Fulminant myocarditis (FM) is an inflammatory process of the myocardium and an important cause of cardiac dysfunction in children; it is characterized by rapid onset, acute progression, and high mortality. The study sought to describe the clinical characteristics and prognostic factors in children with FM.The study population consists of 37 consecutive patients admitted from May 2014 to December 2021 with a diagnosis of FM. According to the prognosis of children with FM during hospitalization, they were divided into “survival” group (25 cases) and “death” group (12 cases). A multivariate logistic regression analysis was performed to identify the independent predictors of in-hospital mortality in the patients, and receiver operating characteristic (ROC) curve was used to explore the predictive value of related factors.P < 0.05), and the left ventricular ejection fraction (LVEF) in the death group was significantly lower than in the survival group (P = 0.002). The binary logistic regression analysis revealed that MYO  and LVEF  were independent predictors of FM. ROC curve analysis showed that the area under ROC curve (AUC) of MYO and LVEF was  and , and the area under the combined ROC curve for MYO + LVEF was significantly higher than that for MYO or LVEF alone (P < 0.05), indicating that the MYO + LVEF combined diagnosis had a higher predictive value for FM.The 37 children with FM had an average age of 8.35 ± 4.36 years old. Twenty-five of the patients survived and 12 died. Twenty-five of the children were discharged from the hospital after a series of active rescue treatments such as nutritional myocardial drugs, high-dose intravenous immunoglobulin (IVIG), glucocorticoids (GCs), temporary pacemaker (TP), extracorporeal membrane oxygenation (ECMO), and continuous renal replacement therapy (CRRT).Twelve of the children were classified into the death group because the resuscitation failed. The levels of procalcitonin (PCT), creatine kinase (CK), and myoglobin (MYO) in the death group were all higher than in the survival group (all The levels of MYO and LVEF can be markers for prognosis of FM and can effectively evaluate the disease severity. Their combination can improve forecast accuracy; thus, the detection of the above-mentioned indexes possesses a higher value for clinical applications. As one of the most serious types of acute myocarditis in children, FM is a rapidly progressing clinical syndrome whose dramatic presenting scenarios include rapidly progressive hemodynamic compromise and fatal arrhythmia, resulting in cardiogenic shock or even sudden death , 2. The The previous study suggested an important role of histological classification of FM, and the histological subtype of FM was a determinant of outcomes . BesidesForty five children were admitted to the First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China  and Children's Hospital of Nanjing Medical University. 5 cases with incomplete data and 3 cases with repeated medical records were excluded, and finally 37 children were retrospectively analyzed . This stAll the children with FM met the diagnostic criteria for myocarditis in the Diagnostic Recommendation For Myocarditis In Children (version 2018) . The patChildren with congenital heart disease, endocardial elastic fibrosis, myocardial infarction, non-ischemic cardiomyopathy, and genetic disease were excluded from this study.The demographic data, vital signs, clinical presentation, laboratory indexes, ECG manifestations, and echo results and the treatment regimen of each child were collected and reviewed. The demographics included age, sex, family history, and past history. The basic vital signs included temperature, systolic blood pressure (SBP), diastolic blood pressure (DBP), respiration, and pulse on admission.Clinical manifestations are mainly a series of uncomfortable reactions of a patient, including chest tightness, chest pain, dyspnea, fever, and other common features of FM, as well as other clinical manifestations of the patient's respiratory system, digestive system, and nervous system.The laboratory indexes included routine tests such as blood routine, biochemistry, liver and kidney functions, especially indicators reflecting cardiac function including myoglobin (MYO), creatine kinase MB (CK-MB), high-sensitivity troponin I (CTnI), B-type natriuretic peptide (BNP), and creatine kinase (CK),which were determined with an OLYMPUS automatic biochemical analyzer (AU2700: Japan).ECG parameters included the type of arrhythmiathe, change of ST segment and the prolongation of QT interval, which were collected by Foton FX-7404 electrocardiograph with standard 12-lead electrocardiogram.The echo mainly recorded LVEF, valvular regurgitation, pericardial effusion, cardiac enlargement, and systolic and diastolic dysfunctions, which were detected with PHILIPS EPIQ 7C color Doppler.t-test. Continuous variables for partial distributions are expressed as medians  [M ], and between-group comparisons are performed by non-parametric test. Count data are expressed as the number of cases (%), and the difference between groups is compared by chi-squared test or Fisher's exact test. A two-tailed P < 0.05 is set as statistically significant. A multivariate logistic regression analysis is performed to identify the independent predictors of in-hospital mortality in the patients, and receiver operating characteristic (ROC) curve is used to explore the predictive value of related factors. Spearman correlation analysis tests the association between MYO and inflammatory biomarkers. A statistical analysis is performed using SPSS 28.0.Continuous variables with a normal distribution are expressed as the means ± standard deviation (x ± s), and between-group comparisons are performed by independent samples Among the 37 children with FM, 16 were males (43.2%) and 21 were females (56.8%). The age distribution was as follows: 5 patients were from 0 to 3 years old, 11 were from 4 to 7 years old, 15 were from 8 to 12 years old, and 6 were from 13 to 17 years old.The patients were divided into two groups: those that survived to discharge  and those that died while in the hospital , and risk factors for in-hospital death were analyzed.The demographic data, vital signs, clinical manifestations, laboratory data, ECG manifestations, and echo measurements on admission are shown in The children with FM were mostly concentrated in two age groups, 4–7 and 8–12 years old, and the morbidity and mortality of children aged 8–12 years were relatively high. Gender differences in children with FM were not significant, and morbidity and mortality were higher in women.Furthermore, we found that the main clinical symptoms of the children with FM were chest tightness, chest pain, fever, dyspnea, fatigue, and other symptoms. Compared with the survival group, the children of the death group had a higher frequency of abnormal neurological manifestations such as headache, syncope, etc.P < 0.05). The rest was not statistically significant.Among the cardiac function indexes, the CK and MYO levels of children in death group were higher than those in the survival group, and the difference were statistically significant (P = 0.002).The ECG manifestations of the children with FM were tachycardia and conduction block, often accompanied by changes in ST-T. Compared with that in the survival group, the level of LVEF in the death group was significantly lower ; P = 0.045] and LVEF  were important predictors of death in children with FM  indicated low risk of death, and high MYO  indicated high risk of death.Therefore, the patients were re-divided into two groups based on absolute myoglobin values. Low MYO . The ROC curve analysis showed that LVEF, MYO, and their combination index did well in predicting the clinical prognosis of children with FM and their AUCs were.957, 0.836, and 0.972, respectively. This current study found that the area under the combined ROC curve for MYO + LVEF was significantly higher than that for MYO or LVEF alone (P < 0.05), indicating that the MYO + LVEF combined diagnosis had a higher predictive value for FM as well as better sensitivity. In addition, we also found that the prognosis of children with different levels of MYO was significantly different. The mortality in the low MYO group was only 4.3%, while the mortality in the high MYO group was as high as 78.6%, which required more medical support and had lower survival rates. At the same time, we found that the increase of MYO was often accompanied by the increase of CRP and PCT, which may indicated that MYO was as important as some markers of myocardial injury. MYO was positively correlated with CRP and PCT.In this retrospective study, MYO and LVEF were closely related to the prognosis of FM  and the Ministry of Science and Technology of the People's Republic of China (Grant No: 2018YFC1003700).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.


K-nearest neighbour (K-NN) have been employed for CVD detection using publicly available University of California Irvine repository data. The performances of the models are optimally increased by removing outliers and attributes having null values. Experimental-based results demonstrate that a higher accuracy in detection of 82.47% and an area-under-the-curve value of 86.41% are obtained using the MLP model, unlike the K-NN model. Therefore, the proposed MLP model was recommended for automatic CVD detection. The proposed methodology can also be employed in detecting other diseases. In addition, the performance of the proposed model can be assessed via other standard data sets.Cardiovascular disease (CVD) makes our heart and blood vessels dysfunctional and often leads to death or physical paralysis. Therefore, early and automatic detection of CVD can save many human lives. Multiple investigations have been carried out to achieve this objective, but there is still room for improvement in performance and reliability. This study is yet another step in this direction. In this study, two reliable machine learning techniques, multi-layer perceptron (MLP), and  However, owing to multiple reasons like unhealthy lifestyles, work stress, psychological strain, and external factors such as pollution, hazardous work environment, and lack of proper health services, millions of people worldwide fall prey to chronic ailments like cardiovascular diseases (CVD), which affect both the heart and blood vessels, resulting in death or disability. In recent years, it was reported that the majority of human deaths were due to CVD ,2. The ar (K-NN) , each wir (K-NN) ,9, humanr (K-NN) ,11, and r (K-NN) ,13,14. R2K-NN. Generally, the method comprises training of the proposed model via respective learning algorithms using relevant input test data of patients and then validating these models based on test data of patients. Finally, performance measurements are evaluated and compared.The goal of this study was to determine whether or not a patient would develop CVD if a set of clinical information is available. The confusion matrix of each technique was obtained, and out of 303 occurrences in the data set, 243 (80%) were used to train the two models. To test the trained models, 60 instances were fed to know the class. This study intends to predict the likelihood of developing CVD via a computerized prediction route that can be useful to health professionals. The materials required for CVD detection are the test data of patients from publicly available standard CVD data from the UCI repository . The claThe following steps are carried out to predict CVD:Step 1: Relevant CVD data set is first collected from the UCI repository.Step 2: Data samples are pre-processed by eliminating null values, filtering for denoizing, and removing outliers present in samples.Step 3: Attributes which are more useful in CVD forecasting are selected, and strongly correlated features are dropped.Step 4: Two ML algorithms that are simple but effective are chosen to classify the selected features based on Step 5: Various performance measures are evaluated to compare and find the better method.2.1The CVD data set used for developing the detection models was taken from the University of California Irvine (UCI) repository  and has K-NN ML methods were employed for binary classification (CVD or no CVD).The data set contains both categorical and continuous features as explained in 2.2K-NN value of 20 was applied. For different k values between 1 and 21, different accuracy values were obtained.There are many missing and noisy data in public data sets. These data are pre-processed to minimize distorted measurements and make predictions more reliable. The pre-process stage involves smoothing, standardization, and aggregation. During the data pre-processing phase, the correlation matrix is used to identify the correlation between different CVD data set features and shows whether the features are positively or negatively associated with one another. After pre-processing of the data set, certain categorical variables such as cp, sex, chol, and trestbps are converted into dummy variables, and the resultant data are scaled before training the ML models. All variables were scaled down using standard normal distribution, and a cross-validation 2.2.1The scatter plot  is a mathematical diagram in cartesian coordinates showing the relationship between two variables of a given data set. It shows the relationship between two quantitative variables. If two variables lie on a line or curve, then they are correlated. Therefore, it objectively determines whether or not a particular cause and effect are related. In this study, various scatter plots are presented to identify potential root causes of CVD.2.3K-NN, and MLP. The main objective of each classifier is to build a model with exceptional disease detection capability. The classifiers used in this investigation, K-NN and MLP, have exceptional detection potentials.ML is described as part of Artificial Intelligence (AI) in which a model acquires knowledge from past experience, without being explicitly programmed. Medical data are used in different ML classifiers for classification or forecasting of diseases. Supervised learning, which requires labelled input data for training the machine, is employed, and the machine learns with features called biomarkers of heart disease. Patient data are fed to the machine, and labelled outcomes are obtained. There are different ML classifiers for building data analysis models such as random forest, 2.3.12.3.1.1K-NN is a non-parametric classifier used to determine whether a patient has CVD or not using a labelled known data set. Predictions are made based on k numbers of frequently used neighbours for a new object, and a different distance metric for finding the K-NN is used. K-NN classifies new training data points based on similarity measurements. Data points are classified by considering the majority of votes from its neighbours. This works effectively for small dimensional data sets. K-NN does not require extra training for classification if a new data point is added to the existing data set. It is an inefficient algorithm for large data sets and requires more memory space for computation and longer model testing times because of the need to compute the distance between training data set and testing data set during each test.2.3.1.2This is a type of artificial neural network. It functions like a human brain, such that information passes from an input node to an output node via hidden nodes in a forward direction. It contains three nodes: input node, output node, and hidden node. It is one of the powerful supervised types of classifiers for the efficient prediction of chronic diseases. An MLP is the combination of a number of neural units known as perceptrons. In this model, each layer contains a number of weights via which perceptrons are connected with each other . To traiP is the number of samples, m is the actual observation, wj is the updated weight, wj is the previous weight, α is the learning rate (0 < α < 1) E is the error term  and , respect2.4The potential of ML algorithms is assessed using a set of performance metrics. To evaluate the parameters, a confusion matrix including the true positive (TP), false positive (FP), true negative (TN), and false negative (FN) for actual and predicted data are obtained. A confusion matrix is a table frequently used to determine performances of classifiers. F1-score, support, and receiver operating characteristics (ROC) – area under the curve  compared to the K-NN model (86.21%). The AUC comparison for the K-NN and MLP models is shown in Fig. S2.The comparison of results indicates that the MLP model has a higher prediction accuracy of 82.47%, followed by the 4A comparison of accuracy values from existing studies is shown in K-NN algorithm, and Pal and Parija [Regarding the literature, Alizadehsani  comparedd Parija  reportedK-NN and MLP. Between these algorithms, MLP provides better accuracy (82.47%) than K-NN with an accuracy of 73.77%. The diagnosis rate was found to be 86.41 and 86.21% for the MLP and K-NN algorithms, respectively. In the medical field, the diagnosis procedure for CVD is costly and time-consuming. The proposed approach suggests that ML can be used as a clinical tool in the detection of CVD and will be particularly useful for physicians in the event of a misdiagnosis. The constructed MLP model offers consistent accuracy compared to other techniques mentioned and is also capable of predicting other diseases. In this study, the performance of the model was improved by removing attributes with null values using an explorative data analysis method and by increasing the number of hidden layer nodes. The proposed method is expected to assist in the further development of the healthcare field. The proposed method can also be used for the classification of other chronic diseases such as breast cancer, liver disease, diabetes mellitus, and thyroid. The developed models can be applied to large data sets to predict chronic diseases using IoT and cloud computing techniques. From the above analysis, the application of ML techniques will vastly aid in preventing fatalities and supplement the efforts of doctors in fighting CVD occurrence among all patient categories of different age groups, genders, and socio-economic backgrounds. If implemented, this would be a classic case of new-age technology application for the benefit of mankind.This study presents a comparison of two ML techniques for CVD prediction:


Cancer is becoming a chronic disease, and the number of cancer survivors continues to increase. Lymphoma survivors are also increasing in numbers, and anxiety and depression are among the consequences they face. This study aimed to explore psychological distress in a sample of 212 lymphoma survivors. Information through a socio-demographic form and the compilation of questionnaires to assess anxiety, depression, quality of life, and the impact of cancer on lymphoma survivors was collected and analyzed. In the sample examined, 17% of lymphoma survivors were anxiety caseness, and 12.3% were depression caseness, and of these, 8% presented with concomitant anxiety depression. This study identified some variables associated with psychological distress in lymphoma survivors: female sex; living as a couple; a diagnosis of Hodgkin lymphoma; systematic treatment and/or radiotherapy; sleep disorders; no regular physical activity; and present or past use of psychiatric drugs. Our cross-sectional study results suggest that some of the variables investigated may be useful in identifying lymphoma survivors who are more likely to report psychological distress. It is important to monitor psychological distress along the entire trajectory of survivorship in order to identify early the presence of anxiety and depression and to provide timely psychological support. The survival rate of cancers continues to rise as cancer increasingly turns into a chronic disease. It is estimated that, in 2018, 43.8 million cancer survivors, diagnosed in the previous 5 years, were alive worldwide . In ItalAdvances in modern oncology and increased patient survival rates have triggered, in healthcare professionals and researchers, a necessary shift of attention toward survival management. In fact, survival is a dynamic dimension that moves along a continuum, and several studies indicate that having experienced an oncological disease leads to medium- and long-term consequences that can translate into physical, psychological, and social problems. The survival rate has also improved in patients with lymphoma, but the side effects and consequences that this type of survivors face are considerable. Studies show that patients with lymphoma have a greater intensity of psychological distress in the treatment phase than lymphoma survivors . HoweverMany cancer survivors do not meet the criteria for significant psychological morbidity but still experience psychological distress . DistresPsychological distress is usually detected by measuring both anxiety and depression, and a high value of anxiety and/or depression is defined as high psychological distress , 2021. LHowever, there is a lack of agreement on the definition of survivorship . The topIn general, the literature indicates a higher prevalence of anxiety and depression and poor QoL in lymphoma survivors compared with other cancer survivors  and withA cross-sectional study was conducted on a sample of lymphoma survivors enrolled from 2017 to 2019 during the routine follow-up visit.The patient inclusion criteria were 18 years of age at the time of diagnosis; free from disease and from having finished the treatments for at least 5 years; language skills (written and spoken) to be able to understand and complete the questionnaires; and signing of the consent form.The patient exclusion criteria were history of psychiatric illness and/or evidence of psychiatric pathology; the presence of physical and/or sensory disabilities interfering with the accessibility of materials; and non-adherence to the inclusion criteria. The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the relevant ethics committee.After having presented the aims and objectives of the project and having received written consent to participate, a psychologist collected information through a socio-demographic form and the compilation of several questionnaires to assess anxiety, depression, QoL, and the impact of cancer on lymphoma survivors.The socio-demographic form collected information with regard to age, marital status, education level, employment status, cancer-related variables, lifestyle, and two questions about psychological support and psychiatric drug. This information was collected through closed-ended questions, and the corresponding categories are shown in The questionnaires examined for this discussion are described below:–Hospital Anxiety and Depression Scale HADS,  is a too–The Impact of Cancer (IOC) Scale  is a sel–The 36-Item Short Form Health Survey Questionnaire (SF-36)  is a genThe collected protocols data were anonymized by assigning a progressive number to each subject and were stored in a dedicated database.t-test or a one-way univariate ANOVA followed by Bonferroni’s post-hoc test. Anxiety and depression intensities were compared using a paired Student’s t-test. The prevalence of both anxiety and depression in the sample was obtained using the case-finding criteria for HADS provided by p < 0.05 (two-tailed) was preset for statistical significance. Statistical Package for the Social Sciences (SPSS.21) was used to perform the analyses. There were no missing data.Anxiety and depression intensities were calculated, respectively, by totaling the HADS-A and HADS-D items. Differences in intensity between subgroups of participants (described below) were tested for significance with either Student’s The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of Centro di Riferimento Oncologico di Aviano (CRO) IRCCS . Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this study.The study sample included 212 lymphoma survivors . There were no refusals. The mean age at the time of the survey was 56.8 (SD 13.5) years. Age at survey was also divided into classes. Socio-demographic characteristics of the sample are summarized in n = 141), while 46 patients underwent systematic treatment only, and 12 patients underwent surgery and systematic treatment and/or radiotherapy. The other categories involved fewer patients. Details of all cancer-related variables investigated are summarized in Regarding cancer-related variables, 102 survivors were diagnosed with Hodgkin lymphoma (HL) and 110 survivors were diagnosed with non-Hodgkin lymphoma (NHL). The mean age at the time of diagnosis was 44.11 (SD 14.9) years, and the average time elapsed from diagnosis was 11 (SD 1.4) years. Since the survivors were enrolled at different times of follow-up, we divided them into classes based on the time since diagnosis. The treatments performed were divided into 7 categories. Most of the patients appeared to have undergone systematic treatment and/or radiotherapy , the patients answered for the majority that they had received some form of psychological support and had not used psychiatric drugs. Data are shown in p < 0.001), respectively.In the sample examined, 17% of lymphoma survivors were anxiety caseness and 12.3% were depression caseness. Cross-tabulation of anxiety caseness and depression caseness found that 9% presented exclusively anxiety, 4.2% presented exclusively depression, and 8% presented concomitance of anxiety and depression. In the sample examined, lymphoma survivors showed higher anxiety intensity than the reported depression intensity; in particular, the average anxiety and depression intensities were 5.4 (SD: 3.7) and 4.0 (SD: 3)  and in depression intensities . Analyzing age at survey divided into classes, no significant differences emerged for anxiety (p = 0.149) and depression (p = 0.613) intensities in the different age groups. For marital status, significant data emerged: individuals living as a couple had higher intensities of both anxiety  and depression  than the intensities of anxiety  and depression  of those who were single. On the contrary, no significant differences emerged with respect to anxiety and depression compared with the education level and employment status (p > 0.05).With respect to gender variable, the analyses showed that women had higher values than men both in anxiety  and depression (p = 0.387) in the different age groups. Similarly, no significant differences were found in the time since diagnosis was divided into classes (p > 0.05) in the different survivorship groups. However, it appeared that, as survivorship progressed, anxiety intensity increased  but not depression intensity . With respect to the types of lymphoma, a significant difference emerged only for anxiety, which was greater in HL  compared with NHL  (p = 0.037). Regarding the type of treatment, both anxiety  and depression  were significantly higher only in lymphoma survivors who had undergone systematic treatment and/or radiotherapy compared with other types of treatment.Analyzing age at diagnosis divided into classes, no significant differences emerged in the intensities of anxiety (p = 0.216) and depression (p = 0.424) intensities in the eating style. Analyzing the sleep variable, significant results emerged for both anxiety (p = 0.006) and depression (p < 0.001). In particular, subjects who reported having unrefreshing sleep showed a higher intensity of anxiety than subjects who reported having regular sleep  (p = 0.001). Instead, for the depression, “regular sleep” survivors showed a lower intensity of depression  than survivors in all other sleep categories, such as “difficulty falling asleep/waking up” , “disturbed sleep” , and “unrefreshing sleep” .For the variables related to lifestyle, no significant differences emerged in anxiety (p = 0.005) and depression (p = 0.007) based on the frequency of physical activity performed. In particular, subjects who did not perform physical activity reported a higher intensity of anxiety  than survivors who regularly engaged in physical activity  (p = 0.001). Similarly for depression, the differences reached statistical significance (p = 0.003) by comparing the subgroups of those who did not perform physical activity  with those who performed a regular physical activity .Concerning the physical activity variable, differences emerged in the intensities of both anxiety (p = 0.855) and depression (p = 0.609) intensities in those who received some form of psychological support compared with those who did not receive it. Instead, there was a significant difference for both anxiety  and depression  scores between those who used psychiatric drugs in the past vs. who had never used it.No significant differences emerged in the anxiety  and timing (time since diagnosis divided into classes) did not report significant differences in anxiety and depression. Moreover, different data are found in the literature but the comparison has limited validity as the studies are not specific to lymphoma survivors. In some studies, it was observed that younger survivors experience higher intensities of anxiety and depression than older survivors ; other sIt is interesting to note that, by comparing the two different types of diagnoses (HL vs. NHL), higher values of both anxiety and depression emerged in the subgroup of HL survivors, differences that reached statistical significance only for anxiety. Regarding these data, useful references were not found in the literature where lymphomas are generally analyzed either separately or in a single sample but not in comparison. However, the data found made us ponder on the different impacts that these diseases can have on survivors and reflect on the usefulness of future studies that consider this difference.For the type of treatment received, it was observed that those who had performed systematic treatment and/or radiotherapy had higher intensities of anxiety and depression than those who had received other treatment types. To this regard, Compared to the information collected on the lifestyle, no significant differences emerged in the intensity of psychological distress in relation to eating style, and we have not found specific studies that investigate the eating style in lymphoma survivors.p < 0.001). However, in the literature, there is less evidence relating to the variable of sleep in lymphoma survivors and slightly more evidence for generic cancer survivors, underlining how this is less studied and taken into consideration. The problems most reported by cancer survivors seem to be problems of falling asleep  and depression caseness (12%). Strengths of the study include a good number in the study cohort and no refusals. In addition, demographic data appeared well matched between gender, age, and lymphoma type, and this adds strength to the findings. The results raise some interesting points that have not been seen before in the literature and outline the need for further prospective and longitudinal studies. It emerges, in fact, the need to systematically investigate survivorship in consideration of the different timing of survivorship (short term and long term) and propose screening programs to monitor psychological distress throughout the duration of survivorship and to promptly address the needs experienced.The original contributions presented in the study are included in the article/This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Centro di Riferimento Oncologico di Aviano (CRO) IRCCS . The patients/participants provided their written informed consent to participate in this study.MA: conceptualization. MA and BM: methodology. BM: formal analysis. GA: investigation, data curation, and writing—original draft preparation. SS and BM: writing—review and editing. MA and MS: project administration and funding acquisition. All authors have read and agreed to the published 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.


Chronic obstructive pulmonary disease (COPD) is considered a major cause of death worldwide, and various studies have been conducted for its early diagnosis. Our work developed a scoring system by predicting and validating COPD and performed predictive model implementations. Participants who underwent a health screening between 2017 and 2020 were extracted from the Korea National Health and Nutrition Examination Survey (KNHANES) database. COPD individuals were defined as aged 40 years or older with prebronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC < 0.7). The logistic regression model was performed, and the C-index was used for variable selection. Receiver operating characteristic (ROC) curves with area under the curve (AUC) values were generated for evaluation. Age, sex, waist circumference and diastolic blood pressure were used to predict COPD and to develop a COPD score based on a multivariable model. A simplified model for COPD was validated with an AUC value of 0.780 from the ROC curves. In addition, we evaluated the association of the derived score with cardiovascular disease (CVD). COPD scores showed significant performance in COPD prediction. The developed score also showed a good effect on the diagnostic ability for CVD risk. In the future, studies comparing the diagnostic accuracy of the derived scores with standard diagnostic tests are needed. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the world, and its global burden is expected to further increase . SeveralAs noted in the 2006 update of the Global Initiative for Obstructive Lung Disease (GOLD) guidelines, the definition of COPD is a preventive and treatable disease . HoweverHerein, we conducted this study to develop a simple COPD score directly applicable to the general population who undergo health screenings, which was validated in an independent cohort. In addition, the association of the developed score with CVD, including coronary heart disease (CHD) and stroke, was evaluated using the Korean National Health and Nutrition Examination Survey (KNHANES) database.KNHANES, conducted by Korea Disease Control and Prevention Agency (KCDC), is the representative national cross-sectional surveillance system that provides data for the evaluation of nutritional status, health policy effectiveness and trends in the prevalence of health risk factors and major chronic diseases . The samCOPD individuals were defined as aged 20 years or older with prebronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC < 0.7) . Drinkert-test was used for the continuous analyses, and the chi-squared test was used for the categorical analyses. Univariable and multivariable analyses were performed using the logistic regression model, which included odds ratios (ORs), 95% confidence intervals (CIs) and the concordance index (C-index). We used the purposeful selection used by Zhang et al. [p < 0.001. If more than one variable with a significant level of p < 0.001 was considered related, only variables with a higher C-index were included in the derivation after using the partial likelihood ratio test. For example, a multivariable model 1 with waist circumference (WC) and body mass index (BMI), and a multivariable model 2 with only WC are not significantly different in their fits for data. We chose model 2 for the principal of parsimony. After the univariable analyses, variables that required a hospital visit to be obtained were excluded for simplification and generalization. The following variables were selected for multivariable analyses: age , sex , WC  and diastolic blood pressure . The derived COPD score was validated in independent participants who underwent a health screening between 2019–2020. A receiver operating characteristic (ROC) curve with an area under the curve (AUC) value was performed using R version 4.1  and generated for the evaluation of sensitivity (Sens), specificity (Spec), positive predictive value (PV+) and negative predictive value (PV−). In addition, the validation cohort was stratified according to the interquartile range of the derived COPD score to determine the score-dependent ORs. Moreover, unadjusted ORs were calculated using logistic regression to confirm whether the derived score was informative in the stratification of individuals at higher risk of CVD, CHD and stroke.All statistical analyses were performed using SAS version 9.4 . Continuous variables and categorical variables were presented as means (standard deviation (SD)) and numbers (%), respectively. The g et al. . The varThe numbers of participants with COPD and non-COPD at baseline were 949 and 6088, respectively . Weight,p = 0.508), TG (p = 0.911) and AST (p = 0.176). For covariate selection, the tests for diabetes mellitus, dyslipidemia, liver function, kidney function and urine were excluded in the simplification process, since these variables require a hospital visit. Subsequently, age, sex, BMI, WC, smoking, SBP and DBP remained potential candidates for the development of the COPD score. Between BMI and WC, WC had a higher C-index. As for SBP and DBP, DBP had a higher C-index. Finally, age, sex, WC and DBP were selected as components for the COPD score. In addition, the univariable analyses of variables among men and women are shown in Nineteen variables from demographic characteristics, measurement, habits, blood pressure and tests for diabetes mellitus, dyslipidemia, liver function, kidney function and urine were evaluated in the univariable analyses . The resp < 0.001), sex , WC  and DBP , which constituted the KNHANES COPD score . When smoking was further added as a component of the model, the difference in the C-index only increased by 0.01 , 3rd  and 4th  quartile groups were directly proportional in the validation dataset , CHD  and stroke  in the training dataset (When evaluating the association of the derived score with CVD risk to testify its applicability in the prediction of CVD, the KNHANES COPD score significantly estimated the risk of CVD (OR, 1.945; 95% CI, 1.776–2.130;  dataset .We conducted this study to develop a self-diagnosis tool for COPD by simplification of the multivariable logistic model that exempted variables requiring hospital visits. The KNHANES COPD score consists of age, sex, WC and DBP, all of which are self-evaluable. The prediction score was developed with a C-index of 0.802 and validated with an AUC of 0.784 for the validation cohort including CVD. In addition, we developed a gender-stratified multivariable logistic model, a separate model due to the difference in COPD incidence and smoking rates between men and women. Through univariable analyses, it was confirmed that smoking was significantly different in the male group, and models when smoking was added and when smoking was not added are here presented. The developed COPD score was in direct proportion to the OR for COPD. Moreover, significant estimates were made for CVD risks using the COPD score. The effect of the developed COPD prediction score on CVD occurrence prediction was confirmed, and COPD prediction was possible with only the results of a general examination report. This suggests that there is potential to predict overall health, such as CVD and CHD.COPD is a disease that exhibits airflow restriction due to airway resistance induced by the destruction of alveolar attachments as a result of the destruction of the pulmonary system and emphysema . These pCOPD can increase the risk of other comorbidities. Severe airway obstruction has been reported to show a higher correlation , and it The strength of this study is that it is the first study to develop and verify a COPD score system using only basic variables that do not require hospital visits. There are previous studies of various approaches using multivariable models or machine learning models for outcome exacerbation prediction. Of the 25 studies using the regression model or cox regression model, most of the models had overall lower performance than this study, and higher performance models also used predictors such as IgG titter and Gold stage, which are difficult to understand alone ,34. ClinThis study includes several limitations that need to be considered. First, since this study is a cross-sectional and questionnaire-based study, it is difficult to identify causal relationships. Second, the study population consisted of the Korean population only. It is worth evaluating our model’s generalizability to other health care systems in other regions. Third, the golden criterion for detecting COPD is based on post-bronchodilator spirometry, and other diseases related to airflow disorders, such as bronchodilation and tuberculosis destruction, are likely to be included because FEV1/FVC <0.7 was used without utilizing chest radiography [In conclusion, the KNHANES COPD score, composed of age, sex, WC and DBP, satisfactorily predicted COPD. The developed score may be supportive in the stratification of individuals at high risk of COPD who require further screening for pulmonary diseases. Future studies comparing the diagnostic accuracy of the derived score with standard diagnostic tests are necessary to validate its accuracy and cost-effectiveness.


The aim of this study was to evaluate the comparison between acupuncture combined with metformin versus metformin alone in improving the pregnancy rate of people with polycystic ovary syndrome (PCOS).A literature search of eight databases resulted in nine randomized controlled trials (RCTs) that assessed the effect of acupuncture combined with metformin on pregnancy rate in PCOS patients compared with metformin alone. Subsequently, data extraction and analysis were conducted to evaluate the quality and risk of bias of the methodological design of the study, and meta-analysis was conducted on the RCT data.Z = 2.72, p = 0.007, relative risk (RR) 1.31, 95% CI 1.08 to 1.60, p = 0.15, I2 = 41%]. Analysis was performed according to different diagnostic criteria of pregnancy . Acupuncture can improve ovulation rate. Subgroup analysis was performed according to the number of ovulation patients  and ovulation cycle . Statistical analysis also showed that acupuncture combined with metformin could improve homeostatic model assessment of insulin resistance (HOMA-IR) .Nine RCTs and 1,159 women were included. Acupuncture can improve pregnancy rate. It was analyzed according to the diagnostic criteria of PCOS [Based on the results of this study, compared with metformin alone, acupuncture combined with metformin has a positive effect on pregnancy rate, ovulation rate, and insulin resistance in PCOS. However, due to the limitations regarding the number and quality of the included studies, the above conclusions need to be verified by further high-quality studies.https://www.crd.york.ac.uk/PROSPERO/#myprospero. Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in women and is also one of the most common factors that cause infertility . With thAcupuncture has become more and more popular in the world as a complementary and alternative therapy for infertility. In 2010, a study in the United States showed that 29% of patients used complementary and alternative drugs with the aim to treat infertility, of whom 22% chose acupuncture –17 but iThere are no detailed and systematic methodological evaluations and data consolidations between acupuncture combined with metformin versus metformin alone. The main objective of this study was to conduct a systematic review and meta-analysis comparing whether acupuncture combined with metformin can further improve pregnancy rates compared to metformin alone, thus providing a more effective treatment for this population.This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) . This stIn this study, the following eight databases  were searched from the database construction to 14 April 2022, including four English databases and four Chinese databases. At the same time, to retrieve Chinese Clinical Trial Register, Clinical Trials.gov, relevant articles in the reference lists were also collected. The retrieval was carried out by the combination of medical subject headings (MeSH). Keywords searched in PubMed include “Acupuncture” and “Metformin” and “Polycystic Ovary Syndrome” and “Infertility” and “Randomized Controlled Trial”. See appendix for detailed search strategies.Two researchers (YL and HYL) independently screened the retrieved articles, read the titles and abstracts, and then excluded the repeated studies and irrelevant articles. According to the inclusion criteria and exclusion criteria, eligible studies were identified, data were extracted and cross-checked, and any ambiguity was resolved through discussion and consensus. If no consensus was reached, a third researcher (QLX) was asked to adjudicate. Any literature that is removed will be recorded. The experimental groups received acupuncture  combined with metformin; the control groups were treated with metformin alone. Inclusion criteria were as follows: (a) subjects were diagnosed with PCOS; (b) the treatment group used acupuncture combined with metformin, while the control group used only metformin; and (c) the study type was a randomized controlled trial. Exclusion criteria were as follows: (a) subjects were treated with drugs other than metformin; (b) the use of traditional Chinese medicine; (c) the study was conducted on animals; and (d) the study was not reported in Chinese or English. This study was divided into two groups: the acupuncture combined with metformin group and the metformin alone group. Data were extracted independently by two researchers (YL and HYL), and checked by another researcher (XC) to extract information that might be related to the research results, as follows: First author, year of publication, number of participants, age, infertility duration, treatment duration, interventions, diagnostic criteria, outcome indicators, side effects and adverse events, and other information. The results were recorded in an Excel spreadsheet Table 1.Cochrane RoB2.0 was used to evaluate risk of bias in the individual studies . The folMain outcome measures: pregnancy rate: positive morning urine beta human chorionic gonadotropin (β-hCG) or blood β-hCG, basal body temperature (BBT) for more than 3 weeks, pregnancy sac detected by color ultrasonography, or fetal bud and heartbeat detected by colour ultrasonography at 7 weeks of gestation.p < 0.05 was considered as a statistically significant difference. According to the study of the object of study, observation group intervention, and control group, judging whether the concrete application of similar clinical outcome index, according to the result of the I2 test to determine the statistical heterogeneity. I2>50% is considered as high heterogeneity. The methods of subgroup analysis and sensitivity analysis were used, and the study adopts a random-effects model.RevMan5.3 software was used for statistical analysis. Relative risk (RR) and its 95% confidence interval (CI) were used for dichotomous variables, MD or standardized mean difference (SMD) were used for continuity variables, and 95% CI was given. In total, 330 related literatures were screened initially, and nine studies −29 ultimWe used the GRADE method to present a “Summary of Findings” table. The quality of evidence for outcome measures  was evaluated for a subject review comparison . We used the GRADE criteria to assess the quality of evidence, study limitations, inconsistencies, inaccuracies, and publication bias. The two researchers (ZL and QLX) independently judged the quality of the evidence  and resolved differences through discussion Z = 3.22, p = 0.001, RR 1.35, 95% CI 1.13 to 1.63, p = 0.12, I2 = 42%), indicating that acupuncture combined with metformin was superior to metformin alone in improving pregnancy. We found that different diagnostic criteria were adopted in clinical studies on pregnancy rate; thus, we conducted subgroup analysis and used B-ultrasound for diagnosis . B-ultrasound was not used for the diagnostic group , indicating that the heterogeneity of the test was mainly derived from the criteria of pregnancy (I2 = 25%) was significantly lower than the overall heterogeneity (I2 = 41%) . Calculated according to ovulation cycle: 683 participants in these studies, cycle ovulation rates were recorded for 278 women in the trial group and 226 women in the control group. The results had low heterogeneity, and indicated that acupuncture combined with metformin had a positive effect on improving ovulation rate compared with metformin alone  , with high heterogeneity . After sensitivity analysis , heterogeneity was derived from a research  was significantly lower than the overall heterogeneity (I2 = 41%). Currently, the Rotterdam standard is generally accepted and internationally recognized. In this study, five articles  . We think more about the diagnosis of pregnancy. Based on the last 3 years of studies retrieved from Clinical Trials.gov, the Chinese Clinical Trial Register and Prosper, in studies of PCOS and VF/ICSI) –39, ultrIn this review, we included only nine RCTs, most of which had small sample sizes. The quality of the evidence was low or very low. The main problems are risk of bias, imprecision, and inconsistency of the research results Table 2.The limitations of this systematic evaluation are as follows (1): the included intervention measures, such as acupuncture forms, acupoint selection, treatment frequency, and course of treatment, vary greatly, and further subgroup analysis cannot be carried out due to the limited number of studies, affecting the accuracy of the results; and (2) due to incomplete information about the authors of most of the studies, we were only able to contact four of the authors by email, and did not receive any replies. It can be seen that the author of the original study is not very positive about the return visit of the author of the systematic evaluation. It may be because the author doesnot commonly use this contact method, or the recognition and research significance of the systematic evaluation are not high within the industry, and the author is not confident in his own scheme.We cannot exclude clinically relevant differences in pregnancy rate, ovulation rate, LH/FSH, HOMA-IR, and FPG for acupuncture combined with metformin versus metformin. The pregnancy rate, ovulation rate and HOMA-IR of participants receiving acupuncture combined with metformin may have improved compared to metformin alone. Due to differences in pregnancy diagnostic criteria, we are not sure if this is effective in studies without a definitive B-ultrasound diagnosis. Due to the low quality of evidence and the limited number of RCTs available in this area, our ability to determine whether acupuncture combined with metformin is more effective at treating PCOS than metformin alone is limited.It is hoped that acupuncture combined with metformin will improve the pregnancy rate of PCOS women.Further well-designed and well-performed randomized controlled trials are needed to definitively answer this question. Under uniform diagnostic criteria, a standard set of acupuncture points and stimulation methods should be considered, and the control group should receive the same metformin regimen as the acupuncture group.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.YL and HYL conducted literature searches, evaluated study inclusion, and extracted data. XC and JLY analyzed data and drafted the manuscript. QLX’s assessment was incorporated into the study and cross-checked with XC. YL revised the language and the article. JW, XYZ, YMZ, CYL, MJW, and ZL conceived the study and revised the manuscript. All authors read and approved the final version of the manuscript.This study was supported by the National Natural Science Foundation of China (81774412 and 82105028) and the Sichuan Administration of Traditional Chinese Medicine (2021MS079).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.


To explore the best treatment of obesity in middle and old age.  80 obese patients in our hospital from January 2020 to December 2021 were randomly divided into the control group and the intervention group according to the numerical table method. The control group was treated with lifestyle intervention, while the intervention group was treated with dapagliflozin combined with lifestyle intervention. The effects of body weight, body mass index (BMI), waist circumference, and blood lipids  were measured and compared. Anxiety and depression scores were assessed using the 2018 Revised Anxiety and Depression Scale. P < 0.05). After treatment, LDL, TC, and TG in the two groups were decreased, and HDL was significantly increased (P < 0.05). After treatment, the blood lipid level in the intervention group was significantly lower than that in the control group (P < 0.05). Anxiety and depression symptoms improved in both groups, and there were no serious adverse effects.  There were no significant differences in body weight, BMI, and waist circumference between the control group and the intervention group before treatment. After treatment, the weight, BMI, and waist circumference of the intervention group were lower than those of the control group, and the difference was statistically significant ( Dapagliflozin in combination with a lifestyle intervention effectively and safely treats excess weight in middle-aged and older adults, reverses obesity-related markers, and improves psychological symptoms. Its curative effect is better than that of using lifestyle intervention alone. Obesity has become one of the major health problems worldwide , 2. Obes2 was overweight, ≥28 kg/m2 was obese, waist ≥ 85 cm for men and ≥80 cm for women was abdominal obesity [The diagnostic criteria for obesity are based on the classification criteria for overweight and obesity in China and the middle-aged and elderly recommended by the “China Academic Conference on Obesity in Middle-aged and Elderly” in 2003: body mass index (BMI) ≥ 24 kg/m obesity .Inclusion criteria: (1) those aged between 35 and 70 years old, who have not received treatment intervention and meet the above diagnostic criteria can be included, and (2) the patients and their families are informed and signed the informed consent. Exclusion criteria: (1) patients with severe heart, liver, kidney, and other vital organ insufficiency; (2) patients with severe diseases of other systems or those who cannot cooperate; and (3) patients who have undergone major surgery recently. This study was carried out after being approved by the Ethics Committee of our hospital.P > 0.05)  durWaist circumference, body weight, and blood lipids  were measured before and after treatment. Height and weight were measured twice within 0.5 cm and averaged to derive BMI. The Revised Anxiety and Depression Scale (RCADS) questionnaire was completed, which produced scores for total anxiety and depression using the RCADS electronic scoring scheme . The folM . The independent sample t-test and Mann–Whitney U test are used for comparison between groups. The count data use case (%) indicates that the χ2 test is used for comparison between groups.Use SPSS 22.0 software for statistical analysis of the data. Normally distributed measurement data is represented by P > 0.05). After 3 months of treatment, compared with the control group, the curative effect of the intervention group was significantly higher than that of the control group; LDL , TC , and TG  levels were significantly decreased; and HDL levels were significantly increased  (P < 0.05)  .P > 0.05). After 3 months of treatment, compared with the control group, the weight , BMI , and waist circumference  decreased significantly higher than that of the control group, and the weight loss of the intervention group was statistically significant compared with the control group (P < 0.05) (There was no significant difference in body weight and BMI level between the two groups before treatment ( < 0.05) .T score > 70), 9 patients with anxiety, accounting for 11.2% of the total, and 6 patients with depression, accounting for 8% of the total. After the intervention, all patient indicators fell below standard values. The anxiety and depression scale  and the separation anxiety scale  before and after the intervention were statistically significant.The patients completed the RCADS questionnaire before and after treatment. The average scores were calculated, and the results showed that all scales and total scores in the control group and the intervention group decreased after treatment compared with before treatment. Before the start of treatment, the scores of the patients on the anxiety and depression scale had significant clinical significance (With the improvement of living standard in recent years, the incidence of obesity in middle-aged and elderly people has increased significantly , 21. ObeIn this study, 80 middle-aged and elderly obese patients were given basic life intervention and routine nursing. In addition, the intervention group was treated with dapagliflozin. Dapagliflozin is a commonly used hypoglycemic drug in clinic. The latest research shows that dapagliflozin can reduce plasma cholesterol level and lipoprotein level and reduce the production of low-density lipoprotein , 29. StuThe advantages of this study include the use of the numerical table method for random allocation to reduce the intragroup differences of the data and the large number of samples to reduce the random error of the experimental results. However, this study also has certain limitations. It is mainly reflected in the fact that the intervention group in this study simply introduced dapagliflozin drug treatment, but no corresponding drug treatment reference was given to the control group, so we can only draw the conclusion that the life intervention combined with dapagliflozin treatment plan is better than the life intervention plan alone.Dapagliflozin in combination with a lifestyle intervention effectively and safely treats excess weight in middle-aged and older adults, reverses obesity-related markers, and improves psychological symptoms. Its curative effect is better than that of using lifestyle intervention alone.


After the interventions, we obtained differences in skeletal muscle mass, skeletal muscle mass/height2, skeletal muscle mass/weight, muscle mass/BMI, and skeletal muscle mass/body fat percentage (p < 0.05). Changes in average daily energy and total daily protein intakes were not significantly different; however, there was an overall improvement in the intervention groups relative to baseline data. There were no changes in the average daily time of moderate physical activity. The Internet was an effective tool of nutrition intervention in the elderly with sarcopenia. The Internet-based nutrition intervention improved high-quality protein intake and skeletal muscle mass in the elderly with sarcopenia.Effective nutrition and exercise interventions may improve sarcopenia in the elderly. The purpose of our study was to investigate the effectiveness of Internet-based nutrition and exercise interventions in the elderly with sarcopenia. Participants were divided into 4 groups: control, nutrition, exercise, and comprehensive (nutrition plus exercise) groups; there was at least 50 participants in each group. Our trial lasted 12 weeks. We conducted dietary and exercise interventions through an app and collected feedback from the participants every three weeks. Information on the diet, skeletal muscle mass, and muscle function was collected before and after the interventions. The comprehensive group had higher high-quality protein intake than the control ( According to the World Health Organization (WHO), a country or region enters the advanced aging stage when the proportion of individuals of 65 years of age or over is >14%. In Shanghai, China, the advanced aging stage is significant. Towards the end of 2020, Shanghai’s registered population over 65 was 25.9% of the city’s registered population [The incidence of sarcopenia has gradually increased in recent years. According to the third National Health and Nutrition Examination Survey, the prevalence of second-degree sarcopenia in men and women over 60 years in the United States was 9.3% and 7.3%, respectively, and the prevalence increased with age . A commuThere are no suitable clinical interventions for sarcopenia. Nutrition and exercise are the primary methods to prevent and treat sarcopenia. Specifically, adequate intakes of energy, protein, especially high-quality protein , long-chThe Consensus of Chinese Experts on Nutrition and Exercise Intervention for Muscle Attenuation Syndrome in 2015  providesOur study used an app to provide health education and personalized guidance to the elderly with sarcopenia based on the Consensus of Chinese Experts released in 2015. The purpose of our study was to explore the effectiveness of Internet-based nutrition and exercise interventions.We used the formula of randomized controlled trials to calculate the sample size: n = 2σ2 × f/(μ1 − μ2)2, where α = 0.05, β = 0.20, and f = 7.9. Based on research data, the standard deviation of skeletal muscle was σ = 2.25, μ1 − μ2 = 1.27 . At leasOur study included a control group and three intervention groups: nutrition, exercise, and comprehensive (nutrition plus exercise) groups. For field feasibility, we randomly selected 4 districts from 16 districts in Shanghai, with a community healthcare center chosen at random from each project area as the test site. The control group originated from Jinhai Community Health Service Center in Fengxian District, all participants in this community were included in this group, and participants in other communities were enrolled in the same manner. The nutrition, exercise, and comprehensive groups originated from the Ganquan Street Community Health Service Center in Putuo District, the Ying Pu Street Community Health Service Center in Qingpu District, and the Laoximen Community Health Service Center in Huangpu District, respectively.Participants (65 to 75 y) had sarcopenia, were able to walk independently, and used a smartphone for 3+ years or were proficient in using a smartphone. Exclusion criteria included the presence of cognitive disorders; infectious diseases or diseases that affected the heart, liver, or kidneys; hip and knee joint pain or dysfunction; recent trauma, fracture, or surgeries, as well as diseases that prevented exercise. Furthermore, subjects were excluded if they consumed specific drugs that might affect the study outcomes, for example, thyroid hormones, steroids, weight-loss drugs, etc.Our study started in November 2020 and ended in February 2021 (12 weeks).The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Shanghai Municipal Center for Disease Control and Prevention Ethical Review Committee (2019-46). All of the participants provided informed consent. The study protocol was registered in the Chinese Clinical Trial Registry (ChiCTR2100048874).To assess sarcopenia, we used a combination of clinical diagnostic methods from the consensus updated by the European Working Group on Sarcopenia in Older People (EWGSOP) in 2018 and criteria from the consensus updated by the Asian Working Group on Sarcopenia (AWGS) in 2019 ,18.The SARC-F questionnaire recommended by EWGSOP was used to screen the elderly in the community. Participants with scores ≥ 4 were further examined as recommended by AWGS .After screening and baseline surveys, we informed the participants of their disease status and provided them with health education on sarcopenia, including the role of nutrition and exercise in sarcopenia, but not how nutrition and exercise adjustments were made. The control group only received health education without any intervention. At the same time, participants in the three intervention groups were trained in the use of the application (APP), including dietary or exercise assessments, feedback, and recommendations for improvement. The nutrition group received dietary management information through an app. The app featured the ability to assess each participant’s diet and provide recommendations for adjustments, focusing on energy and protein intake, especially the high-quality protein, and give recommended recipes. For example, the APP would show that the gap between the recommended intake and actual intake of energy and protein and every 50 g of fish and shrimp or 25 g of lean meat or 40 g of poultry contains 10 g of high-quality protein, etc., which was convenient for participants to adjust their intake spontaneously. The exercise group received exercise management information. The app evaluated the participant’s exercise status and recommended the amount of exercise, such as 40 to 60 min of moderate-to-high-intensity exercise  and resistance training  for 30 min, 3 days a week or more. The comprehensive group received both dietary and exercise management information. The specific content was consistent with the above two intervention groups. Every 2 weeks, the app’s automatic reminder function would remind participants for assessment and feedback. At least five assessments and feedback had to be completed. After 12 weeks, all participants had free access to the full version of the app.Our team did not actively contact the participants during the intervention period, unless the participants had difficulty on using the APP, and this contact did not include any nutritional or exercise instructions.The survey contents were consistent before and after the intervention including questionnaires, physical examinations, and muscle function tests.Questionnaires consisted of a general situation questionnaire , food frequency questionnaire (FFQ), disease history survey, and activity quantitative survey. The FFQ was a validated and reliable questionnaire including 15 food categories with a total of 117-item to assess the frequency and average intake of food in the past three months . These fHigh-quality protein was defined as protein derived from soyabean, milk and dairy products, meat and poultry, fish and seafood, eggs, preserved animal food, snacks, dietary supplement.We used calibrated electronic grip actuator  to assess grip strength and INBODY 770  to assess height, waist circumference, hip circumference, and blood pressure.Muscle function tests included balance test, 4-m timed walking test, and timing sitting and standing tests.The primary outcomes were changes in skeletal muscle mass, the other indicators include muscle function .p < 0.05 was statistically significant.We used IBM SPSS Statistics version 21.0  to analyze the data. Normally distributed data were presented as mean ± SD (standard deviation). Factors measured at baseline such as gender, age, education level, marital status, pre-retirement occupation, smoking, energy intake, total protein intake, high-quality protein intake and BMI etc. that may influence the outcome of the intervention were analyzed by propensity score method. The score was used as covariate in analysis of covariance of multi-group comparisons. We used one-way analysis of variance (ANOVA) for multi-group comparisons. The test for homogeneity of variance was >0.05. LSD was used for post-hoc pairwise comparison and when it was <0.05, we used Tamhane’s T2 for comparisons. Classification data were expressed by composition ratio, and the differences of each group were compared by Chi-square test; There were 54, 58, 62, and 60 participants in the control, nutrition, exercise, and comprehensive groups, respectively. The number of participants who completed the 12-week follow-up were 51 (control group), 50 (nutrition group), 50 (exercise group), and 50 (comprehensive group), which met the minimum sample size required for the study. The lost to follow-up rates were 5.6% (control group), 12.1% (nutrition group), 19.4% (exercise group), and 16.7% (comprehensive group).The frequency of app feedback/evaluation provided by the different intervention groups had no statistically significant differences .p < 0.05). Based on age and skeletal muscle mass, the nutrition group was younger than the other three groups . Skeletal muscle mass was higher in the comprehensive group than in the control (p = 0.006) and nutrition (p = 0.031) groups. There were no significant differences among the groups in gender, smoking, energy, total protein, high-quality protein, or BMI . Specifically, daily average intake of high-quality protein was higher in the comprehensive group than in the control and exercise groups  and BMI was the highest in the nutrition group followed by the comprehensive, control, and exercise groups .We compared the changes in skeletal muscle mass and related indexes of muscle function among the groups before and after the intervention. There were no significant differences among the 4 groups before and after the intervention in the changes in balance test (the third posture), 4-m regular walking time, and regular sitting and standing times. The changes in skeletal muscle mass, skeletal muscle mass/heightp1, p2, p5 < 0.001, p6 = 0.004). Skeletal muscle mass/height2 in female was higher in the comprehensive and nutrition groups than in the control and exercise groups . Compared to the control group, the comprehensive, nutrition, and exercise groups had higher skeletal muscle mass/body weight . Skeletal muscle mass/BMI was higher in the comprehensive and exercise groups than in the control group . Finally, skeletal muscle mass/body fat percentage was higher in the comprehensive, nutrition, and exercise groups than in the control group  . In addiThe Internet is an effective health tool for elderly patients with sarcopenia. Internet-based nutrition interventions were effective, and they can optimize the diets of elderly patients with sarcopenia and improve skeletal muscle mass; however, they cannot improve skeletal muscle function. The Internet-based exercise intervention have failed by not improving physical activity in the elderly. We recommend the use of the Internet coupled with dietary interventions.


The strongest positive correlations were between Share-FI score and the number of diseases (rS = 0.31), GDS (rS = 0.32), while negative correlations with IADL (rS = −0.47) and HGS (rS = −0.35). The study shows that FS is associated with age, comorbidities, number of medications taken, and widowhood. The present study has also demonstrated that FA, depression, and especially HGS are essential determinants of FS of elderly hospitalized people.Frailty syndrome (FS) is a condition characterized by a decline in reserves, observed with aging. The most important consequences of the frailty syndrome include disability, hospitalization, fractures, institutionalization, and early mortality. The aim of this study was to identify the most important risk factors for FS in a group of older hospitalized patients in Poland. A total of one hundred and forty-one  elderly patients from the Departments of Internal Medicine of the Medical University of Lodz (Poland) were recruited for this study. Frailty Instrument of the Survey of Health, Aging and Retirement in Europe (SHARE-FI), handgrip strength (HGS), depressive symptoms using the Geriatric Depression Scale (GDS), and functional ability (FA) using the Instrumental Activities of Daily Living (IADL) were assessed. According to SHARE-FI score, participants were divided into control group, frail, and pre-frail patients. Out of all 141 tested patients, FS was confirmed in 55 patients, and pre-frailty was observed in 52 patients. The occurrence of FS in the group of studied patients was related to age ( In recent years, the identification of the elderly with frailty syndrome (FS), or those at risk of developing FS has become a cornerstone of geriatric care . Due to FS may be conceptually defined as a clinically recognizable state in older people who have increased vulnerability, resulting from age-associated declines in physiological reserve and function across multiple organ systems, such that the ability to cope with every day or acute stressors is compromised ,5,16,17.The prevalence of FS in people over 65 in Europe ranges from 5.8% to 27.3%; in addition, from 34.6% to 50.9% are classified as "pre-frail" . Lodz isTherefore, the objective of this study was to identify the most important risk factors for FS in a group of elderly patients hospitalized in Polish Departments of Internal Medicine. In particular, the relationship between FS and HGS, depression, FA was analyzed.i) aged over 65 years, (ii) good verbal and logical communication (without severe dementia), (iii) no considerable hearing disorders significantly hampering understanding of questions at the time of the study. All patients staying in the hospital during the specified period and meeting the above criteria were included in the study. Each subject underwent a multidimensional assessment, which included: demographic and social parameters, health conditions, and physical function. The following set of instruments commonly used for health assessments of elderly populations was utilized: functional abilities (FA), depressive symptoms , handgrip strength (HGS), and Frailty Syndrome (FS) (SHARE-FI questionnaire). This study was conducted as part of obligatory practical classes in geriatric nursing with students in a strictly defined period of the academic year from March to June 2022. Out of all elderly patients staying, at that time, in three Departments of Internal Medicine of the Medical University of Lodz, Poland, 141 (63 men and 78 women) elderly patients were selected who met the inclusion criteria of the study. The study covered patients suffering from various chronic conditions: high blood pressure or hypertension; diabetes or high blood sugar; chronic lung disease, such as chronic bronchitis or emphysema; asthma; osteoporosis; rheumatic disease; stroke victims; and others. The inclusion criteria of the study were as follows: . SHARE-FI is especially recommended in primary health care and hospital care in elderly people ,23. Tran® . The dynamometer facilitates measurements of isometric force to 90 kg. According to the literature, measurements are influenced by subject position when carrying out the test . Scientific evidence has shown better results with a standing position. Each of the participants carried out the handgrip strength test while standing with his/her shoulder adducted and neutrally rotated, and with the elbow in 90 degrees flexion with no radioulnar deviation. The measurements were performed two times each for the right and left hand with pauses between measurements. The results were recorded as kilogram force [Handgrip strength (HGS) was tested using a hydraulic hand dynamometer by Jamaram force . The betUsing the Instrumental Activities of Daily Living scale (IADL), the ability to perform complex activities of daily living, such as using the phone, shopping, preparing meals, cleaning, laundry, use of different means of transport, and self-managing medication and handling money were evaluated. The total score is relevant to a particular patient and a fall in the score on consecutive examinations reflects a deteriorated general state. The result of the activity of daily living assessment of an elderly person on this scale allows for the objectivization of the patient’s needs for care or necessary assistance. The maximum number of points that can be obtained on this scale is 27 [Evaluation of the participants’ emotional status was undertaken using the GDS, characterizing the state of well-being of the subject in the previous two weeks. The GDS contains 15 questions characterizing a person’s depressive status. Scores ranging from 0 to 5 indicate normal mood; scores between 5 and 9 indicate a risk of depressive symptoms; and scores > 9 indicate severe depressive symptoms .p ≤ 0.05. The analyses were performed using Statistica 13.1 .The normality of distribution was verified using the Shapiro–Wilk test. All the continuous variables were not normally distributed, therefore they were presented by median and interquartile difference (from the first (25%) to the third (75%) quartile). The quantitative variables (between the sexes), were compared using the Mann–Whitney U-test. The occurrence of differences between the 3 groups was assessed using a one-way ANOVA, Kruskal–Wallis test and the chi-square test or Fischer’s exact test. Spearman correlations between SHARE-FI score and numerical data were calculated. Logistic stepwise regression ) was used to assess which independent variables predicted the presence of FS. The following variables were taken into account when building the model: age, marital status, heart diseases, number of diseases, IADL, GDS, and HGS max. The model was adjusted for sex and BMI. Statistical significance was set at The proposal of this study did not require the approval of the Bioethics Committee, as it does not bear the hallmarks of a medical experiment. The study was conducted in accordance with the guidelines of the Helsinki Declaration. Patients signed informed consent for all the diagnostic and therapeutic procedures during hospitalization. All of the gathered data were confidential.p < 0.05) and respiratory system diseases which were more common in men (p < 0.01).p < 0.01). Patients with FS had a statistically significantly higher number of diseases and a higher number of medications taken compared to patients with pre-frail and the control group (p < 0.001). The most common diseases in the subjects with FS were heart diseases (p < 0.05). The other diseases were not statistically significant. There were no significant differences between body mass, height, BMI of the subjects and the frequency of FS occurrence. A lower level of FA, weaker HGS, and a greater number of depressive symptoms were demonstrated by patients with frailty compared to the pre-frail as well as the control group (p < 0.001). People with frailty were also significantly more often widowed, while pre-frail patients and with the control group were married (p < 0.01). To improve the visualization of these obtained relationships, examples are presented in the form of box plots  and IADL .p < 0.001); number of diseases (OR = 1.5 (1.2–1.96), p < 0.001) IADL (OR = 0.87 (0.79–0.96), p = 0.004). Heart diseases, age, sex, BMI, GDS, and marital status (widowed) did not enter the model. The ROC (Receiver Operating Characteristics) curve was generated for the model, the area under the AUC (Area Under The Curve) curve is 0.84, and the AUC error = 0.032, which proves the high correctness of the classification.Additionally, all these statistically significant factors and obtained differences in previous analyses were confirmed by logistic regression. The following were statistically significant in the model: HGS (OR = 0.91 (0.86–0.96), FS is a serious problem that concerns elderly people. It contributes to the deterioration of the quality of life of seniors at all levels of their functioning . It is aThe results of this study, conducted with 141 elderly hospitalized people, showed that the prevalence of pre-frailty syndrome was 36.9% and the level of actual suffering from FS was 39%. The available data in the literature are, in most cases, consistent with the results obtained in this research, and prove that FS is a common problem for the aging population in Poland, as well as worldwide . When itOur study did not show any relationship between the occurrence of the FS and the gender of the respondents, similar to the study conducted in Poland by Muszalik et al. . The occThe present study found a relationship between the prevalence of the FS and FA, as well as emotional status among hospitalized patients. Seniors with FS were much more often characterized by declining FA and suffering from depression. In a cross-sectional study conducted by Thinuan et al. the existence of such a relationship was confirmed, especially in developed countries . ResearcIn conclusion, the present study has demonstrated that age, comorbidities, in particular cardiovascular diseases, polypharmacy, and widowhood are risk factors of FS in elderly people hospitalized in the Departments of Internal Medicine. Additionally, we showed that depression, decrease in FA, and weak HGS are the most important determinants for FS development in elderly patients. Our results confirm that FS in women is associated with older age, multi-disease, and worse FA. However, the occurrence of FS in men is strongly related to both worse FA and weak HGS. According to the obtained results, it seems that in hospitalized older adults, the occurrence of FS depends on multiple factors and may be important for further prognosis. An especially important aspect of FS prevention seems to be caring for muscle strength. Previous and present data show that low HGS is a crucial element of FS and should be included as a standard screening test for older adults’ care. Patients with a low score should be given special care and have a further diagnosis of frailty syndrome. Undoubtedly, further studies are needed to investigate the potential possibilities of alleviating the symptoms of FS.This study has several limitations, including (1) the relatively small sample of participants, (2) inclusion of only the Caucasian race in the study, (3) no use of the gait speed method. It is worth emphasizing that the strength of this study is that it demonstrates a significant relationship between FS and poorer HGS. It points to the need to introduce HGS measurement in older adults as a recommended component of the Comprehensive Geriatric Assessment in medical facilities. Bearing in mind these limitations, the present study requires caution in data interpretation and should be continued and confirmed in future studies in larger groups of seniors.


Geographical disparities in cancer incidence are observed at different scales and may highlight areas of high risk that need special attention to improve health policies. In Guadeloupe, a French archipelago in the Caribbean, environmental and socioeconomic factors are potential factors associated with cancer incidence. Our objective was to describe geographical variations of cancer incidence in Guadeloupe at a small-area level, in order to identify potential clusters.We conducted spatial analyses for the 18 most frequent cancer sites, using data collected by the population-based cancer registry of Guadeloupe over the period 2008–2017. For each cancer sites, we used the Besag, York and Mollié model to estimate smoothed standardized incidence ratios (SIRs) at a sub-municipality level. In addition, we performed ascendant hierarchical clustering of these smoothed SIRs to describe the relationship between the different cancer sites and to identify geographical clusters.We observed geographical disparities with a spatial pattern that varied across cancer sites. Clustering of the smoothed SIRs showed aggregations between breast cancer and multiple myeloma, thyroid and stomach cancer, cervical and head and neck cancers, lung and rectal cancers, ovarian and endometrial cancers. Cluster analysis also identified six geographical clusters. Features of these clusters suggest alcohol consumption, exposure to pesticides, pollution generated by open landfills, and ethnicity as possible explanatory factors.Our study provided for the first time an extensive description of geographical disparities in cancer incidence in Guadeloupe, in a region where socioeconomic and environmental issues are major concerns. Although the identification of underlying factors was out of the scope of the present study, we highlighted areas of special interest and put forward some hypotheses that warrant to be further investigated in more in-depth analyses.The online version contains supplementary material available at 10.1186/s12885-022-09886-6. With more than 19 million new cases and nearly 10 million deaths in 2020 [Guadeloupe is a French overseas territory in the Caribbean, composed of five islands  with a population of about 400,000 inhabitants Fig. S1). The population is multi-ethnic but mostly from African descent. The population faces a high prevalence of cardiovascular and metabolic diseases, with 48% of the population being overweight or obese . Cancer . The popOur objective was to describe geographical variations of cancer incidence in Guadeloupe, at a small-area level in order to identify potential clusters.We used data from the Guadeloupe cancer registry, which collects all new cancer cases of patients residing in Guadeloupe since 2008. The registry routinely collects for all cancer sites: the date of diagnosis, the topographical and morphological codes of the International Classification of Diseases for Oncology, (ICD-O3) and sociodemographic data . The registry belongs to the French Network of Cancer Registries (FRANCIM) and meets high quality criteria; the completeness and data quality are regularly assessed by the “Comité d'évaluation des registres” (CER).We conducted spatial analysis for the 18 most frequent cancer sites: prostate , breast , colon , rectum , stomach , esophagus , pancreas , liver , multiple myeloma and plasmocytoma , cervix , uterus corpus , ovary , kidney , brain , thyroid ), upper aero-digestive tract (UADT)  and melanoma . We studied only invasive tumors over the period 2008–2016, i.e., 12,397 tumors.As a geographical level, we used a sub-municipality level, the IRIS level . The IRIS is the smallest geographical census unit available in France. There are 136 IRIS in Guadeloupe. For each patient, the address was geocoded to assign the IRIS of residence. Population for each IRIS by sex and age group  was obtained from census data for the years 2008–2016.i the number of observed cases in IRIS i, assumed to follow a Poisson distribution, Ei the number of expected cases calculated with indirect standardization for age and sex, θi = Oi/Ei the SIR in IRIS i. The BYM model is written as follows:We first conducted spatial analyses of cancer incidence for the 18 main cancer sites. We used the Besag, York and Mollié model  to estimα + ui + vi.Where:log α is the interceptui represents the non-spatial random effects and , vi represents the spatial heterogeneity and was modeled by a conditional autoregressive model (CAR).The convergence of the model was verified with the Geweke criterion . The graWe then performed ascendant hierarchical clustering (AHC) of the smoothed SIRs, using Ward’s method implementation ward. D2) in the hclust function of R stats package . Two AHC in the hTable Excess risks of head and neck, colon, rectum and liver cancers were observed in the eastern part of Guadeloupe (Grande-Terre Island). The western part of Guadeloupe (Basse-Terre) showed an excess risk of esophageal, stomach and pancreatic cancers. Marie-Galante, the island located in the south-east had high incidence areas for all digestive cancers, excluding those of the pancreas, as well as for head and neck cancers. In this territory SIRs were particularly elevated for esophageal and liver cancers Fig. .Fig. 1SmHigh incidence areas for cancers of the corpus uteri and ovary were mainly found in Basse-Terre. The areas of high incidence of breast and cervical cancers were mostly found in Grande-Terre. Areas with an excess risk of prostate cancer were in the center of Grande-Terre, in the north of Basse Terre and in Marie-Galante. La Désirade, the island located to the east, presented an excess risk of breast, cervical and ovarian cancers Fig. .Fig. 2SmRegarding other cancer sites, areas with an excess risk of brain cancer and multiple myeloma were mainly found in Grande-Terre, whereas Basse-Terre had the majority of the areas with an excess risk of thyroid cancer and melanoma. La Désirade was an area of excess incidence for lung cancer, melanoma, brain cancer and thyroid cancer. Fig. Fig. 3SmoFigure The ascending hierarchical clustering of the 136 IRIS resulted in an optimal number of 6 classes. Figure We observed geographical disparities, with a spatial pattern that varied across cancer sites. Environmental, socioeconomic factors, as well as ethnicity may partially explain these disparities. Our objective was not to identify precisely the underlying causes, but rather to provide leads for further study and to generate hypotheses. Nevertheless, some potential explanatory factors are briefly discussed below.For prostate cancer, the most frequent cancer in Guadeloupe, no clear spatial pattern emerged. Prostate cancer has been related to exposure to pesticides in general, and in Guadeloupe particularly has been found to be associated with chlordecone, an insecticide previously used in banana plantations . Howeverhelicobacter pylori.For digestive cancers, the spatial distribution of cancers of the colon differed markedly from that of rectal cancers. The cancer sites are often grouped in epidemiological studies, despite possible differences in risk factors . The incBesides the spatial analysis of each cancer site, results of the cluster analysis may help formulate hypotheses by identifying areas with high incidence of several cancer sites that may share common risk factors. Some of the six identified clusters warrant further attention. Cluster 1, in the North of Basse-Terre, is characterized by a high incidence of stomach and thyroid cancer, for which we were not able to identify a common risk factor. Cluster 2 in the center of Guadeloupe, is an area where the majority of sugarcane plantations are located as well as the main sugar and rum factories. This area showed an excess incidence of liver cancer, the main risk factor being alcohol consumption , and an Cluster 5 corresponds to the island of Marie-Galante, with many sugar cane plantations and a sugar factory. This area showed the highest incidence for most of the cancer sites, particularly for alcohol-related cancers . UnfortuAn important limitation of our study is the relatively small number of cases for most cancer sites, which notably precluded separate analyses in men and women. Small numbers also prevented the analysis of rare cancer sites, although some of them were of special interest, such as subtypes of hematological malignancies. These shortcomings will be overcome when a longer follow-up period will become available. In addition, although we used the smallest available census unit, some of the IRIS in Guadeloupe are relatively large, and then probably heterogeneous. Despite these limitations, our study provided for the first time an extensive description of geographical disparities in cancer incidence, in a region where socioeconomic and environmental issues are major concerns. Although the identification of explanatory factors was out of the scope of the present study, we nevertheless highlighted areas of special interest and put forward some hypotheses that warrant to be further investigated in more in-depth analyses. Etiological studies are planned for some cancer sites. Furthermore, a mapping of the use of pesticides, which take into account the diversity of pollutants and their historical use is in progress, and will allow ecological studies. Taking together, these findings will inform health policies in the territory.Additional file 1.Additional file 2.