Patients with Parkinson’s disease (PD) suffer from a range of physical, psychological, and social problems. The disease affects the quality of life (QOL) of the affected person. Several factors contribute to QOL, and these factors should be examined to develop appropriate strategies. This study aimed to determine the factors related to QOL in patients with PD. A cross-sectional, descriptive study was conducted using a tool with strong validity and reliability (39-Item Parkinson’s Disease Questionnaire (PDQ-39)) to assess the quality of life. Descriptive statistics were used to analyze the data, and non-parametric chi-square tests were applied to evaluate the relationship between QOL and the variables. Frequent hospital admissions, level of education, and marital status were among the factors that affected QOL. The ability to perform Ramadan fasting correlated with the degree of QOL. The coronavirus disease 2019 (COVID-19) pandemic has adversely affected the quality of life due to changes in access to medical care and medications. To improve QOL in patients with PD, a comprehensive approach is required in many healthcare domains that includes physiotherapy together with the conventional pharmacotherapy, other treatments, and psychological support. Parkinson’s disease (PD) is a chronic disease of the central nervous system that is characterized by both physical and psychological symptoms . PatientPatients affected by PD have motor and non-motor symptoms, and treating these symptoms may improve their QOL. Receiving care from a multidisciplinary team also helps to improve QOL ,4. PatieQOL refers to the standard of health, comfort, and happiness experienced by an individual or group . Living There are different treatment modalities available to manage PD-related symptoms that result in improvement of the QOL in this patient group ,13. FailThere are certain cultural differences around the world that may contribute to the assessment of QOL. Ramadan fasting is practiced in many countries around the world, and few studies have investigated the recommendations and the ability of PD patients to perform fasting ,15. No sStudy design and settingThis study has a cross-sectional, descriptive design. This design was selected to examine factors that influence QOL in patients with PD. The data were collected from multiple healthcare institutions in Saudi Arabia and from the Saudi Society for Parkinson’s Patients. Ethical approval and permission from the study sites was obtained before the data collection. These settings were chosen based on the availability of the samples for the study. The population of this study included patients diagnosed with PD. The participants were chosen based on their availability during the data collection period, and the non-probability convenience sampling method was used to select the participants.Inclusion and exclusion criteriaPatients who were diagnosed with PD and were receiving treatment for PD were eligible to participate in the study. Patients with PD with severe comorbidities, such as stroke, bedridden, or other severe medical illnesses, contraindicate the questionnaire application. In addition, severe cognitive and patients with dementia were excluded from participating in the study.Data source and toolsData were collected using web-based questionnaires. The link was distributed to all patients who met the inclusion criteria and decided to participate in the study. Data were collected between April 2021 and May 2022. The consent form included detailed information about the purpose of the study, risks and benefits, and confidentiality of the participants’ information. Participants were only able to access the questionnaires after reading and signing the consent form. Participants were informed that their information would only be accessible to the research team. They were informed that their responses would be reported in aggregate form and would be destroyed following the publication of the study.The data collection instrument consisted of four sections: demographic data, determinants of fasting for Ramadan, determinants of COVID-19, and a scale to assess the QOL (PDQ-39). The demographic data form consisted of the basic demographic data about the participant, including age, gender, level of education, marital status, employment status, number of children, and initial diagnosis with PD. Two scales were developed for this study: determinants of fasting for Ramadan and determinants of COVID-19. Development of these scales required several steps: reviewing the literature, drafting the items, and sending the questionnaires to four subject matter experts in the fields of epidemiology, neuroscience, surgery, and nursing. Pilot testing was used to assess the clarity of the questionnaires. All the questionnaires were sent to 10 participants. After completing the data collection, Cronbach’s alpha of the determinants of fasting for Ramadan was .77, and Cronbach’s alpha of the determinants of COVID-19 was .70, indicating the reliability of these tools. The validity of the tools was not evaluated in this study.The Parkinson's impact scale contains 10 items: Self (Positive), Self (Negative), Family Relationships, Community Relationships, Work, Travel, Leisure, Safety, Financial Security, and Sexuality ,19. The The study used the PDQ-39 questionnaire . This stDeterminants of fasting for RamadanParticipants were instructed to rate their degree of agreement regarding factors related to fasting for Ramadan after they had been diagnosed with PD. These factors were: difficulty with fasting, increase in Parkinson’s symptoms during Ramadan, routine changes in the dosing of medicines during Ramadan, changes to their treatment plan during Ramadan, and accessing emergency services while fasting for Ramadan. After grouping these items together, Cronbach’s alpha was .76.Determinants of COVID-19Participants provided their degree of agreement regarding the determinants of COVID-19. The items were related to the difficulty obtaining medical services and prescriptions during the pandemic, increases in Parkinson’s symptoms during the pandemic, differences in care, and fear of COVID-19. When these items were grouped together, Cronbach’s alpha was .71.Statistical analysisData were entered and analyzed using the Statistical Package for Social Sciences version 28.0 . Descriptive statistics  and inferential statistics (Pearson’s product moment correlation and multiple linear regression) were used to determine the relationships between the variables of interest.Ethical considerationInstitutional review board approval was obtained from King Saud University’s research ethics committee (KSU-HE-21-322). Participation in the study was voluntary. Participants were informed that they had the right to withdraw their participation at any time without any consequences. The contact information of the institutional review board and authors was provided to the participants.The total sample size was 82. Most participants were aged between 51 and 64 years (40.2%) or older (34.1%). The majority of the participants (58.5%) were male, had a university degree (41.5%), and were married (79.3%), and 43.9% were diagnosed with PD over seven years prior to this study. In addition, more than one-half of the sample (56.1%) had other concomitant diseases. Table Quality of life in patients with Parkinson’s diseaseThe mean QOL score was 80.3 (SD = 37.9). The scores for the PDQ-39 dimensions are listed in Table Determinants of fasting for Ramadan, COVID-19, and quality of life in patients with Parkinson’s diseaseDeterminants of fasting for Ramadan in patients with PD were significantly correlated with QOL . Participants had difficulty fasting during Ramadan, experienced an increase in Parkinson’s symptoms, changed the dosing of medicines or their treatment plan, and experienced decreased QOL . Participants had difficulty accessing medical services, experienced increased Parkinson’s symptoms, faced differences in care, were afraid of contracting COVID-19, and experienced decreased QOL. Additional information regarding the correlation between each item and QOL is presented in Table Relationship between participants’ characteristics and quality of lifeFollowing regression analyses, the participants’ demographic and clinical characteristics explained 24.5% of the variance in QOL  = 2.72, p = .009)  are common in PD patients, and these factors can decrease patients’ QOL. As expected, our study revealed that the QOL in general was affected by the disease, which is in line with other studies from different countries . EducatiThe COVID-19 pandemic has impacted healthcare delivery, and this alone has adversely affected the care delivered to PD patients ,27,28. IThis is the first study to evaluate the QOL of patients with PD in Saudi Arabia. Although the study was based on a limited number of patients, the results provide insights into the comprehensive care requirements of patients with PD. To improve QOL, patients with PD require physical rehabilitation with conventional pharmacotherapy and other treatments, in addition to timely adjunctive psychotherapy. The limitations of the present study are that certain factors related to QOL, such as illness duration, disease severity, medical service system, and the treatment provided, were not analyzed. In addition, the study was limited by the use of the PDQ-39 without other instruments to measure more specific factors, the limited number of patients, and the nature of survey subjectivity.QOL in PD patients is determined by multiple domain-based factors. Frequent hospital admissions, level of education, and marital status are among the factors that affect QOL. The ability to perform Ramadan fasting correlated with the degree of QOL. The COVID-19 pandemic has adversely affected QOL due to changes in access to medical care and medications. To improve QOL in patients with PD, a comprehensive approach is required in many healthcare domains, including physiotherapy, conventional pharmacotherapy, other treatments, and psychological support.


Chitosan is the deacetylated form of chitin regarded as one of the most abundant polymers and due to its properties, both chitosan alone or in combination with bioactive substances for the production of biodegradable films and coatings is gaining attention in terms of applications in the food industry. To enhance the antimicrobial and antioxidant properties of chitosan, a vast variety of plant extracts have been incorporated to meet consumer demands for more environmentally friendly and synthetic preservative-free foods. This review provides knowledge about the antioxidant and antibacterial properties of chitosan films and coatings enriched with natural extracts as well as their applications in various food products and the effects they had on them. In a nutshell, it has been demonstrated that chitosan can act as a coating or packaging material with excellent antimicrobial and antioxidant properties in addition to its biodegradability, biocompatibility, and non-toxicity. However, further research should be carried out to widen the applications of bioactive chitosan coatings to more foods and industries as well was their industrial scale-up, thus helping to minimize the use of plastic materials. The main function of food packaging is to isolate food product(s) from the surrounding environment, diminishing or inhibiting contact with spoilage factors such as microorganisms, oxygen, temperature, and/or moisture to avoid or delay loss of nutritional value or quality and consequently improve and extend the product’s shelf life . For thiNowadays, chitosan is one of the best-known and most widely used polysaccharides in preparing edible films and coatings due to its high antimicrobial activity, biocompatibility, biodegradability, and non-toxic profile . Chitosaw/v) and are dissolved in an aqueous solution acidified with acetic acid or lactic acid in concentrations that ranged between 1% and 3% (v/v) [Among the various properties, it is important to highlight that chitosan is a natural cationic polymer, while the majority of polysaccharides are either neutral or have an anionic charge. This property permits the production of multilayer structures or electrostatic complexes with other synthetic polymers or negatively charged natural ones . Additio3% (v/v) . Edible 3% (v/v) ,8,9. Fin3% (v/v) . These aThe properties of chitosan edible films and coatings can vary depending on the degree of deacetylation and molecular weight of the chitosan used in its formulation, plasticizers, and viscosity among others. Depending on these factors, the gas permeability to oxygen and carbon dioxide as well as the mechanical and thermal properties may vary significantly. Likewise, chitosan films/coatings can act as a vehicle carrier of bioactive substances such as polyphenolic compounds, bacteriocins, essential oils, or plant extracts to develop novel active packaging materials with antioxidant and antimicrobial properties ,10. To iOne of the main advantages of these films is that they allow a slow and controlled migration of the bioactive compounds from the coating to the products. In this sense, several studies have been carried out regarding edible chitosan films embedded with several bioactive compounds in order to evaluate the effects of these substances on the lipid oxidation and microbiological stability of several food products such as meat, fish, and seafood products, dairy products, and fruits and vegetables.The present review will examine the current literature on both the antibacterial and antioxidant properties of edible films supplemented with bioactive compounds and their applications in food products for their preservation and shelf-life extension.In the last years, several efforts have been dedicated to the development of edible films and coatings based on natural bio-materials such as chitosan. As mentioned above, one of the main approaches currently used is the incorporation of bioactive compounds in biodegradable coating bases to provide them with antimicrobial properties. This strategy is regarded as a promising way to develop edible films and coatings with antibacterial or antifungal properties, which could be potentially used as food packaging films. Additionally, natural extracts are considered safe for humans and more environmentally friendly in comparison with the nano-antibacterial agents prepared from different inorganic materials . Among tThe mechanism of action has yet need to be completely acknowledged, but the studies carried out so far suggest that this process involves cell lysis, rupture of the cytoplasmic membrane barrier, electrostatic interactions between the positively charged glucosamine monomers of chitosan, and the negatively charged sites of microbial cells, or the chelation of trace metal cations . It is wThe rapid emergence of microorganisms resistant to common synthetic antimicrobial compounds has led to the urgent need to find and use alternative compounds to help solve this issue. In this sense, the use of antimicrobial compounds of natural origin such as essential oils has emerged as one of the most promising alternatives due to their antimicrobial properties against a broad range of microorganisms . The useThe edible films and coatings may reduce the distribution of bioactive compounds with antimicrobial activity into the product since the essential oils form part of the chemical structure of the film and interact with the polymer and the plasticizer . The relThe antibacterial activity of chitosan-based films formulated with essential oils extracted from plants has been extensively studied during the last few years. However, the methodology used to prepare the films, the concentration of essential oil added, the method used to determine the antibacterial activity, as well as the bacterial strains used are very different among the different studies present in the scientific literature, making it very difficult to compare studies.Staphylococcus aureus, Escherichia coli, Enterococcus faecium, and Lactobacillus rhamnosus, respectively, whilst the minimum bactericidal concentration was 5, 1.25, 5, and >10 µL/mL for the same bacterial strains in the same order. The authors stated that the antibacterial activity of the films may be due to the fact that the positively charged chitosan supplemented with essential oils creates a semi-permeable barrier that can reduce respiration and delay microbial growth. Souza et al. [E. coli, Pseudomonas aeruginosa, Enterobacter faecalis, S. aureus, and Listeria monocytogenes, respectively.For instance, Raphaël and Meimandipour  carried a et al.  analyzedL. monocytogenes and E. coli of chitosan edible film and chitosan films incorporated with citrus essential oils was assessed by Li et al. [E. coli and L. monocytogenes were 12.24 and 13.35 mm, respectively, while the inhibition zone diameters of chitosan incorporated with citrus essential oil on E. coli and L. monocytogenes were 17.23 and 19.19 mm, respectively. These authors also presented the evaluation of the sensory quality of Pacific mackerel treated with chitosan and citrus EO coatings carried out by 37 trained panelists. The results showed that although some odor of the essential oil was detected, this did not affect the sensory acceptability throughout the storage period. In a similar study, Hadidi et al. [L. monocytogenes, S. aureus, Salmonella typhi, and E. coli with inhibition halos of 48.0, 47.8, 44.9, and 39.5 mm, respectively. In the same way, Mohammadi et al. [E. coli, S. aureus, and P. aeruginosa, proving that they represent a promising and suitable option for active packaging.The antibacterial activity against i et al. . The resi et al.  analyzedi et al.  studied Candida albicans and Penicillium roqueforti with inhibition halos of 11 and 20 mm, respectively. Clove essential oil was encapsulated in halloysite nanotubes and combined with chitosan to develop active films for food [E. coli and Bacillus mojavensis, confirming their suitability for application as food-active coatings. It is important to note that this antimicrobial activity is carried out in in vitro studies. The real challenge that must be overcome with the use of chitosan films mixed with essential oils is their application in food. Their use will depend on numerous factors such as the type of food matrix, temperature and storage time, storage conditions, and, most importantly, from our point of view, the possible changes at the sensory level that may appear.Recently, Odjo et al.  developefor food . This woPlants and other vegetal raw materials represent an unlimited source of novel phytochemicals compounds, which have potential use in the food industry and other applications. Conventionally, the raw extracts obtained from different parts of several plants, including the root, stem, flower, fruit, and twigs, are commonly utilized for prevention or disease treatments . Crude eE. coli, B. cereus, S. aureus, and S. typhimurium with inhibitory halo zones ranging from 9.76 to 16.12 mm, 11.66 to19.48 mm, 10.86 to 18.11 mm, and 7.13 to 14.47 mm, respectively. This antibacterial activity is mainly related to the bioactive phenolic compounds that could exert physiological changes in the microbial cell membrane and eventually result in bacteria death [Pistacia terebinthus) were investigated against food-borne pathogens by Kaya et al. [Proteus microbilis, Proteus vulgaris, P. aeruginosa, and E. coli with inhibition zones between 28.19 and 21.33 mm. The antifungal properties of chitosan coatings with an ethanolic extract from Santolina chamaecyparissus were evaluated by Ortiz de Elguea-Culebras et al. [Aspergillus flavus by more than 50% after 3 days of incubation. Penicillium verrucosum was the most susceptible mold to the antifungal action of the coating, which inhibited 67.7% of the growth after 3 days while the control showed no inhibition.In this context, Riaz et al.  incorporia death . In a sia et al. . They fos et al. . The coaE. coli, Salmonella spp., S. aureus, and L. monocytogenes with inhibition zones of 5.40, 5.92, 6.57, and 5.48 mm, respectively. Similarly, Koosha and Hamedi [E. coli, P. aeruginosa, and S. aureus of 40.00, 35.63, and 44.56, respectively. These last two studies relate the antimicrobial activity of films to the presence of anthocyanins. Numerous antibacterial mechanisms have been suggested for the action of anthocyanins including destabilization of the cytoplasmic membrane, permeabilization of the plasma membrane, inhibition of extracellular enzyme secretion, direct action on cellular metabolism, and prevention of substrate delivery required for bacterial growth [Garcinia mangostana L.) rind powder at different concentrations to develop active packaging. They reported that mangosteen-chitosan films had antibacterial activity against E. coli , Salmonella , S. aureus  and L. monocytogenes . These authors affirmed that the antimicrobial action of polyphenols is related to an increase in cell membrane permeability, the deformation of cells, and the inhibition of DNA/RNA synthesis.Qin et al.  analyzedd Hamedi  investigl growth  investigE. coli, and between 42.99 and 82.19% for S. aureus. Likewise, biodegradable films based on passion fruit peel pectin/chitosan with a bioactive extract from Piper betle L. leaf proved to be more effective against different bacterial stains  than the control films. The inhibition halos obtained ranged from 6 to 9.67 mm for B. cereus, 6–10.33 mm for K. pneumoniae, 8–11 mm against P. aeruginosa, and 11–14.67 mm against S. aureus [In a recently published study, Nadira et al.  prepared. aureus .Lactococcus lactis subsp. lactis., and the polypeptide chain contains l-amino acids and the unusual sulfur-amino acids lanthionine and β-methyl-lanthionine. So far, nisin (E234) is the only bacteriocin approved as a food preservative, being recognized as GRAS by the US FDA in 1988 and normally used at maximum concentrations of 12.5 mg/kg in cheeses to prevent the growth of Clostridium botulinum [Bacteriocins are usually defined as peptides or ribosomal proteins synthesized by bacteria that can inhibit or kill other bacteria either from the same species or from other genera . They arotulinum , a widelE. coli, S. aureus, S. typhimurium, L. monocytogenes, and B. cereus. These authors found that the chitosan-nisin films were not active on E. coli and S. typhimurium. However, for S. aureus, L. monocytogenes, and B. cereus the inhibition halos ranged between 22.67 and 26.50 mm; 28.67–31.83 mm, and 22.17–22.83 mm, respectively. Hu et al. [w/w) showing antimicrobial activity against Bacillus subtilis with an inhibition zone diameter of 19.85 mm. Similarly, antimicrobial bilayer films using chitosan, cellulose, and nisin at 500 and 1000 μg/mL were prepared using the catalyzed sol-gel technique [L. monocytogenes with inhibition zones of 23 and 26 mm at concentrations of 500 and 1000 μg/mL, respectively.Pranoto et al.  analyzedu et al.  developeechnique . The resL. monocytogenes growth while the incorporation of this bacteriocin increased the antimicrobial spectrum of the films, effectively inhibiting the growth of L. monocytogenes and E. coli.In a recently published study, Chen et al.  evaluateReactive oxygen species (ROS) are responsible for oxidation in both food and biological systems. The oxidation process is one of the main causes of chemical deterioration in many food products due to exposure to air, heat, and/or light. One of the most common oxidative processes in foods is lipid peroxidation, which results in the production of undesirable chemical compounds  causing a loss of nutritional value and a reduction in the shelf life of lipid-containing foods . AnotherIn biological organisms, ROS causes lipid oxidation in cells, decreasing the membrane fluidity, triggering mutations in cellular DNA and the possibility of cancer . In thisAntioxidants are substances that can protect cells against oxidative processes due to various mechanisms such as the scavenging species that initiate peroxidation, breaking the auto-oxidative chain reaction initiated by ROS, chelating metal ions to prevent the formation of ROS or decomposing peroxides and decreasing localized oxygen concentrations .Most natural antioxidants are sourced from plants, vegetables, herbs, or spices and can be classified into three groups: phenolic compounds, vitamins, and carotenoids . As mentChitosan, besides its excellent properties as an antibacterial agent, also has antioxidant properties. Thus, in recent years, a wide assessment of the antioxidant and free radical scavenging capacities of chitosan and its derivatives has been reported. As with its antibacterial properties, chitosan has antioxidant activity by itself, and its mechanism of antioxidant activity could be attributed to the residual amino groups of chitosan that form a stable fluorosphere with volatile aldehydes derived from the breakdown of fats during oxidation such as malondialdehyde .On the other hand, it is a common strategy to incorporate bioactive compounds that have demonstrated their antioxidant activity such as essential oils or vegetal extracts in order to improve the antioxidant properties of chitosan films or coatings .Essential oils extracted from herbs and spices are an excellent source of phenolic compounds that possess antioxidant properties and have been used for decades as a flavoring agent ,70. HoweThere are several studies related to the mechanisms of action involved in the antioxidant activity of essential oil compounds, which include free radical scavenging, chain initiation prevention, reducing agents, peroxide termination, singlet oxygen quenching, and metal ion catalyst binding ,73,74,75Gelidium corneum-chitosan composite films supplemented with citronella java essential oil was evaluated by Go and Song [In this regard, the antioxidant capacity of and Song . The radand Song  developeNanoencapsulation of bioactive compounds has been proven to be a reliable and effective technique to increase the chemical stability of the compounds by protecting them from volatilization and extending their effectiveness . In thisThis study showed that the incorporation of the essential oil into the films resulted in increased antioxidant activity , and the authors suggest that it may be due to a synergistic effect between the phenolic compounds of the EO and chitosan.In a subsequent study carried out by Cazón et al. , biodegrv/v), showing a significant increase in DPPH radical scavenging with values of 38.03%, 50.98, and 70.40% for the 0.5%, 1%, and 1.5% v/v of oregano EO, respectively, while the control film (chitosan/casein) had a value of 17.32% [Recently, edible films were formulated with chitosan, casein, and oregano EO  and BHT butylated hydroxytoluene the most commonly used synthetic antioxidants . HoweverIn this context, vegetal and plant extracts obtained from several sources such as fruits , plants, or vegetables  have been widely studied for their antioxidant properties and their ability to reduce or prevent lipid oxidation . Most ofIt is also noteworthy to mention that the by-products generated during the processing of these foods and raw materials are also an excellent source of valuable antioxidant compounds whose use allows a reevaluation of their role in reducing the amount of waste generated, and economic losses as well as promoting the circular economy ,87.The profile and the concentration of phenolic compounds extracted from the plant and vegetal matrices can vary depending on several factors such as climate, species, cultivation method, and especially the extraction method and solvent used . RegardiPowder extracts from pine nut shells, peanut shells, and jujube leaves were incorporated at 0.8% into chitosan films in order to study their antioxidant properties. These plant extracts improved the antioxidant capacity of the films reaching values up to 3.8 times higher than films formulated with only chitosan when winter jujube leaf extract was incorporated . The authors relate this antioxidant capacity to the polyphenol and flavonoid content of the extracts and suggest that the developed films could be useful to inhibit browning and extend the shelf life of foods . SimilarArtemisia campestris hydroalcoholic extract and aqueous extract were developed by Moalla et al. [w/v), showing an enhancement in the antioxidant capacity compared to the control films. The films formulated only with chitosan presented a slight antioxidant capacity  while those containing the hydroalcoholic extract exhibited the highest values of DPPH radical scavenging activity, chelating effect and reducing power .Active food films based on chitosan and supplemented with a et al.  in order2O μmol eq/g dry film. Likewise, the authors observed that sage aqueous extract compounds exerted better DPPH activity on the films than rosemary extract, demonstrating that these bioactive films would be effective in preventing oxidative processes in food.Recently, Kahya et al.  conducteThe casting method was utilized to develop a novel green bioactive composite film with antioxidant properties by combining peony leaf extract  and chitosan. The antioxidant capacity of the formulated films increased significantly with the incorporation of peony leaf extract being almost three times higher than the chitosan film. It has been demonstrated that this increase is related to the phenolic compounds of the peony leaf extract, which possess free radical scavenging activity and singlet oxygen quenching ability .The degradation process of meat and meat products can occur basically for three reasons: (i) lipid oxidation and (ii) spoilage caused by microorganisms and (iii) enzymatic action. Lipid oxidation can be subject to several factors such as fatty acid profile, the occurrence of pro-oxidant substances such as certain transition metals, and the presence and concentration of natural antioxidants such as vitamin E. The oxidation products may cause rancid odors and flavors, decrease the shelf life, alter texture and color, and decrease the nutritional values of products due to the degradation of proteins, carbohydrates, and vitamins . The micThymus kotschyanus EO  over 21 days of storage at 4 °C [The shelf life of fresh beef was improved by the application of coatings developed from chitosan/pomegranate peel extract and supplemented with  at 4 °C . The res at 4 °C  developeEnterobacteriaceae counts when they applied chitosan coatings enriched with oregano essential oil (1% v/v) and grape seed extract (1 or 2% v/v) to skinned turkey breast fillet during 20 days storage. The results showed that these coatings were also able to reduce lipid oxidation with significantly lower TBARs values than the control samples, reaching values between 1.16 and 1.29 mg MDA/kg vs. 1.56 mg MDA/kg at the end of storage. Antioxidant and antimicrobial properties of chitosan coatings containing Artemisia fragrans essential oil  were demonstrated on the chicken breasts during refrigerated storage with the aim of extending their shelf life [Artemisia fragrans EO were capable of prolonging chicken breast stability and are presented as a potential alternative to commercial plastic-based coatings.Langroodi et al.  also repelf life . The stuw/v) against spoilage and pathogenic bacteria affecting meat was investigated by Gaba et al. [Pseudomonas was reduced to 0.6–1 log CFU/g compared to the control (6 log CFU/g) with films containing oregano essential oil. Regarding the growth of pathogenic bacteria, the study showed that the control films were not able to inhibit them, while those formulated with essential oils showed a reduction of ~2.3 and 1 log unit of E. coli and 3–4 log CFU/g in the case of S. aureus, remaining constant until the end of the study period. Based on the results, these authors were able to extend the beef shelf life by ~10 days compared to samples coated only with chitosan, and those coated with chitosan combined with essential oils also showed enhanced sensory acceptability for up to 25 days, confirming the suitability of the films for improving the quality and safety of fresh or refrigerated meat products. Pérez-Córdoba et al. [v/v) to evaluate their effect on the shelf life of sliced omega-3 rich mortadella stored for 7 days at 6 °C. Their antimicrobial capacity against pathogenic bacteria was evaluated by inoculating the mortadella slices with L. monocytogenes and P. aeruginosa, and a significant reduction was observed in the counts of the coated samples compared to the control. This reduction was also observed in aerobic mesophilic and psychrotrophic (between two and three logarithmic cycles) bacteria, and LAB proved to be the most sensitive to the effect of the bioactive coating since no growth was detected in the coated mortadella slices. In addition, the active films were able to maintain the TBARs values below 1.0 mg MDA/kg for up to 5 days of storage, and it can be deduced that the lipid oxidation of omega-3-rich mortadella slices can be delayed, thus extending their shelf life.Later, the efficacy of chitosan films supplemented with oregano and thyme essential oils  autolytic spoilage, (ii) oxidative spoilage, and (iii) microbial spoilage. Protein degeneration by native enzymes begins just after the end of rigor mortis and in combination with the production of biogenic amines, the products of proteolysis can serve as nutrients for microbial growth leading to spoilage . In the Therefore, it is very important to adopt adequate preservation methods to maintain the quality and prolong the shelf life of these products. The most commonly used preservation methods in the fish processing industry are the traditional chilling, freezing, salting, and drying approaches along with modified atmosphere packaging (MAP), vacuum packaging, irradiation, and high-pressure processing . HoweverOncorhynchus mykiss) was investigated by Rezaeifar et al. [2S-producing bacteria. The sensory evaluation performed by ten trained panelists revealed that the incorporation of lemon verbena EO improved the sensory quality of the fish at the end of storage. Ehsani et al. [Pseudomonas spp. from 7.82 to 5.12 log CFU/g). Moreover, counts of Shewanella spp., considered one of the main fish spoilage bacteria due to its characteristics , were also analyzed, obtaining a reduction from 7.29 to 5.64 log CFU/g after 20 days of storage. The incorporation of sage essential oil prevented the samples from producing off-odors, obtaining overall sensory acceptability while the control samples were unacceptable at the end of the storage period.In this regard, the effect of chitosan coatings formulated with lemon verbena extract and essential oil on the shelf life of vacuum rainbow trout  and ethyl lauroyl arginate (0.1% w/w) to mackerel fillet, noticing an increased antioxidant capacity compared to untreated samples  at the end of the storage period. Smart films based on chitosan/Methylcellulose incorporated with anthocyanin from Phyllanthus reticulatus ripened fruit (5 and 10 wt%) were applied to fish fillets to monitor their freshness. The developed films changed color upon pH variations (caused by the formation of volatile nitrogen compounds after protein degradation), with a change from dark gray (fresh) to light yellow when spoilage occurred in the fillets [Lipid oxidation results in the formation of potentially toxic compounds that cause fish degradation and unpleasant flavors. Therefore, Demircan et al.  applied  fillets .Oncorhynchus mykiss) fillets. Samples coated with the formulation containing the 2% showed the lowest values of aerobic mesophilic bacteria (3.05 Log CFU/g) and lipid oxidation (0.506 mEq O2/kg and 1.53 mg MDA/kg) at 21 days of storage. Recently, Surendhiran et al. [B. cereus for up to 6 days of storage (2.42 log CFU/g), but after that time bacterial multiplication was observed, reaching values of 4.66 log CFU/g at the end of the study time. The authors attribute this fact to an uncontrolled release of the essential oil and showed that this problem was overcome by applying the bionanocomposite film since it exhibited a slower, controlled release of the essential oil, reducing bacterial growth (2.78 log CFU/g at the end of the storage period) and extending the shelf life of the surimi.A current study carried out by Zamani et al.  revealedn et al.  performeMilk and dairy products such as cheese are an essential part of the daily diet as they contain essential nutrients such as proteins, lipids, minerals, and unsaturated fatty acids. Films and coatings are mainly applied to cheeses to prevent loss of quality during the ripening period, transportation, and commercialization, as these products are particularly prone to microbial spoilage due to their pH, water activity, and nutritional composition . DippingAfter carrying out a comprehensive review, it has been observed that the literature available so far is more limited in comparison with the numerous studies that have already been done on the application of chitosan films enriched with natural bioactive compounds in food products, so there is a clear need for further research in this field .A chitosan/guar gum/zinc oxide bionanocomposite coating enriched with roselle calyx extract was applied to Ras cheese to evaluate its properties during ripening in comparison with uncoated cheese . The resEnterobacteriaceae counts reached 4.45 and 6.39 log CFU/g for films with thyme extract and those with papaya leaves, respectively, while the control samples displayed a value of 8.55 log CFU/g at the same time of ripening. The lowest count of yeasts and molds was recorded in coated samples at 24 days of storage compared to the untreated cheese (8.87 vs. 3.42–4.56 log CFU/g).In a more recent study, the effect of chitosan/gelatin coating reinforced with papaya leaves and thyme extract on the quality and shelf life of Kareish cheese during chilled storage was evaluated by Hassan et al. . The extNowadays, consumers are more concerned about their health and about spending as little time as possible on the preparation of meals. In this context, fruits and vegetables are associated with a healthy diet in addition to meeting these demands for ready-to-eat products. These foods are rich in vitamins, essential minerals, antioxidant compounds such as polyphenols or flavonoids, and dietary fiber, and their consumption can help prevent the development of health problems such as chronic diseases, osteoporosis, or neurodegenerative diseases . Fruits Furthermore, the preservation of minimally processed and ready-to-eat products demanded by consumers is becoming a major challenge as these foods experience rapid deterioration due to an increase in the respiration rate and ethylene production as well as an accelerated consumption of sugars, lipids, and organic acids during the ripening process. All of these modifications can lead to loss of texture and water along with undesirable changes in flavor and color produced by the senescence . These sThe aim of the use of coatings and films on fruits and vegetables is to delay the transfer of gas, water vapor, and volatiles resulting in a decrease in respiration, senescence, and loss of aroma, thus retaining moisture and delaying drastic color changes during ripening and storage . In the It has been shown that chitosan-nisin films reinforced with silicon dioxide nanoparticles were effective for fresh blueberry preservation at room temperature . The resBotrytis cinerea during 7 days of storage and the one formulated with green tea extract prolonged the antioxidant properties of the strawberries from 4 to 8 days at 20 °C.In a later study on the application of chitosan coating on fruits, Yang et al.  enrichedv/v), and the ones with the lowest dose effectively inhibited the browning, prevented weight loss, and maintained firmness. In addition, there was a reduction in total plate counts, yeast and mold counts, total coliform counts, lactic acid bacteria count, and L. monocytogenes . Roshandel-Hesari et al. [Origanum vulgare L. essential oil and its effect on the quality maintenance of cherry tomatoes. At the end of storage, cherry tomatoes with coatings containing the highest EO concentration (1.5%) displayed lower shrinkage and weight loss, thus preserving the quality and firmness of the cherry tomatoes for 32 days.With regards to the application of these bioactive coatings in the preservation of vegetables, chitosan coatings with cinnamon essential oil have been developed to improve the quality and microbiological safety of fresh-cut potatoes . Samplesi et al.  investigThe main source of commercial chitosan is chitin, which is the second most abundant polysaccharide preceded by cellulose. It can be obtained from green algae, the cell walls of fungi, the cuticles of insects and arachnids, and in the exoskeleton of crustaceans; the major chitin source used at the industrial level is the shells from crustaceans . The industrial production of chitosan involves different chemical processes such as decalcification, deproteinization, decolorization, and deacetylation. Acidic and alkali treatments are extremely harmful to the environment so biological treatments are presented as an alternative method for chitin extraction and chitosan production in a more sustainable manner. In this sense, lactic acid-producing bacteria and proteases have been used for demineralization and deproteinization, respectively . HoweverNormally, chitosan is produced using conventional chemical and enzymatic methods, but in some cases, microwave technology has been employed as an alternative to conventional thermal heating because of its increased reaction rates, shorter reaction times, higher yields, energy savings, and a reduction in side reactions in addition to being highly effective for chitosan depolymerization and production of low molecular weight chitosan. This environmentally friendly method greatly reduces extraction times compared to conventional methods , proving to be a viable method to scale up chitosan production .Cyclotella sp., which produces extracellular nanofibers composed of β-chitin that can be extruded from the cell [The volatility of resource availability, the residual presence of allergens and/or contaminants that require costly purification and refining of the final products as well as a low degree of deacetylation might limit the industrial scale-up of chitosan production using chitin obtained from shellfish waste . Therefothe cell . Likewisthe cell . One of the cell .®, Norwegian Chitosan, trading chitin and chitosan under the brands NorLife and Kitoflok™, respectively, and G. T.C. Bio Corporation, which produces and sells chitin and chitosan at different grades with prices ranging from 18 to 45 EUR/kg for chitosan and around 20 EUR/kg for chitin (depending on the degree of purity) [The manufacturers and suppliers of chitosan and chitin products can be found worldwide and among them are Primex, selling chitosan for packaging applications under the brand ChitoClear purity) .As demonstrated throughout the present review, the production of chitosan films and coatings has been extensively studied over the last decades; however, most of them utilized the casting method for their production mainly at the laboratory scale. This method consists of dissolving the polysaccharide in a solvent, which is an acetic acid solution in the case of chitosan, and simultaneous incorporation of the plasticizer followed by pouring the mixture on an inert surface for the evaporation of the solvent and the obtainment of a thin film. Therefore, one of the main challenges in the use of chitosan as a new material for the manufacture of packaging is to scale up this method at the industrial level or to find alternative production methods that can replace this method. The application of plasticizing processes by thermomechanical treatments could be an alternative to the traditional casting for the production of films that would allow the manufacture of these biodegradable films on a large scale .Another of the main limitations of chitosan films is that they have poor mechanical properties, so researchers have focused their interest on the use of other compounds such as gelatin, starch, and alginates to improve the mechanical stability of the films .Throughout this review, we have discussed bioactive compounds that can be incorporated into chitosan to develop coatings and films with antimicrobial and/or antioxidant properties. These compounds have been proven to be useful in extending shelf life and maintaining food quality as well as controlling the growth of molds and pathogenic bacteria. However, further work is needed to fully understand the interactions between chitosan and bioactive compounds to optimize their effectiveness as well as to overcome the challenge of maintaining the antimicrobial/antioxidant properties of essential oils or other plant extracts in the films at the high temperatures used in plastics production processes . MoreoveConsidering the wide variety of studies on the development of edible and biodegradable coatings and films, it is clear that the food industries have to cut down on the use of plastic materials as packaging due to their well-known disadvantages and the pollution problems they are causing.The challenges in food preservation have prompted research in the development and use of films and coatings with types of polymers that serve as carriers of bioactive compounds for industrial application in the manufacture of packaging or films to increase the useful life of different food matrices and find the shortest biodegradability time of each element used for this purpose, in addition to being an ecological alternative to plastic packaging, which causes contamination and takes long periods of time to degrade, in contrast to packaging made with natural polymers such as chitosan, which have shown a minimum degradation time.In this respect, chitosan has proven to be a suitable biodegradable coating material with great potential to become a food packaging material. This review gathered the studies undertaken in recent years on the development of chitosan films and coatings incorporated with bioactive substances of natural origin to improve the stability of products during storage, inhibit microbial spoilage and lipid oxidation as well as increase the quality and shelf life of the foods to which they are applied.These films and coatings can protect food products by reducing bacterial counts and deterioration reactions such as lipid oxidation or browning to improve their appearance and acceptability. The number of research studies on the development of chitosan coatings is relatively high, but further research is still needed to be undertaken with the aim of finding new sources of bioactive compounds from natural and renewable sources and new polymer blend combinations to improve the characteristics of chitosan coatings in order to compete commercially with current packaging used in the agri-food industry.


Substantial evidence shows that diagnostic inertia leads to failure to achieve screening and diagnosis objectives for arterial hypertension (AHT). In addition, different studies suggest that the results may differ between men and women. This study aimed to evaluate the differences in diagnostic inertia in women and men attending public primary care centers, to identify potential gender biases in the clinical management of AHT.Cross-sectional descriptive and analytical estimates were obtained nested on an epidemiological ambispective cohort study of patients aged ≥30 years who attended public primary care centers in a Spanish region in the period 2008–2012, belonging to the ESCARVAL-RISK cohort. We applied a consistent operational definition of diagnostic inertia to a registry- reflected population group of 44,221 patients with diagnosed hypertension or meeting the criteria for diagnosis (51.2% women), with a mean age of 63.4 years (62.4 years in men and 64.4 years in women).Of the total population, 95.5% had a diagnosis of hypertension registered in their electronic health record. Another 1,968 patients met the inclusion criteria for diagnostic inertia of hypertension, representing 4.5% of the total population (5% of men and 3.9% of women). The factors significantly associated with inertia were younger age, normal body mass index, elevated total cholesterol, coexistence of diabetes and dyslipidemia, and treatment with oral antidiabetic drugs. Lower inertia was associated with age over 50 years, higher body mass index, normal total cholesterol, no diabetes or dyslipidemia, and treatment with lipid-lowering, antiplatelet, and anticoagulant drugs. The only gender difference in the association of factors with diagnostic inertia was found in waist circumference.In the ESCARVAL-RISK study population presenting registered AHT or meeting the functional diagnostic criteria for AHT, diagnostic inertia appears to be greater in men than in women. Arterial hypertension (AHT) is a major modifiable risk factor for cardiovascular disease and death; its adequate control is a strategy with a high degree of evidence and population benefit . Given iA critical analysis of the guidelines, adapted to the context of PHC, proposes that all patients with hypertension should have a target BP of <140/90 . At presThe European guidelines  specificTherefore, greater knowledge of clinical practice guidelines by clinicians and individualized prescription of treatment are key to avoiding inertia, which will benefit hypertensive patients and contribute to improving the health of the population. Analyzing whether this has implications according to the sex  and gender  of patients is presently essential.Classically, differences between sexes have been estimated in the cardiovascular (CV) area. Men are more likely to develop coronary heart disease as the first event, whereas women are more likely to have cerebrovascular disease or heart failure as the first manifestation, although these appear more frequently at advanced ages . AnotherDespite recent progress in basic and clinical research on the differences in the management and outcomes of AHT in men and women, the main guidelines of the leading AHT societies continue not to identify gender differences due to the lack of conclusive results in clinical trials , 4, 10. Subgroup analyses comparing results between women and men have been subsequently published, but they only contributed to highlight that their results were inconclusive for women and that implementation of their results concerning sex should be considered with caution –14. In sThis study aimed to analyze, within the ESCARVAL-RISK study cohort, the difference in the diagnostic management and results of AHT between women and men attending public primary care centers, including those meeting the criteria for AHT diagnosis and, according to clinical practice guidelines, not properly diagnosed or treated in the PHC setting. In addition, it aimed to describe the profile of patients affected by diagnostic inertia (DI).This was a cross-sectional epidemiological study nested on an epidemiological ambispective cohort study carried out in the Valencian Community (an autonomous community of Spain with an estimated population of over 5 million people) in 2020 . This stPatients were selected from the ESCARVAL-RISK cohort . This inA patient was considered to have AHT if, during a baseline window period of 6 months from inclusion: (a) they had AHT coded in the EHR  and were being treated for this  or (b) despite no diagnosis of AHT, they had been prescribed antihypertensive drugs or had two altered systolic (SBP) or diastolic (DBP) blood pressure readings (SBP ≥ 140 or DBP ≥ 90), in accordance with the criteria established by the clinical practice guidelines for the period analyzed , 26. PatThe primary variable was DI in AHT, considered operationally when a patient had two altered blood pressure readings (SBP ≥ 140 or DBP ≥ 90), as established by clinical guidelines , 26, durOther variables studied were sociodemographic variables (age and sex/gender), clinical variables , variables related to lifestyle (smoking status), and analytical indicators . A value was considered missing when no data existed for the variable in the EHR (≥ 50%). In addition, variables corresponding to pathologies recorded in the EHR according to the ICD-9 code were collected: diabetes mellitus (250.0), dyslipidemia (272.0), proteinuria (791.0), retinopathy (362.0), metabolic syndrome (277.7), ischemic heart disease (410.0–14.0), heart failure (428.0), peripheral artery disease (440.20), atrial fibrillation (427.31), and chronic kidney disease (585.9). Finally, variables related to medication were collected: antihypertensive treatment, lipid-lowering drugs (statins and others), oral antidiabetic drugs, insulin, and antiplatelet or anticoagulant agents.The source of information for all the variables was the ABUCASIS EHR, which is centralized and unique for the entire Valencian Community.To estimate the prevalence of DI, the number and frequency of inertia cases were calculated for the total and by sex. To evaluate the patient profile according to their DI in each category of qualitative variables, double-entry tables were made by applying the Chi-Square statistical test.v. 26.0  and R software, v. 4.0.2 .Prevalence ratios (PRs) and 95% confidence intervals (95% CIs) of inertia at each level of the explanatory variables were estimated using multivariate Poisson regression models with robust variance , differeA total of 44,221 patients with diagnosed AHT, or meeting the diagnostic criteria for AHT and undiagnosed or on antihypertensive treatment and coded in the EHR, were included (51.2% women). The mean age of the patients was 63.4 years (range 30–97 years), being 62.4 years in men (range 30–95 years) and 64.4 years in women (range 30–97 years).p < 0.001; A total of 1,968 patients were identified who met the DI inclusion criteria and had no coded diagnosis of AHT, representing 4.5% of the total population studied. By sex, 5% were men and 3.9% were women (p < 0.001) and waist circumference (p < 0.001), who were smokers (p < 0.02), with normal HDL (p < 0.001), and with cholesterol >200 mg/dL (p < 0.001). In women, the highest DI was associated with the youngest age group (p < 0.013), normal BMI (p < 0.001), and total cholesterol >200 mg/dL (p < 0.001).p < 0.028) or peripheral artery disease (p < 0.001), with diabetes (p < 0.001) and dyslipidemia (p < 0.016), on oral antidiabetic treatment (p < 0.001), and not taking lipid-lowering, antiplatelet, or anticoagulant treatment (p < 0.001). In women, the highest DI was observed in those with diabetes and dyslipidemia (p < 0.001), without heart failure (p < 0.018), treated with oral antidiabetic drugs (p < 0.001), and not on antiplatelet or anticoagulant therapy (p < 0.001).p < 0.001) and presented adequate classification indicators .p < 0.001). Although this may seem low, the great difference from other studies is that the denominator in our study is not the entire population but only those with hypertension or meeting diagnostic criteria. Therefore, these figures are particularly relevant from the clinical viewpoint.This study aimed to shed light on the magnitude of DI in the study population, that is, individuals who were undiagnosed and untreated for arterial hypertension despite meeting the criteria that should have led to being diagnosed and adequately treated for this condition. The highest DI occurred in the population aged 30–49 years, with normal BMI, elevated cholesterol (≥ 200 mg/dl), coexistence of diabetes and dyslipidemia, and taking oral antidiabetic treatment. Gender differences in DI were detected in women with a waist circumference ≥ 88 cm. In the population of the ESCARVAL-RISK cohort with AHT criteria, the percentage was 4.5%, being higher in men than in women  had a greater association with DI in men than in women, in contrast to the results observed by Meador et al.  in the Up < 0.02). Ji et al.  has made efforts to ensure that all primary care offices had validated and calibrated BP measurement devices.The main theoretical limitation of this study is that, although it works on the basis of an epidemiological cohort study, its strict design is cross-sectional. Establishing a temporal sequence between the factors and the dependent variable (inertia) is not realizable, although the status of undiagnosed hypertensive patients can be assessed and their needs determined, which are key elements in the fight against the lack of awareness of this problem and provide a basis for prioritizing better health planning. We are aware that the main potential bias that could have threatened the validity of this study is in selection, but we have tried to minimize this. Furthermore, the virtue of the study is that it translates routine clinical practice and is based on the fact that these are all patients attending PHC centers. We must also ask ourselves about the precise quality of the data obtained from the EHR and entered by the health professionals. To minimize this potential error, all physicians have previously been given the opportunity to participate in courses on cardiovascular risk , providing training on cardiovascular diseases, their risk factors, and their control objectives . AdditioPhysicians attending PHC consultations should be attentive to BP values ≥140/90 mmHg, verify them, confirm them, and record them in the EHR, in addition to properly coding patients who are already on antihypertensive treatment to reduce the DI in AHT. Although it should be all patients, special attention should be paid to young women who are not properly identified, thus avoiding possible health inequalities derived from DI. In our study, the overall DI was higher in men than in women; this difference may be due to the type of population more likely to seek consultation in PHC, corresponding to women and older patients. The information provided by this study could be valuable for improving clinical practice in the PHC setting and could favor future research to explore the reasons for the conservative attitude of PHC physicians regarding this type of patient. Future studies should address the causes of the gender difference in the prevalence of DI in AHT and whether it affects other entities that increase CV morbidity and mortality. Therefore, the strategy should be comprehensive and close any knowledge gap, optimizing the diagnosis and control of AHT at a global level.When comparing the population diagnosed with AHT with the population not diagnosed but presenting diagnostic criteria, the highest DI (in both men and women) was in the population aged 30–49 years, with normal BMI, high cholesterol, and coexistence of diabetes and dyslipidemia, and taking oral antidiabetic treatment. The lowest DI was in the population over 50 years of age, with overweight or obesity by BMI, normal cholesterol, no diabetes or dyslipidemia, and taking antiplatelet, anticoagulant, or lipid- lowering therapy. The only gender difference in this study was found in waist circumference. In women, a greater DI was found from 88 cm, and in men, the higher the BMI, the lower the DI.Although AHT is simple to diagnose and relatively easy to treat with currently low-cost drugs , important gaps exist in the diagnosis that can have a negative impact on prognosis and evolution, which should be identified and addressed.psalud_val@gva.es.The data analyzed in this study is subject to the following licenses/restrictions: data on all patients registered in Primary Care of the Health System of the Valencian Community in Spain. The data were anonymised after a rigorous validation process, and are subject to personal data protection regulations. Requests to access these datasets should be directed to Conselleria de Sanitat Universal i Salut Pública, The studies involving human participants were reviewed and approved by Ethics Committee of the University of Valencia Hospital Clinic, Valencia, Spain. The patients/participants provided their written informed consent to participate in this study.Conceptualization, methodology, writing—review and editing, and funding acquisition: VP-C, CC-M, AL-P, JQ, VG-G, DO-B, JA-S, JN-P, and JM-M. Writing—original draft preparation and supervision: VP-C, CC-M, VG-G, and JM-M. Project administration: JM-M. All authors have read and agreed to the published version of the manuscript.Fondo de Investigación Sanitaria—Instituto de Salud Carlos III, co-funded by the European Regional Development Fund/European Social Fund: A way to make Europe/Investing in Your Future. This funding source had no role in the design of the study, its execution and analyses, the interpretation of the data, or the decision to submit results.The authors acknowledge support from the Health Research Projects—Strategic Action in Health (Reference: PI18/01937) of the Spanish The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The preventative factors for AD and MCI, separately, included a happy marriage  and higher education . The risk factors for AD and MCI, separately, included infrequent participation in social activities  and infrequent communication with children . The prevalence of AD for people aged 60 or over in the Hubei province was lower than the national average of 3.06%. The prevalence of MCI was within the national range (5.2–23.4%). The influencing factors of AD and MCI were associated with the participants’ social connections, lifestyle behaviors, somatic diseases and so on. The elderly people who study and communicate with others, take part in regular physical exercise and choose a healthy lifestyle will prevent or slow the decline in cognitive ability. The conclusion section has been replaced.Utilize the prevalence, associated factors and population distribution of AD and MCI among residents of the Hubei province aged 60 years or over to prove that elderly people who study and communicate with others, take part in regular physical exercise and choose a healthy lifestyle, will prevent or slow the decline in cognitive ability. If elderly people study and communicate with others, take part in regular physical exercise and choose a healthy lifestyle, can prevent or slow the decline in cognitive ability. A cross-sectional study was used for the recruitment of subjects. The screened patients with AD and MCI were then selected as patients in a case–control study. A total of 4314 subjects were recruited into the study. The prevalence of AD and MCI was 1.44% and 10.04%, respectively. The prevalence of AD and MCI differed significantly as a function of age and gender ( Alzheimer’s disease (AD) is an increasingly serious global health problem. In 1990, it was the 28th leading cause of death and by 2017, it had risen to the 8th leading cause of death . It is eAD is a serious threat to human health and quality of life due to its high morbidity, disability, and mortality rates, and brings a heavy burden on families and society . To dateA meta-analysis by Ward et al. ,14 foundThere are a large number of studies showing that having caregivers, age and residency are the main associated factors for the quality of life of patients with AD and MCI ,18. To iZ is the statistic for significance test, p is the prevalence of AD in the elderly and δ is the tolerance error), Z was taken as 1.96 (α = 0.05), δ = p × 10% = 0.02, and n = 1536. To ensure sufficient sample size, an average of 2000 people were selected from each project county/district. Stage 2: One township and one street were randomly selected from each project county/district using PPS sampling method proportional to population size. Stage 3: A total of 4–8 administrative villages or neighborhood committees are selected by cluster sampling in the selected towns/streets. Stage 4: At least 100–200 households with members aged 60 or above in each administrative village (neighborhood committee) were randomly selected as the investigation households. Stage 5: Invite all permanent residents aged 60 or above to carry out the survey.The population for this study was individuals aged 60 years or over who had a local household registration and had lived in the Hubei Province for more than one year. A multi-stage, stratified, clustered, random sampling method was used for recruitment. The specific sampling method includes the following five steps: Stage 1: Based on urban communities and rural township communities, Jingmen city and Huanggang City of Hubei Province were selected. Then, one county and one district were simply selected at random. Based on the sample size calculation formula: After multi-stage sampling, 2032 individuals from Qichun County, Huanggang City, Hubei Province were recruited, together with 2282 individuals from Jingmen City, Dongbao District, Hubei Province. After the preliminary screening of the survey participants, 58 patients with AD and 404 patients with MCI were identified and were selected as the case group.Potential AD and MCI subjects were identified through initial screening. Inclusion criteria to be included in this study were (1) age ≥ 60 years; (2) participants voluntarily agreed to cooperate with all investigators. Exclusion criteria were non-residents of the community; (3) those who refuse to provide correct information; (4) temporary residents; (5) patients with severe depression, schizophrenia and other mental diseases. Questionnaires, physical examinations, and laboratory tests were performed in a home-based and centralized manner by uniformly trained investigators. The Mini-Mental State Examination (MMSE)  and the (1)Inquiry and investigation. The main contents of the survey include: family status registration form and personal questionnaire survey. Among them, the contents of the family status registration form include family records, family demographic information , family elderly AD information, etc. Personal questionnaire contents include basic information such as demographic data, daily habits such as smoking, drinking, diet, physical activity and other behavior risk factors), primary hypertension-related information , daily life ability and self-evaluation of health, and other major health problems such as dementia screening.(2)Physical examination. The examination content mainly includes: body and height measurement. Physical measurements include height, weight, waist circumference, blood pressure and heart rate. Height measurement using height sitting meter ; electronic scales are used for weight measurement ; waist circumference measurement using waist ruler ; blood pressure and heart rate were measured using an electronic sphygmomanometer with an accuracy of 1 mmHg.(3)Laboratory testing. The detection content includes: routine blood biochemical index detection, namely fasting blood glucose and lipid. If the respondents can produce results of tests conducted within one year by other accredited medical institutions, these results are copied in the questionnaire. If not, fasting venous blood was collected from all subjects on site, and four tests of fasting blood glucose and blood lipid were performed.A conceptual framework is constructed based on a literature review.p < 0.05 was considered statistically significant.Epidata 3.1  and SPSS 18.0 software were used for data processing and statistical analysis. Different descriptive statistics and hypothesis testing methods were used for the various types of statistical data. The rate and percentage were used to describe count data, and paired chi-square tests were used for between-groups comparisons. Measurement data were expressed as mean ± standard deviation (Mean ± SD). Multivariate conditional logistic regression models were used to analyze the association between the two groups and the various influencing factors. The potential risk factors were further screened by a step-by-step method, and the odds ratio (OR) and 95% confidence interval (CI) was calculated to evaluate the strength of the association between each factor and AD and MCI, respectively. All tests were two-tailed with α = 0.05; (1)Before on-site investigation began, pre-investigation, revision, and improvement of a series of survey design schemes were performed.(2)During the process of the field investigation, there was a clear field workflow, a reasonable arrangement of on-site investigators, and timely feedback of the survey results.(3)After the completion of the field investigation, the quality of data entry was the focus. Each project site made local backups of the collected data every day and 5% of the questionnaires from each investigation site were extracted for review. Timely feedback was provided when problems were identified.A total of 4314 people aged 60 years or over were recruited into this study from the Qichun County of Huanggang City and Dongbao District of Jingmen City, Hubei Province. A total of 304 invalid questionnaires were excluded from the analysis . Thus, a total of 4010 respondents were included in the analysis, with a response rate of 92.95%.Of the 4010 people included in the study, ranged in age from 60 to 110 years old, 2069 were female, and 1941 were male. The structure and category of the sample was shown in A total of 4010 people aged 60 years or over were included in this study, among which, 58 patients met the diagnostic criteria for AD, with an AD prevalence of 1.44%. Among the patients with AD, 17 were male (29.3%) and 41 were female (70.7%). A total of 404 patients met the diagnostic criteria for MCI, with an MCI prevalence of 10.07%. Among the patients diagnosed with MCI, 150 were male (37.1%) and 254 were female (62.9%). The average MMSE scores of the AD and MCI patients were 10.24 ± 0.59 and 18.75 ± 0.29, respectively. The MMSE scores were divided into six groups based on level of cognitive function. The specific scores are shown in p > 0.05), which was shown in p < 0.05).With increasing age, the prevalence of AD and MCI first increased and then decreased; by ordinal logistic regression there was no statistically significant difference among the age groups (p < 0.05). There was no statistically significant difference in the proportion of MCI between the two groups (p > 0.05).Among the two areas selected for this study, Qichun County is a rural area and Dongbao District is an urban area. The prevalence of AD and MCI in the two areas was 1.44% and 10.04%, respectively. As shown in p > 0.05), indicating that the groups were comparable. The influence of other demographic factors on the prevalence of AD and MCI is shown in 2 test showed that the incidence of AD differed significantly as a function of region and education level (p < 0.05). There were no significant differences in the prevalence of AD as a function of marital status and occupational status (p > 0.05). Univariate logistic regression analysis revealed that urban residence, happy marriage, higher education level, and previous relatively easy occupation were statistically significant, suggesting that these factors may be a protective factor for AD. Having a relatively easy occupation, higher education level, and happy marriage may also be protective factors for MCI; these relationships were statistically significant (p < 0.05).Equilibrium analysis showed that there were no statistically significant differences in age and gender between the AD and MCI case groups and the respective control group  reduced the risk of AD, and frequent low to moderate physical exercise reduced the risk of MCI. Smoking and high levels of physical activity increased the risk of AD, while having sleep disturbances, regular smoking, drinking tea, and alcohol increased the risk of MCI. See Univariate logistic regression analysis showed that diabetes, stroke, disc herniation, hearing loss, and tumors were all protective factors for AD. High blood pressure, coronary heart disease, chronic bronchitis, asthma, tuberculosis, arthritis, and cervical spondylosis were risk factors for AD. Both coronary heart disease and stroke were risk factors for MCI. See p > 0.05), and there was no statistically significant difference in the rate of reading for interest between the controls and AD patients (p > 0.05). There was a significant difference in the rate of reading for interest between controls and the MCI case group (p < 0.05). There was also a statistically significant difference in the rate of playing chess and cards between controls and AD patients (p < 0.05), but no statistically significant difference between controls and MCI patients (p > 0.05). The results of the univariate logistic regression analysis showed that reading books and newspapers, playing chess and cards, and properly using computers to surf the Internet were all protective factors for AD and MCI.As can be seen from The single factors associated with AD and MCI as identified in the above analyses were included in a multivariate conditional logistic regression analysis. The stepwise method was used to enter variables. The results showed no statistically significant difference in the associated factors between the AD case group and the control group. Compared with the control group, higher education level, harmonious neighborhood relationship, and happy marriage were protective factors for MCI. Coronary heart disease, poor sleep quality, and frequent communication with children were risk factors for MCI. See This current study identified 58 patients with AD and 404 patients with MCI among the elderly population aged 60 years or above living in the Hubei Province. The overall prevalence of AD and MCI was 1.44% and 10.07%, respectively, which is significantly lower than the prevalence rates reported in other domestic populations ,24,25. TThe possible factors associated with the occurrence of AD in this study included education, neighborhood associations, physical examinations, BMI, waist circumference, tea consumption, smoking, and playing chess and cards. Higher education level was a protective factor that reduced the risk of AD . This is consistent with previous results . During The factors affecting the occurrence of MCI in this study were education level, neighborhood communication, communication with children, coronary heart disease, sleep, and marital status. Higher education level was associated with a lower risk of MCI, making it a protective factor for MCI . This is consistent with previous findings . FrequenCoronary heart disease was also found to be associated with MCI. Li et al. studied the relationship between cardiovascular disease and MCI and found that cardiovascular disease leads to cognitive impairment . Thus, bCognitive ability and self-care in Alzheimer’s patients have also been found to be associated with quality care . GallawaTogether with research on the pathogenesis, early diagnosis, and drug treatment of MCI and AD, research on factors influencing the incidence of MCI and AD, including diet and nutrition, may contribute to interventions for high-risk AD and MCI groups and improved prevention, early detection, early diagnosis, and treatment for AD and MCI. Such research also provides a scientific basis for the establishment of relevant government policies.This is the first cross-sectional study to analyze the sporadic AD and MCI, as well as the influencing factors in urban and rural elderly people. Our study, conducted in Hubei Province, had a large sample size of the aged over 60 to explore epidemiological characteristics and influencing factors. Moreover, we obtained the prevalence data. The vast majority of AD cases have no known genetic cause, so it is crucial to identify environmental factors associated with the onset and progression of the disease. This study explores the living environment and lifestyle of patients with AD and MCI, combined with published studies to synthesize the risk factors and protective factors that are most likely to affect AD and MCI in older adults.All of these provide valuable clues for follow-up research and preventive and intervening measures for AD and MCI.This study also has several limitations . First, In this study, we found that the prevalence of AD in the elderly population aged 60 or over in the Hubei province was lower than the national average, which was significantly higher in females than in males. Additionally, the prevalence of MCI was within the range nationally. There were also differences in the prevalence of AD and MCI as a function of age, gender, and region. The influencing factors of AD and MCI were associated with their social connections, lifestyle behaviors and somatic diseases and so on. There is no effective treatment for AD and MCI, which poses a great challenge to the national and regional health, welfare, social services and other relevant departments, and has attracted the high attention of governments and health personnel. Therefore, how to generally carry out effective early screening, improve the early diagnosis rate and strengthen the standardized management of diseases, so as to delay the occurrence of diseases is the prevention and control strategy concerned by countries all over the world.We believed that the elderly could be encourage to study, communicate, participate in social activities  and choose a healthy lifestyle and the government departments carry out capacity building training for medical and health workers in the disease control system and workers in primary medical and health service institutions, so as to prevent or slow the decline of cognitive ability.


Trace metals have side-effect on human health. The association between trace metals exposure and hearing loss remains unclear.A total of 8,128 participants were exacted for analysis of association between trace metals and hearing loss from the database of the National Health and Nutrition Examination Survey (NHANES) (2013–2018). Multivariable logistic regression and restricted cubic spline models were used to examine the association between trace metals and hearing loss.p < 0.05). After adjusting for confounders, compared with the reference of the lowest quartile, the ORs with 95%CIs for hearing loss across quartiles were 1.14 , 1.49 , 1.32  for cobalt, and 1.35 , 1.58 , 1.75  for tin. Individuals with the level of cobalt at third quartile had 49% higher risks of hearing loss than those at lowest quartile. And participants with highest quartile of tin had 1.75-folds risks of hearing loss than those with lowest quartile of tin. There were increasing trends in risks of hearing loss with a raised level of thallium (p for trend <0.05). Restricted cubic spline regression analysis indicated that there was a nonlinear association between hearing loss and the levels of tin (p for nonlinearity = 0.021). Subgroup analysis showed that individuals of female, without hypertension and diabetes, and with a higher level of low-density lipoprotein cholesterol had modified effects on the associations between hearing loss and exposure to tin.Participants with hearing loss had a higher level of lead, cadmium, molybdenum, tin, thallium, and tungsten (all Our study indicated that exposure to cobalt and tin were significantly associated with hearing loss. It is widely known that metals perform a critical function in the biochemical process. Essential trace elements  play a crucial role in enzyme synthesis, which regulate cellular homeostasis and energy production . Other eHearing loss is the fourth leading contributor to years lived with a disability worldwide . Varioushttps://www.cdc.gov/nchs/nhanes/index.htm). Potential participants were exacted from the dataset of 2013–2018 . Excluding those with unclear hearing conditions , and missing data on urine trace metals . A total of 8,128 participants were enrolled for further analysis. The survey protocol was approved by the NCHS research ethics review board, and all participants provided written informed consent. This study complied with the Declaration of Helsinki.The NHANES survey is a cross-sectional program recruiting a representative sample of participants from the United States population based on a complex, multistage probability design. The program collected data from demographic, clinical, and laboratory tests for surveyed individuals. The NHANES database can be acquired publicly from the Centers for Disease Control and Prevention National Center for Health Statistics .Urine samples were measured for trace level element analysis by inductively coupled plasma mass spectrometry (ICP-MS) coupled with dynamic reaction cell technology (DRC). Liquid samples were introduced into the ICP through a nebulizer and spray chamber carried by a flowing argon stream, which ionizes the atoms. The ions are finally counted in rapid sequence at the detector allowing individual isotopes of an element to be determined. More detailed descriptions can be available at Hearing loss in this study was defined as severe difficulty hearing. A household questionnaire on disability was provided to the surveyed participants by trained interviewers. Hearing loss was recorded if the person answered “yes” to the following question: are you deaf or do you have serious difficulty hearing.Demographic data including age, gender, and race/ethnicity  were collected from self-reports. As atherogenic risk factors are involved in the pathogenesis of hearing loss, covariates related to atherosclerosis were selected and controlled. Self-reported diabetes history, hypertension history, or hyperlipidemia history (yes/no), smoker (smoked at least 100 cigarettes in life), and alcohol user  were documented from questionnaire data. Noise exposure was defined as “ever exposed to very loud noise at work.” The level of triglyceride, total cholesterol, low-density lipoprotein cholesterol, and urine trace metals were obtained from laboratory data.t-test. Nonnormal distributed continuous data were reported as median with interquartile range (IQR) and compared by nonparametric Mann–Whitney U-test. Categorical variables were calculated with counts and percentages and were assessed by the Chi-square test. Log2-transform of trace metals was performed to facilitate the interpretation due to its skewed distribution.Data distribution was determined by the Kolmogorov-Smirnov test. Continuous data with normal distribution were presented as mean ± deviation and were analyzed with independent sample student's Multivariate logistic regression analysis was used to assess the association of trace metals quartiles with hearing loss. Model 1 was adjusted for age and gender. Model 2 was adjusted for age, gender, race, hypertension, diabetes, hyperlipidemia, and noise exposure. And model 3 was adjusted for age, gender, race, hypertension, diabetes, hyperlipidemia, noise exposure, triglyceride, total cholesterol, and low-density lipoprotein cholesterol. In order to explore the effect of multiple-metal on hearing loss, we conducted a collinearity diagnostic to determine whether there are collinearities among these metals. Variance inflation factors (VIF) and tolerance are used to identify a collinearity (Tolerance<0.1 or VIF>10 is considered to be collinear). We include ten trace metals into covariates when they are non-collinear, as well as the covariates in the model 3 to build a multiple-metal based model. The odds ratio (OR) with 95% confidence intervals (CI) was calculated.p < 0.05 was considered statistically significant.A restricted cubic spline regression model was applied to explore any nonlinear relationship between trace metals and hearing loss . Subgrop < 0.05). As for the concentration of urine trace metals, the hearing loss group had a higher level of lead, cadmium, molybdenum, tin, thallium, and tungsten (All p < 0.05). The general presentation of baseline characteristics was shown in A total of 8,128 participants were included in this study, with a prevalence of hearing loss of approximately 5.5%. There were significant differences between the hearing group and non-hearing group in age, gender, race/ethnicity, hypertension, diabetes, hyperlipidemia, noise exposure, levels of triglyceride, total cholesterol, and low-density lipoprotein cholesterol (All p < 0.05). Individuals with the level of cobalt at third quartile had 49% higher risks of hearing loss than those at lowest quartile. And participants with highest quartile of tin had 1.75-folds risks of hearing loss than those with lowest quartile of tin. Restricted cubic spline indicated that there was a nonlinear association between hearing loss and the levels of tin  in the prevalence of hearing loss. Secondly, tin was firstly found to be significantly associated with hearing loss in a large sample cross-sectional study. Lastly, the trends of association between hearing loss and the level of tin were nonlinear.Hearing loss affects individuals worldwide with nearly 6%-8% of the world population . In our A series of case reports showed that systemic cobalt toxicity was closed related to peripheral neuropathy, vision loss, sensorineural hearing loss, and cognitive decline , 7, 12. Tin is a naturally existing element, which is found in inorganic and organic forms in the environment. Exposure to tin and tin compounds in the U.S. population is almost ubiquitous . Tin levHeavy metals are particular chemical class of elements and present in the environment. Most of them are harmful even at low concentrations. Several potential mechanisms are implicated in metals toxicity including production of oxygen reactive species (ROS), interaction with thiol groups of proteins, incorrect protein folding and mimicry of the essential elements for intracellular transport, and depletion of antioxidants enzymes . CadmiumThere are several limitations of our study. Firstly, a cross-sectional study design can only infer the correlation, but causality. Secondly, despite the attempts to adjust hearing-related confounders, unmeasured or unknown covariates may influence the effectiveness of the conclusion. Additionally, the mechanism of the association between hearing loss and trace metals has not been fully addressed. Finally, the data of this study was derived from the United state, the generalizability of the conclusion to other regions or populations should be very cautious.Our study indicated that exposure to cobalt and tin were significantly associated with hearing loss.https://www.cdc.gov/nchs/nhanes/index.htm.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The studies involving human participants were reviewed and the survey protocol was approved by the NCHS research ethics review board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.PZ: conceptualization, methodology, and writing-original draft. ML: data curation, software, formal analysis, and writing-review and editing. WC: writing-original draft. JJ, FX, and LX: investigation. YC: validation. All authors contributed to the article and approved the submitted version.This work was supported by the Strengthening Health through Science and Education Program of Nanjing Commission of Health (SZDZK202002). The funding body played no role in the design of the study and collection, analysis, and interpretation of data, and in writing 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.