain mortar and mineralized using the CEM MARS 5 system. The bone tissue (at least 0.1 g of weight) was then allowed 30 min of pre-reaction time in the clean hood. After completion of the pre-reaction time, 1 mL of non-stabilized 30% HSerum molar concentrations of Zn and Cu were calculated according to the following formula: molar concentration (nmol/g) = concentration (nmol/g) × 1000/atomic weight (g/mol) , with no2 [2 [Dual-energy X ray absorptiometry (DXA)  was used to assess total body BMD and body composition, including BMC, lean mass (a surrogate measure of muscle mass), and total fat mass, using the automatic whole-body scan mode. From lean mass, appendicular skeletal mass (ASM) was calculated as the sum of the muscle mass of both arms and legs, assuming that all nonfat and nonbone tissue is skeletal muscle. From ASM and height, the ASM index was calculated using the following formula: ASMI = ASM/height2 ,18, with2 [2 . Viscerat-test; otherwise, the nonparametric Mann–Whitney U-test was used. The relationship between pairs of quantitative variables was analyzed using Pearson’s linear correlation coefficient. Multiple linear regression models with the Bonferroni correction were adjusted for age and body mass index (BMI). A receiver operating characteristic (ROC) curve analysis was used to assess the accuracy of the Zn/Cu ratio. The accuracy was measured using the area under the curve (AUC) with a 95% confidence interval (CI). To determine the specific cutoff point for Zn/Cu ratio, the score with the highest combination of sensitivity and specificity (Youden’s index) was considered optimal. Statistical analyses were performed using Statistica . The significance level was set at p ≤ 0.05. The statistical power of the study with 144 subjects was sufficient to detect with 80% probability true associations with strength corresponding to correlation coefficient or standardized beta coefficient equal to ±0.24 at a statistical significance level of p = 0.05.Quantitative variables were presented as means (ranges) and standard deviation (SD). Data were checked for normality using the Shapiro–Wilk test. In the case of normal distribution, means were compared using Student’s 2), and 59 (41%) were obese. Serum Zn/Cu ratio was 1.4, and that in the bone was 171.7. The mean values of ASMI, as well as sex hormones and markers of bone turnover, were within normal ranges. However, up to 50% patients had elevated E2 and 41% had low osteocalcin levels .Correlations of Zn and Cu with age, BMI, sex hormones, bone turnover markers, and densitometric parameters are shown in r = 0.504 and r = 0.473 for total BMD and BMC, respectively). Rather unexpectedly, markers of bone turnover correlated neither with BMD nor with BMC. Similarly, they also were not correlated with sex hormone levels.Next, we tested the correlates of total body BMD and BMC. As shown in z-score >−1 SD. However, the value of Youden’s index, which was used as a measure of quality for optimal cutoff, was relatively low. ROC curve analysis of the bone Zn/Cu ratio for prediction of normal BMD is shown in In multiple regression, only ASMI, the Zn/Cu ratio (both in serum and in bone), and serum Cu concentration were significantly associated with total body BMD and BMC after adjustment for age and BMI . In the The study was performed on patients aged 60–75 years with advanced OA and frequent coincidence of overweight/obesity. This is a typical cohort for hip replacement in terms of age, comorbidities, and indications for this procedure ,21. ThisWe found in bone specimens that Zn and Cu contents were correlated neither with age nor with sex hormones, suggesting other mechanisms to be involved in the accumulation of these minerals in bones. Similarly, Zn and Cu did not correlate with markers of bone turnover. Moreover, serum levels of both trace elements did not correlate with their content in the femoral neck. The latter finding may suggest a different pathway of Zn and Cu accumulation in bones which is independent from their serum concentrations, at least if they are within normal ranges. Hence, it can be speculated that, if both elements are given as dietary supplements, their positive effects on overall bone health could be questionable. As opposed to the serum levels, bone Zn showed positive correlations with BMD and BMC, but the association became insignificant after controlling for confounders. On the other hand, the bone Zn/Cu ratio, similarly to the serum ratio, was positively associated with bone mineral density and content, confirming that the balance between these two elements both in serum and in bone appears to be important for bone maintenance. From a practical point of view, in further studies evaluating the content of Zn and Cu in bones, we suggest the use of the Zn/Cu ratio rather than the opposite Cu/Zn ratio, as bone content of Zn is much higher than Cu .Another finding of this study refers to the association between body composition and bone mass. We found that visceral fat and total body fat were significantly positively correlated with total body BMD and BMC. However, after adjusting for confounders, these associations were no longer significant. In our previous study, total fat was a significant predictor of lumbar spine and total hip BMD, and visceral fat of lumbar spine BMD in older men . On the We did not find the associations of sex hormones with bone outcomes. Generally, in contrast to menopause, a decline in testicular function in men can be initiated in any time point during or after middle age and a decrease in testosterone level is usually gradual and much less overt in comparison with postmenopausal deficit of estrogens ,2,44. InOur study had some limitations. Firstly, it was an observational study, and it cannot be assumed that the associations among trace elements, fat distribution, and bone mass were causal. Secondly, we did not evaluate the level of physical activity, alcohol consumption, dietary and supplementary intake of calcium, Zn, and Cu, and vitamin D concentration, which are known to affect BMD/BMC. Lastly, the current study was performed on patients with OA and, hence, the generalization of our findings to healthy individuals or patients with other bone disorders and other medical conditions should be exercised with caution.In conclusion, in aging men with OA, the Zn/Cu ratios in both the serum and the bone but not visceral fat, sex hormones, and markers of bone turnover were positively associated with total body BMD and BMC after controlling for confounders.


With the widespread spread of novel coronavirus pneumonia, more and more countries have been affected. Some research reports have shown that traditional Chinese medicine has a significant effect on COVID-19 infection, and the treatment of traditional Chinese medicine is used in some special people, such as children. At present, there is a lack of high-quality systematic reviews on the safety and efficacy of using Chinese medicine to treat children with novel coronavirus pneumonia.We will search Cochran library, MEDLINE, EMBASE, China National Knowledge Infrastructure Database (CNKI), China Biomedical Database (CBM), VIP Database (VIP), and Wanfang database for research. This study includes randomized controlled trials (RCTs) and non-RCTs, and uses the Cochrane systematic review to review the safety and efficacy of traditional Chinese medicine in preventing and treating children with novel coronavirus pneumonia. RCT research tools and quantitative research quality assessment tools for non-randomized studies will be used to assess the risk of bias in studies included in the systematic review. We will use Revman 5.3 software for meta-analysis, the main result is odds ratio, and then a subgroup analysis will be performed based on the age, intervention degree, and disease severity of the patients reviewed.This systematic review protocol is designed to provide evidence regarding the effectiveness and safety of traditional Chinese medicine for the treatment of children with COVID-19, such evidence may be useful and important for clinical treatment decisions. The results should be disseminated through publication in a peer-reviewed journal. Since the data and results used in the systematic review will be extracted exclusively from published studies, approval from an ethics committee will not be required.PROSPERO CRD42020179150. Globally, as of 2:00 a.m. CEST, April 16, 2020, there have been 1,995,983 confirmed cases of COVID-19, including 131,037 deaths, reported to WHO.,3 A large number of clinical practice results show that traditional Chinese medicine plays an important role in the treatment of COVID-19.So far, there is no special medicine to treat the disease in the world. In our “COVID-19 Treatment Plan ,” a Chinese medicine treatment plan is proposed, in traditional treatment methods, more than 85% of infected people in China receive traditional Chinese medicine treatment. Some therapeutic drugs for adult patients are not suitable for children. Therefore, when treating pediatric patients, relatively gentle traditional Chinese medicine treatment can be considered. At present, studies have shown that on the basis of conventional treatment, the combined application of four seasons antiviral drugs is a safe and effective measure for the treatment of respiratory infections in children.For children, most children have mild clinical manifestations and a good prognosis.Although there are many studies reporting that traditional Chinese medicine treats COVID-19 better, there are fewer reports on children treated with traditional Chinese medicine, and there is a lack of theoretical research and data analysis on more children treated with traditional Chinese medicine. This study aims to collect more clinical data and make a high-quality evaluation of the safety and efficacy of traditional Chinese medicine treatment of children, which is of great significance for pediatricians to make clinical decisions.2The purpose of this study is to evaluate the efficacy and safety of traditional Chinese medicine in the treatment of children with COVID-19 infection. Due to novel coronavirus pneumonia, novel coronavirus pneumonia is increasing in children all over the world, most of which are mild. Traditional Chinese medicine can effectively improve the symptoms of light patients, so it is necessary to analyze the safety and effectiveness of traditional Chinese medicine treatment for children infected with COVID-19.3 and Cochrane Collaboration Handbook. The data and results used in this paper are form online databases.This is a systematic review and meta-analysis protocol, which is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement3.13.1.1Randomized controlled trials (RCTs), non-randomized studies and quasi-experimental studies.3.1.23.1.2.1Children and young people (up to 18 years) who have be diagnosed as COVID-19.3.1.2.2There is no laboratory evidence of COVID-19 infection in children.3.1.2.3Traditional Chinese medicine as the main treatment for the intervention measures.3.1.2.4Blank control (no treatment), placebo control (pseudo-drug), cross control  or other active treatment recommended by the guideline.3.1.3We will use the following results to evaluate the effectiveness and safety of Chinese medicine treatment.Main results: effective rate and mortality rate.Secondary results:1.Degree of remission of clinical symptoms .2.Time to return to normal for laboratory measures .3.Overall evaluation of lung function after treatment.4.Proportion of patients admitted to ICU.5.The frequency at which it needs to be oxygenated.6.Adverse event rate3.23.2.1The databases we will search include Cochran library, EMBASE, MEDLINE, China Biology Medicine Database (CBM), China National Knowledge Infrastructure Database (CNKI), VIP, and Wang Fang database. The search will be started from December 2019 with language restriction in English and Chinese. Our search terms and relative variants will include novel coronavirus pneumonia, new coronavirus, COVID-19, 2019 nCoV, sars-cov-2, child, children, traditional Chinese medicine, Chinese herbal medicine, Chinese patent medicine, Chinese medicine, TCM. The search strategies of MEDLINE are shown in Table 3.3Inclusion and exclusion of reference studies will follow PRISMA flow charts to the letter  screened the title, abstract and other information of the study according to the inclusion and exclusion criteria.After we get the results, we will download the full text to the corresponding database according to the results, and then the other two reviewers  will read the full text and filter it again. When the literature results are repeated, the study with large sample content or long follow-up time will be selected. If the repeated study cannot be determined, the author of this study will be contacted. Any inconsistencies in the process will be resolved by discussion.A unified data extraction form (excel spreadsheet) will be generated after the review panel discussion. The data extraction form contains the following information:Research characteristics: publishing time, publishing unit, publishing country, research object, research type, and research method.Patient baseline characteristics, exposure characteristics, intervention measures  and outcome indicators; Information such as risk assessment of bias. In the process of data extraction, if there is any disagreement between the two reviewers, the third reviewer will be contacted for discussion and resolution.After data extraction, we will use the Cochrane study tool to assess the quality of the study and the risk of bias. The two reviewers will use the double-blind method to independently assess the risk of bias. If there is any difference, it will be resolved through discussion.3.4We will use the Cochrane bias risk assessment tools from random sequence and allocation concealment, blinding researchers and subjects, study outcome blind evaluation, integrity of outcome data, selective reporting of research findings, and other sources of bias that six aspects to evaluate risk of bias, according to the risk of bias assessment criteria to make a “low risk of bias,” “high risk of bias,” and “not clear” to judge the results.3.5Q test is used to determine the heterogeneity of the data. I2 index is used to describe the percentage of heterogeneity in the total variation caused by non-sampling error caused by each study. If I2 < 50%, it is considered that there is no obvious heterogeneity of the data. If the test results indicate statistical heterogeneity, the source of heterogeneity needs to be further analyzed. According to the heterogeneity size, it is necessary to determine whether the data can be analyzed by using the random effect model directly. If the heterogeneity is small, the effect scale can be merged by using the random effect model directly. If it is larger, it is necessary to adopt subgroup analysis to exclude the sources of heterogeneity, and then merge, and then use forest map to reflect the merger results. Generally, I2 ≥ 75% is regarded as the critical point of high heterogeneity. For categorical variables, we will use odds ratio (OR) and relative risk (RR) as the effect scale. For the data of quantitative variables, the weighted mean difference (WMD) and the standardized mean difference (SMD) are used as the effect scales. These are all expressed as 95% confidence intervals. Funnel plot and Egger linear regression method are used to judge whether there is publication bias. If P value < .10, there is publication bias.Meta analysis is carried out by using RevMan 5.3, a standardized software for systematic evaluation by Cochrane collaboration network. 3.6When the data is collected, if it can be allowed for subgroup analyses, we will analyze it according to the age of the patients, the degree of intervention, and disease severity. If the interaction test between related subgroups is <0.05, we will analyze and adjust them to eliminate deviation and risk to ensure the stability of evidence.3.7After excluding the abnormal results, the meta-analysis was performed again and the results of two meta-analyses were compared to explore the stability of the results.3.8,10Published bias will be measured by using a funnel plot (by Review Manager 5.3 software), Begg test and Egger test (by Stata software 14.0).4The purpose of this system review is to provide evidence for the efficacy and safety of traditional Chinese medicine for children with COVID-19. These evidences are of great significance in providing clinical treatment decisions. The results of the study will be published in public journals. Because the data and results used in this systematic review are all from published studies, approval from an ethics committee is not required.5 During the outbreak of severe acute respiratory syndrome (SARS) in 2003, the effectiveness of traditional Chinese medicine in controlling infectious diseases was confirmed. Therefore, the Chinese government encourages the use of herbal medicine to combat this new type of viral pneumonia. According to reports, 26 Chinese herbal medicines have been screened and considered to be effective for COVID-19. They can directly inhibit novel coronavirus pneumonia. China has launched 303 clinical trials aimed at evaluating the treatment effect and safety of patients. Among them, 50 cases (16.5%) were related to the application of traditional Chinese medicine.At present, there is no effective treatment for patients infected with COVID-19, so the morbidity and mortality are higher than influenza. Traditional Chinese medicine has been widely used in clinical practice in China, but in many countries in the world, it is still challenging for traditional Chinese medicine to treat patients with COVID-19 infection. among them, yinqiao powder is used for patients with high fever and Sangju drink is used for patients with severe cough, which can clear lung heat, remove phlegm, stop cough, regulate lung, and restore normal lung function.Depending on the stage of the disease and symptoms, different herbs used in the Chinese medicine system are recommended for the treatment of COVID-19. During clinical treatment, Qingfei Paidu Decoction, Xiyanping Injection, Xuebijing Injection, Reduning Injection, and Tanreqing Injection,Recently, 4 provincial hospitals in China applied Qingfei Paidu Decoction to treat 214 patients with COVID-19. The course of treatment was 3 days. The total effective rate was more than 90%. Among them, 60% of patients had significantly improved symptoms and imaging performance, and 30% of patients symptoms are stable without deterioration. At the Eighth People's Hospital in Guangzhou, China, doctors found that 50 patients with mild COVID-19 were treated with Toujie Quwen granule. Their overall symptoms improved significantly without any serious symptoms. The study found that this drug can significantly improve the clinical symptoms caused by COVID-19, and has a tendency to reduce the incidence of severe pneumonia.In view of the fact that Chinese medicine treatment of COVID-19 infection in adults can effectively improve the clinical symptoms of mild patients, it may be considered to apply Chinese medicine treatment to children infected with COVID-19, so that the children's recovery is good. According to the latest diagnosis and treatment plan, the symptoms of children's cases are relatively mild, so it is very necessary to apply Chinese medicine treatment to the treatment of children infected.At present, there are limited clinical trial data on the effectiveness and safety of traditional Chinese medicine treatment for infected children, and there is a lack of a comprehensive review and summary. Therefore, this article aims to study the Chinese medicine treatment of COVID-19 infected children and provide clinicians with decision-making for clinical diagnosis and treatment of COVID-19 infection in children. The systematic review also has certain limitations. First, the literature we included only included Chinese and English literature, which may cause some omissions. Secondly, the included studies were non-RCTs and observational studies, which may also lead to lack of reliability in the conclusions.All authors have read and approved the manuscript, agreed to publish it, and made sure it is true.LYQ, YXJ, DL, XQ provide COVID-19 related professional knowledge.LYL, BL, HXX undertake data management.LYQ, BL, WQX complete the draft writing.LYQ, LYL, BL complete the revision and editing.LYL, BL, WQX provide research methods.LX manages the project.Research design and concept of XQ and LYQ.Resources provided by LX, YXJ, LYQ, XQ.LX, XQ, LYQ reviewed and approved the release.LYL, BL, HXX, WQX carry out software operation.