The major focus of the study was the impact of the COVID-19 pandemic on healthcare workers’ mental health. Nurses are the workers who were exposed to pandemic–related stress, being the most affected. The present cross-sectional study was focused on finding out the differences of the level of work-related stress and quality of life in nurses of the three Central European states, specifically the Czech Republic, the Slovak Republic, and Poland. A structured anonymous online questionnaire was created, and then the link was distributed to the target population through executives. Data analysis was performed by using the R programme–version 4.1.3. The study found that nurses from the Czech Republic achieved lower stress levels and had a higher quality of life than nurses from Poland and Slovakia. In January 2020, the World Health Organization declared the outbreak of a new coronavirus disease, COVID-19, to be a public health emergency of international concern. COVID-19 affected people from many countries, in many geographical locations. In 2020, countries reported that, on average, about half of the essential health services were disrupted. The COVID-19 pandemic is an example of a fast-emerging pandemic that has placed immense pressure on the healthcare workforce, globally [Nurses play a vital role in providing health services. Nursing professionals constitute approximately half of the global health workforce, and in the current pandemic, they perform the majority of tasks related to preventing and containing infections. Nursing professionals’ role in caring for COVID-19-infected patients and patients’ family members may have negative consequences to their mental health. Increasing COVID-19 cases have coincided with increased workloads, particularly for front-line healthcare professionals. Recognizing potential adverse effects on the mental health of these professionals has instigated research efforts in several countries. For example, the Brasil study by Michele Mandagará de Oliveira et al. 2022) described higher prevalence of depression, anxiety, sleep disorders, and minor psychiatric disorders 022 descr. The resThe Polish study of Malinowska-Lipień et al. (2022) examined the relationship between working conditions in Polish hospitals during the COVID-19 pandemic and nurses’ attitudes towards factors promoting patient safety. Working conditions influence nurses’ attitudes towards safety of the hospitalized patients .As can be seen from the above, there are many studies looking at the impact of the COVID-19 pandemic on nurses’ mental health. The present study compares perception of the level of work-related stress  and quaThe purpose of this study was to compare work-related stress and quality of life among nurses depending on the workplace during the COVID-19 pandemic in three neighboring countries: the Czech Republic, Poland, and Slovakia. Psychosocial strain plays a huge role in the work of nurses, especially in times of huge staff shortages. Knowing the level of work-related stress and quality of life can provide a benchmark for developing preventive programs for this professional group. Hence, conducting research in this area is very important.www.webankieta.pl (accessed on 12 February 2023) platform. For this purpose, 3 electronic versions of the questionnaire were prepared in Polish, Czech, and Slovak languages. Links to the survey were then distributed to nurses working in the healthcare system in Poland, the Czech Republic, and Slovakia. Email addresses of scientific societies dedicated to nurses, social media groups dedicated to nurses, and local government organizations for nurses were used to distribute the link. The survey was fully anonymous and voluntary. To eliminate the risk of duplicate responses by a single person, a database filter was applied, and duplicate IP addresses were discarded. The study was conducted from 1 September 2021 to 30 November 2021. During this time, data were collected. The survey was conducted fully online, using the Inclusion criteria for the study were possession of a professional nursing license and working in the profession during the COVID-19 pandemic in the healthcare system. A total of 1303 nurses were included in the study: 450 from the Czech Republic, 297 from Poland, and 556 from Slovakia. Additionally, 134 questionnaires were rejected due to incomplete data. The study used random sampling.The survey instrument consisted of three parts: a socio-demographic metric, questionnaire of Meister, and the SF 36v2. questionnaire.The study was conducted using a standardized questionnaire of the Meister , which d(a)overload-time pressure, responsibility, interpersonal conflicts with problems at work;(b)monotony-dissatisfaction, tedious and monotonous work;(c)non-specific load-nervousness, fatigue, exhaustion, dissimilar work performance for longer time.The questionnaire contains ten questions, which are divided into three sections, as follows:(a)1–no, I totally disagree;(b)2–rather no;(c)3–undecided, sometimes yes, sometimes no;(d)4–rather yes;(e)5–yes, I agree fully.Respondents expressed their subjective feelings which were assessed on a scale of 1–5:(a)Psychological stress that is not likely to affect health.(b)Psychological stress, which can periodically affect the subjective state or performance.(c)Psychological stress, in which health risks cannot be ruled out. The assessment of burdening factors is based on exceeding critical median values. However, in our study, we investigated the dependence of the results of the subscales of the Meister questionnaire on the quality of life of nurses.The results are used for the group assessment. Then, data can be compared with measured critical medians for every question and calculated by the standard method for classification of grade of psychic overload. The load rating has three levels:(a)Physical fitness—PF (b)Restriction of activity due to physical problems—RP (c)Pain—BP (Bodily Pain)(d)General perception of health—GH (e)Vitality—VT(f)Social Functioning—SF(g)Sense of mental health—MH (h)Restriction of activity due to emotional problems—RE (i)Change in health—HT (j)Functioning in the physical dimension, general physical health—PCS(k)Mental functioning, general mental health—MCSThe study used a shortened version for health-related quality-of-life assessment. The following 11 areas can be assessed:The quality of life in each of the domains is expressed by a number from 0 to 100. Higher numbers mean a better quality of life. The authors were licensed to use the SF-36v2 questionnaire —Office oThe study was carried out in accordance with the tenets of the Declaration of Helsinki and guidelines of Good Clinical Practice . Written information about the study was provided as an introduction to the survey, with an emphasis on the voluntary and anonymous nature of participation and its guaranteed confidentiality. By answering the questionnaire, participants gave their consent to participate in the study. The research project was approved by the independent Bioethics Committee at the Wroclaw Medical University (No KB–613/2021).The R program (version 4.1.3.) was used for computations. Chi-squared test (with Yates’ correction for 2 × 2 tables) was used to compare qualitative variables among groups. In case of low values in contingency tables, Fisher’s exact test was used instead. Mann–Whitney test was used to compare quantitative variables between two groups, while Kruskal–Wallis test (followed by Dunn’s post-hoc test) was used for more than two groups. The relationship between two quantitative variables was assessed with Spearman’s coefficient of correlation. The significance level for all statistical tests was set to 0.05.p-values of less than 0.05 indicate significant differences between the groups from each country in terms of socio-demographic data, which includes place of residence, as Poles (city over 500th inh. 23.57%) lived in larger cities than Czechs (city over 500th inh. 6.22%) and Slovaks (city over 500th inh. 7.73%) . In addition, Poles (71.72%) were more likely to be married than Czechs (58.67%) and Slovaks (59.89%) and less likely to be divorced. In contrast, Slovaks had the most children and Czechs the fewest children. In terms of educational attainment, Poles (14.48%) were more likely to have a master’s degree than Slovaks (12.77%) or Czechs (3.11%). Statistically significant differences were also observed in the parameter of place of work. The most common place of work for Czechs (49.11%) and Poles (55.22%) were hospital departments, while for Slovaks, the place classified as “other” (27.74%). Detailed socio-demographic data can be found in The average age of nurses from all three countries was similar: in the Czech Republic 44.32 ± 11.19, in Poland 45.27 ± 11.11, and in Slovakia 45.31 ± 9.78. No differences were also noted in seniority, as the average obtained for each of the three countries oscillated around 23 years. All groups from each country were heavily feminized, with the percentage of men ranging from 2.36% to 5.33%. The p < 0.05 indicate the following statistically significant relationships:(a)Quality of life in the domains of PF , BP (Bodily Pain), MH , and HT  was significantly higher in Czechs than in Poles and Slovaks.(b)Quality of life in the domains of PF , VT , RP , and RE  was significantly higher in Czechs and Poles than in Slovaks.(c)Quality of life in the domains of PF , GH , SF , PCS , and MCS  was significantly higher in Czechs than in Poles and Slovaks, and, moreover, was significantly higher in Poles than in Slovaks.This study also analyzed the quality of life of nurses from the Czech Republic, Poland, and Slovakia. The quality-of-life results were presented in 11 dimensions . This may be compounded by the cultural proximity of the countries involved in the study, the competence of the nurses, and the comparable lifestyles of the population, and thus the nurses. It should also be noted that in areas where Poland directly borders the Czech Republic, cultures or lifestyles intermingle. Nurses from Poland work in Czech hospitals and vice versa.p < 0.05):(a)The level of overload was significantly higher in Poles than in Czechs and Slovaks, and was also significantly higher in Slovaks than in Czechs;(b)The level of monotony, non-specific factor, and overall level of burden were significantly higher in Poles and Slovaks than in Czechs.The level of work-related stress as a whole was evaluated , which also compared the performance of nurses from Poland, the Czech Republic, and Slovakia in terms of job burnout and work-related stress . The stuThe work of nurses is burdened with many stressors, which can directly or indirectly affect a person’s perceived stress level. Stress, in turn, affects the quality of life, and the transfer of problems from work to the private sphere is a common phenomenon. This study showed that the level of stress affects the quality of life of nurses. It is worth looking at the factors that cause stress in the work of nurses. Undoubtedly, it can be staffing shortages that cause excessive workloads and can induce rationing of care and many others. Healthcare systems are facing a staffing deficit that will not be solved overnight. Therefore, it is very important to provide nurses with preventive measures. The ergonomics of the workplace, including psychosocial factors, are very important. At present, the implementation of preventive programs to reduce stress levels among nursing staff may be the only effective action in the field of professional work against the reduction of quality of life. As part of improving the ergonomics of the workplace and to avoid monotony, which can contribute to significant overload, mandatory rotations within different hospital departments can be implemented . In addition, some hospitals are already implementing work–life balance programs and group classes with a psychologist to reduce bad emotions. These are preventive measures that can be implemented in any facility.The authors recognize some limitations of the study. Assuming random selection of study participants, it is difficult to assess whether there were any limitations in access to the entire geographical range of participants. Since the survey was conducted online, people who are not so eager to use the Internet could have been excluded—this also includes digital exclusion.


Breastfeeding might prevent childhood cancer by stimulating the immune system.The following databases, including PubMed, Embase, and Cochrane Library, were searched from inception to January 10, 2021.In dose-dependent manner, there was a statistically significant inverse association between any breastfeeding and the incidence of childhood cancer. There was no evidence that breastfeeding was inversely related to childhood cancer of the skeletal, reproductive, or sensory systems. However, breastfeeding was inversely associated with the incidence of hematological malignancies and cancers of the nervous and urinary systems. Among hematological malignancies, the relationship was significant for acute lymphocytic leukemia (ALL) and acute myeloid leukemia (AML), but not for acute non-lymphocytic leukemia (ANLL), Hodgkin’s lymphoma (HL), or non-HL.The evidences demonstrated that breastfeeding have a potential protective role in preventing selective childhood cancer growth, especially for ALL, AML, cancer of nervous and urinary systems. This study recommended that breastfeeding be extended for as long as possible or maintained for at least 6 months to prevent selective childhood cancer growth.The online version contains supplementary material available at 10.1186/s13052-022-01292-9. The incidence and mortality associated with childhood cancer is increasing sharply in developed and developing countries . The mosBreastfeeding is the major food for newborn babies, who receive almost all essential needs to meet the requirements of growth and development . It has There were eight studies reporting the results of meta-analyses on the relationship between breastfeeding and childhood cancer , 9–15. TPubMed and Embase were systematically searched for relevant studies that met our eligibility criteria. The literature search was carried out on January 10, 2021 to identify published studies on the relationship of breastfeeding and cancer in children. Two authors were responsible for screening the studies to obtain full manuscripts, as well as the titles and abstracts. To ensure completeness and accuracy of this meta-analysis and systematic review, two reviewers participated in the entire literature search process without interfering with one another. The search terms for this study were as follows: “Childhood”, “Children”, “Child”, “Neoplasms”, “Cancer”, “Tumour”, “Neoplastic”, “Malignancy”, “Bottle-feeding”, “Breastfeeding”, “Infant nutrition”, “Perinatal”, and “Milk”, with language and publication status restrictions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed .Studies were included in the meta-analysis if they met the following criteria: (1) the study was published in English; (2) the exposure of interest was breastfeeding; (3) the outcome was childhood cancer; (4) the age of included population was less than 18 years old; and (5) the estimates of the relative odds ratio (OR) with 95% confidence interval (CI) were reported.Exclusion criteria were as follows: (1) duplicated reports; (2) defective study designs; (3) incomplete data and uncertain outcome effects; and (4) incorrect statistical methods or those that could not be amended, could not be provided, or could not be converted into OR.The following data were extracted from each study: country of the patients, individual ages and average ages, types of cancer , the modes of breastfeeding , feeding duration, and the number of patients in the breastfeeding and control. Adjustment factors and other directly extractable data were first extracted for each study. The durations of breastfeeding were classified as either past breastfeeding or never breastfed, greater than or equal to 6 months or less than 6 months, and greater than or equal to 12 months or less than 12 months.The Newcastle-Ottawa Scale (NOS) was used to assess quality of included studies in this meta-analysis and systematic review . NOS inc2 statistics. Initial analyses with I2 < 40% were performed using a fixed-effects model; otherwise, a random effects model was adopted. Potential confounders, including the modes of breastfeeding , duration of breastfeeding , different countries, and cancers of different systems were regarded as the main sources of heterogeneity. Subgroup and sensitivity analyses were employed. We used the one-stage robust error meta-regression model to establish the potential dose-response relationship between duration of breastfeeding and risk of cancer [The effect of breastfeeding on childhood cancer was analyzed using OR and 95%CI as the effect measure. Between-study heterogeneity  was assef cancer , 25. Thif cancer . The resf cancer . The remf cancer . All staA total of 3348 studies were obtained through a search of electronic databases, and 46 studies, including 20,066 cases and 448,661 control individuals, met our eligibility criteria. A total of 770 studies were removed for being duplicates, 2443 for being irrelevant (as determined by reading the title and abstracts), and 89 for reasons determined by reading the full text. Studies also were excluded if data could not be extracted or could not be obtained by contact with the author  . The risks of cancer were inversely associated with the duration of breastfeeding: as duration of breastfeeding increased, the odds of cancer significantly decreased Fig. .Fig. 4DoGrouped based on the duration of breastfeeding, there were cut-off points at months 1, 6, and 12 for exclusive breastfeeding. Table ).Regarding exclusive breastfeeding for 6 months, four studies , 47, 52 1Because of various economic levels among countries, breastfeeding conditions were inconsistent, as was the incidence of childhood cancer. The data of 31 studies were analyzed , 64–68 fOnly the differences with respect to gender in the incidence of childhood cancer had been compared, and there were no data on the prevalence of males and females in the various breastfeeding conditions. Twenty-nine studies , 63–65, The studies with more than 1000 cases were considered the largest studies . The lar). However, the common comparison was 6 months or more of breastfeeding compared with a shorter duration in the three largest studies; the results demonstrated weak evidence of a protective association between breastfeeding for duration of 6 months or more and the incidence of childhood cancer .These three studies were analyzed separately by our reviewers without interfering with one another , 62, 69.1NOS for assessing the quality of included studies was shown in Additional file Whatever modes of breastfeeding and any length of breastfeeding were associated with lower risk of hematological malignancy  .Separate subgroup analyses were also performed for leukemia  and lymphoma (HL and NHL). For leukemia, there were 19 studies , 62, 66 (Table 1).The subgroup analysis for lymphoma included five studies , 18–20  because of the absence of data.The data from developed countries were considered separately from those of countries accounting for the majority of the collected data in this meta-analysis. Therefore, the conclusions needed to be confirmed further and compared with those of the total sample. The protective effect in the total sample was better than that of the developed countries. The hypothesis was that developing countries may do better than developed countries with respect to breastfeeding. The relationship of breastfeeding to childhood cancer in developed and developing countries needed to be further explored in the future.There were several limitations of this meta-analysis. Firstly, the data collected from single studies were not complete and available, and some negative results might be missed, this might produce certain biases in the meta-analysis. In addition, unpublished literature was not included in terms of eligibility criteria. Secondly, the definitions of some studies did not clearly specify mixed breastfeeding, exclusive breastfeeding or bottle feeding, and the data were insufficient. Furthermore, the sample sizes of studies regarding the relationship between breastfeeding and cancers of certain systems of childhood were small, and this may affected the reliability of the meta-analysis. Thirdly, Most of populations included in this study come from high-income countries, and there was a lack of evidence support from low-income countries. Therefore, the conclusion of this study may only be applicable to population in high-income countries, and evidence applicable to population in low-income countries needs to be further produced and verified. In the course of cancer development, children may be exposed to more uncertain potential cancer risk factors. However, the original study did not provide relevant information about the potential cancer risk of children, which may have some effect on the accuracy of results. Finally, there was no information on covariates that may serve as mediators or confounders, including parental smoking behavior and family history of cancer.Current evidence demonstrated that breastfeeding have a potential protective role in preventing selective childhood cancer growth, especially in ALL and AML among hematological malignancies. However, breastfeeding did not appear to protect children from ANLL, HL, or NHL. Breastfeeding appeared to be beneficial in reducing the incidence of childhood cancer of the nervous and urinary systems. There was no evidence that breastfeeding was inversely related to the incidence of childhood malignancies of the skeletal, reproductive, or sensory systems. Notably, this meta-analysis indicated that the modes of mixed-breastfeeding and exclusive breastfeeding were recommended for preventing selective childhood cancer growth. This study recommended that breastfeeding be extended for as long as possible or maintained for at least 6 months to prevent selective childhood cancer growth. In addition, the current evidences were from population in high-income countries, and its applicability in low-income countries needed to be verified by evidences from population in low-income countries in the future.Additional file 1: Table 1. Main characteristics of the studies included in the meta-analysis. Table 2. The reasons of exclude literature. Table 3. Quality assessment of included studies in the meta-analysis using the Newcastle-Ottawa scale (NOS).


To establish and validate a nomogram to predict the overall survival (OS) and cancer-specific survival (CSS) in patients with nasopharyngeal carcinoma (NPC) receiving radiotherapy by integrating multiple independent prognostic factors.  Data from 5663 patients with NPC who received definite radiotherapy between 2004 and 2018 were included and divided into training and validation cohorts. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors of patients with NPC after radiotherapy. Thereafter, the predictive accuracy of the nomogram model was evaluated. P < 0.05).  Age, race, marital status, pathological type, tumor size, T stage, N stage, M stage, American Joint Committee on Cancer stage, and chemotherapy were independent factors affecting the prognosis of patients with NPC receiving radiotherapy. Nomograms with a concordance index of 0.726 : 0.675–0.777) and 0.732 (95% CI: 0.680–0.785) were able to predict OS and CSS, respectively. The area under the curve showed excellent predictive performance. Additionally, the calibration curve indicated that the predicted survival rate was consistent with the actual survival rate, and the decision curve indicated its clinical value. The established risk stratification system was able to accurately stratify patients receiving radiotherapy for NPC into three risk subgroups with significant differences in prognosis ( The constructed nomogram had good prognostic performance and could be used as an effective tool to evaluate the prognosis of patients with NPC after radiotherapy. This nomogram could be further used to guide clinical decisions and personalized treatment plans. Nasopharyngeal carcinoma (NPC) is one of the most common head and neck malignancies, which occurs mainly in Guangdong, Hainan, Hunan, and other regions in China , 2. NPC In recent years, various studies have used nomograms to construct prediction models as a tool for oncology and medical prognosis evaluation. Nomograms can generate individual predictions by integrating multiple prognostic and determining variables for personalized patient identification and stratification , 14. The∗Stat software . The inclusion criteria were as follows: (1) patients were diagnosed between 2004 and 2018; (2) their tumors were staged according to the 6th, 7th, and 8th versions of AJCC  and were available in the SEER database; (3) they had newly diagnosed NPC without a history of surgery; (4) they had received definite radiotherapy; and (5) the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3), was used to classify tumors according to histological types determined by the World Health Organization (WHO) classification scheme. Squamous cell carcinoma (SCC) (ICD-O-3 codes 8070 and 8071) represents the histological subtypes of keratinizing squamous cell carcinoma (KSCC), while nonkeratinizing carcinoma (NKC) (ICD-O-3 codes 8072 and 8073) represents the histological subtypes of differentiated NKC. Undifferentiated, anaplastic, and lymphoepithelial carcinomas  represent undifferentiated NKC histologic subtypes. Carcinoma that was not specified (ICD-O-3 code 8010) was assigned to form an NOS histologic subtype. For such cases, the causes of death and survival time were known.This was a retrospective study where information on patients diagnosed with NPC between 2004 and 2018 was obtained from the SEER database using the SEERPatients were excluded if (1) the diagnostic method was unknown; (2) their race and/or marital status was unknown; (3) their cause of death was unknown; (4) they had an unknown or incomplete TNM staging and/or an unknown metastasis; (5) their radiotherapy status was unknown; (6) their available follow-up time was less than 1 month; and (7) they received nonbeam radiation. Beam radiotherapy was defined as external beam radiation using gamma rays generated from a cobalt-60 source or high-energy photons generated from a linear accelerator. Nonbeam radiation was defined as any type of brachytherapy, unsealed source, intraoperative radiation not otherwise specified, or radiation not otherwise specified. This group of patients was excluded to reduce potential selection bias caused by different radiotherapy modalities.N = 3967) and validation (N = 1696) cohorts using a 7 : 3 ratio. The variables included for each patient were age, sex, race, year of diagnosis, marital status, pathological type, histological grade, tumor size, TNM stage, AJCC stage, chemotherapy record, diagnostic confirmation record, cause-specific death classification, follow-up time, and survival status. The main endpoints for this study were OS and CSS. OS was defined as the time between the date of NPC diagnosis and the date of death from any cause or the last follow-up date. CSS was defined as the time from the date of diagnosis to death attributable to NPC.Data from 8599 patients with NPC was collected from the SEER database. The data processing flowchart is shown in P < 0.05 was considered statistically significant.Statistical analysis was conducted using SPSS version 25.0 and R version 4.1.2. The R function “createDataPartition” was used to divide the patients into training and validation cohorts using a 7 : 3 ratio to ensure randomization. The training cohort was used to filter variables and build prediction models. Variables that were significant in the univariate Cox regression model were included in the multivariate Cox regression model, and multivariate proportional hazard models ) were used to identify independent prognostic factors associated with OS and CSS. The prognostic nomogram was constructed based on the multivariate analysis of the training cohort, and it was used to predict the 3- and 5-year OS and CSS by representing the total points for each variable . IndividP > 0.05).In total, 5663 screened patients with NPC had a median follow-up of 44 months. Overall, 3967 and 1696 patients were randomly divided into the training and validation cohorts, of whom 1556 and 673 died, respectively. Clinical and demographic information for the two groups is shown in P < 0.05) with the exception of sex (P < 0.05)  .Based on independent prognostic factors determined in the multivariate Cox regression analysis, a nomogram was constructed to predict 3- and 5-year OS and CSS for the training cohort . Age, raP < 0.05)  .Radiotherapy is still the cornerstone of NPC treatment , 19. In th edition) relying on improved local control of IMRT, as well as more detailed MRI preprocessing imaging, which results in a more consistent definition of T2 (with T4) and N3 diseases [The AJCC/UICC TNM staging system is the most widely accepted universal language for describing tumors, is the most common staging system for NPC, and is an important basis for guiding clinical activity in judging prognosis –25. Thisdiseases . Howeverdiseases .NPC is sensitive to radiotherapy and chemotherapy. The combination of chemotherapy and radiotherapy is considered a breakthrough in the treatment of locally advanced NPC. A number of randomized trials have shown relatively consistent results, with chemotherapy plus radiotherapy having better survival correlates , 29. Au In this study, age, race, marital status, pathologic type, tumor size, T stage, N stage, M stage, AJCC stage, and chemotherapy were identified as independent prognostic variables for OS. The nomogram is based on multivariate regression analysis, which calculates the individual end event forecast value using the individual score and end event occurrence probability function transformation. Previous studies have shown that complex regression equations can be transformed into visual graphs to make the results of the prediction model more readable and to facilitate the evaluation of patients , 37. TraOur study developed a 3- and 5-year OS and CSS nomogram for NPC patients based on 5663 samples obtained from the SEER database. Among them, M staging, age, and race contributed the most substantially to the OS nomogram, while M staging, age, and AJCC staging contributed the most substantially to the CSS nomogram. Although we used different versions of AJCC staging system, it was helpful to analyze the results and showed a good comparability. By comparing the C-index of the nomogram and AJCC stages, the C-index of the nomogram for OS and CSS prediction was found to be higher than that of AJCC in the training and validation cohorts. These findings suggest that this model has a good recognition ability, and the C-index is better than the AJCC staging prediction model. The correction curve showed that the predicted probability of the nomogram was in agreement with the actual probability calculated using the Kaplan-Meier analysis, and the 3- and 5-year survival rates were in good agreement. These results highlight that this nomogram could be used in clinical practice with less deviation and better accuracy. Decision curve analysis combines benefits and harms to measure the net benefits of an approach or predictive model. Compared with the ROC curve, the decision curve considers the clinical application value, which is an important indicator to evaluate whether patients can benefit from it. However, only a few papers have applied it to the survival prediction for NPC. In our study, we calculated not only the net benefit of the nomogram but also evaluated the AJCC staging prediction model and found that the net benefit of the nomogram was higher than that of the AJCC staging prediction model, indicating that this nomogram is feasible for clinical use.Additionally, we established a prognostic nomogram risk stratification system to accurately classify patients into three risk subgroups and identify high-risk subgroups that may require more intensive treatment. This provided guidance for patient counseling and clinical risk management. For high-risk patients, more psychological and emotional care may also be needed. Additionally, they may be encouraged to participate in clinical trials evaluating new drugs, such as immunotherapy and targeted drugs. The use of this model for stratification helped to reduce heterogeneity among the different treatment groups and thus should be considered for future use.This study has some limitations which merit mentioning. First, it was a retrospective study, in which patient selection was based on rigorous inclusion and exclusion criteria; thus, potential selection bias may have occurred. Second, the SEER database does not specify procedures, operators, and other factors, which may induce bias due to the different experience levels of the operators and pathologists. Third, because of the limited number of variables collected in the SEER database, some important variables were not available, such as Epstein-Barr virus (EBV) infection, complications, detailed chemotherapy regimens, chemotherapy course and duration, AJCC integration, and staging information based on MRI images. Fourth, SEER does not mention tumor location (primary or metastatic) or dose and mode of radiotherapy, and it does not specify the specific radiotherapy technique, making the study of the survival benefit of patients treated with radiotherapy somewhat limited. Finally, in the absence of external validation, analysis of US population-based data is not necessarily generalizable to the global population, especially to patients with NPC in endemic areas. Therefore, to improve the predictive value of the model, it will be important to consider integrating multicenter Chinese and foreign databases in the future.Based on clinical features and treatment-related information evaluated, our study established a useful nomogram for the prediction of 3- and 5-year OS and CSS in patients with NPC receiving radiotherapy. The results showed that our nomogram was superior to the AJCC staging prediction model and was successful in predicting individual survival. Further external validation using prospective data should be conducted to verify these findings. Nonetheless, this nomogram could be used in the future to assist clinicians in devising the best treatment plans for patients with NPC.


Anthropometric and body composition parameters of children were measured at 6 ± 3 months (T1) and 12 ± 3 months (T2). A total of 451 non-related children who accessed the service were analyzed: 220 (48.7%) of them returned at least once (attrition rate 51.3%). Returner outpatients showed higher age (p = 0.046) and father’s educational level (p = 0.041) than non-returner ones. Adherence to the treatment was found to be related to father’s  and mother’s  educational level. All the outcomes improved between T0 and T1 (p < 0.001), while only body mass index (BMI) decreased significantly at T2. Changes in BMI-SDS were associated with baseline value . The multidisciplinary approach seems to be promising to treat childhood obesity in this geographic context. Lower parents’ educational level should be considered as an attrition determinant.Childhood obesity must be faced through an integrated multi-level preventive approach. This study was aimed at assessing the adherence and the outcomes of an outpatient service for childhood obesity treatment activated in the province of Naples, Italy, throughout a 2-year follow-up period. At first visit (T Currently, childhood obesity represents a public health challenge, due to its negative effects on the health of children and adolescents affected and its role in determining obesity and related morbidity and mortality in adulthood . SeveralIn the last four decades, the number of obese children and adolescents has risen tenfold worldwide, with negative future perspectives on global health . In EuroGiven its complex etiology, an integrated multi-level approach is necessary to treat childhood obesity. According to the World Health Organization recommendations, primary healthcare services are important for the early detection and management of obesity and its associated complications in children and adolescents. Subsequently, appropriate family-based, multicomponent  weight management services, delivered by multiprofessional teams with appropriate training and resources, should be offered as part of universal health coverage following a staged approach ,11. SpecIn March 2018, a second-level outpatient service for childhood obesity treatment was activated in the province of Naples, county town of the Campania region, south Italy. It is based on a family-based approach by which outpatients receive psychological support and nutritional and physical activity counseling.This study was aimed to analyze retrospectively the adherence to treatment and the anthropometric and body composition outcomes produced in the adherent outpatients throughout a 2-year observation period.0) between 2018 and 2020 were consecutively included, and two follow-up times were considered: 6 ± 3 months (T1) and 12 ± 3 months (T2). Children who returned to at least one follow-up visit were defined as “returners”. At admission, parents or guardians of the outpatients signed an informed consent to the use of their personal information.Data from children and adolescents seeking obesity treatment at the outpatient clinic “Second Level Assistance Center for Diabetes and Obesity in Childhood” of the Local Health Authority “Napoli 3 Sud” were retrospectively analyzed in this study. Children aged 5–14 years with diagnosed obesity are addressed from their primary care pediatrician to the Center. For the purposes of this study, those who received their first visit  [The multidisciplinary intervention consists of counseling sessions about nutrition, PA, and motivational support carried out by a multidisciplinary team . The counseling is performed in a single day and in the presence of parents; it lasts about 1 h and 45 min and is structured in three phases. In the first thirty minutes, the nutritionist discusses with the outpatient and their parents/guardians to collect personal and anamnestic data as well as eating habits of the outpatient and their family. In particular, dietary assessment, aimed to investigate energy intake and eating habits, is performed by using a food frequency questionnaire . SuccessBMI-SDS) . BMI/ageBMI-SDS) ,18. WaisBMI-SDS) . Fat masThereafter, the psychologist supports outpatients and their families in changing nutrition and lifestyle habits detecting their own physical, psychological, and relational resources. The psychological visit (45 min) is aimed to structure an adequate motivation in changing lifestyle. It consists of a psychological welcome interview with the whole family unit aimed to detect the relational dynamics and the context in which the patient grows up, to analyze the intrapsychic area , to investigate the social area , to evaluate the motivation to change, and to perceive any psychological aspects related to eating behavior . Motivational counseling sessions are scheduled in case of poor compliance with the treatment and/or severe obesity and/or relationship difficulties . In partIn the last 30 min, the kinesiologist estimates physical and sedentary activities of both patients and their parents. The Physical Activity Questionnaire for Children (PAQ-C)  is adminLastly, a personalized balanced nutritional scheme, according to the individual nutritional history, caloric requirement, resting energy expenditure, and physical activity, is developed for each subject and released to outpatients and their families . A multiThe study was approved by the Local Health Authority “Napoli 3 Sud” of Naples (Deliberation n. 92 of 31.01.2020).0) and first (T1) or second (T2) follow-up. A Spearman correlation was used to assess possible correlations between baseline characteristics of the sample, attending follow-up visits, and BMI/BMI-SDS changes at follow-ups. The Mann–Whitney test was used to compare the baseline characteristics of returners who showed or not an increase in BMI-SDS at T1 or at T2. The chi-squared test was used to analyze the differences in parents’ educational level of outpatients who attended the Center for one, two, or three visits. A linear regression was carried out considering changes in BMI-SDS as outcomes and baseline characteristics as independent variables. The length of follow-up was included as a covariate. Results were reported as Odds Ratios and Confidence Interval 95% .A descriptive analysis was performed on sociodemographic, anthropometric, and body composition characteristics and PA levels of the sample and on PA levels of their parents. Categorical variables were reported as number and percentage of subjects, while all the other variables were expressed as median values and interquartile ranges, having assessed their non-normal distribution. The chi-squared test was used to assess differences in gender and educational level of parents between returners and non-returners. The Mann–Whitney U test was employed to compare median values of age and anthropometric and body composition characteristics. A Spearman correlation analysis was performed to highlight possible relationships between sociodemographic and behavioral features of parents and baseline children parameters. The Wilcoxon signed rank test was used to evaluate changes that occurred in compliant patients between baseline  (“returners”) returned for at least a follow-up appointment: 141 (64.1%) attended only one control visit and 79 (35.9%) attended two appointments in the observation period.Significant differences between the two groups were detected for age and father’s educational level.p < 0.001), WC , WC/H , FM (%) , FM (kg) , FFM (%) , FFM (kg) , and BMI-SDS ; mother’s educational level was related with BMI , WC , WC/H , FM (%) , FM (kg) , FFM (%) , and BMI-SDS . In addition, CPAQ score was found to be related with FM (kg)  and parents’ IPAQ score .In the correlation analysis performed at baseline, father’s educational level was related with BMI  variables but not for the body composition variables between T0 and T2. Only BMI continued to decrease significantly between T1 and T2.The comparisons between anthropometric parameters and body composition values registered at TThe individual changes in BMI-SDS that occurred in children and adolescents who underwent a second and a third visit are shown in 1 and 24 out of 94 (25.5%) patients at T2. In the comparison between baseline characteristics of patients who increased their BMI-SDS and those who did not, only baseline WC values differed significantly .An increase in BMI-SDS was registered in 32 out of 205 (15.6%) patients at Tp = 0.005) and mother’s  educational level. p = 0.082 and p = 0.096 for father’s and mother’s educational level, respectively).In the correlation analysis, adherence to treatment was found to be related with father’s , initial BMI , WC , FM (kg) , FFM (%) , and parents’ IPAQ score ; BMI changes between T0 and T2 were related with age , initial BMI , WC , FM (kg) , and FFM (kg) . No correlations were found regarding BMI-SDS changes and the baseline variables.BMI changes between Tp = 0.029).In the regression analysis, only baseline BMI-SDS was associated with changes in BMI-SDS at follow-up (OR 0.158, 95%CI 0.017-0.298, This study shows the main characteristics and preliminary outcomes of a multidisciplinary approach to childhood obesity treatment implemented in a region of southern Italy with a high prevalence of childhood obesity. The results suggest that this type of intervention may be promising to improve anthropometric parameters among children with obesity in the geographical area studied.In the last decades, a growing body of literature has analyzed the outcomes of multicomponent interventions aimed at treating childhood obesity . The comMoreover, beyond specific experimental experiences, real life requires that easy to manage, accessible, and sustainable services are offered to people with obesity and their families. In light of this, we examined the performance of the first service implemented in a territory with a higher prevalence of childhood obesity. Our follow-up analysis allowed to observe retrospectively the participation in the program throughout two years. A consistent dropout was observed, since more than the half of the admitted outpatients did not continue the treatment offered to them . DiffereAs for the treatment outcomes, we assessed a reduction in BMI-SDS in the greatest part of children and adolescents who continued to attend the outpatient service. In the correlation analyses, an increase in BMI was negatively associated with age and the extent of BMI at baseline, and BMI-SDS growth was negatively related with baseline value in the regression analysis, contrary to other studies reporting that younger and less overweight children particularly benefit from lifestyle interventions ,40. FurtNotwithstanding the discrepancy with other experiences, these associations show that, among our returner outpatients, better outcomes were obtained from those who presented a worse initial condition. This may strengthen the importance of the service offered to the population of the area, which also shows the higher prevalence of severe obese children among the Italian regions .Our findings highlight differences in the participation in the outpatient treatment, such as in the adherence to the treatment components. However, the available data were not sufficient to clearly define the determinants of these differences. The literature suggests that a unique approach for treating obesity in children and adolescents does not exist . TherefoBeyond these aspects, it should be accepted that lifestyle interventions can be ineffective for some individuals due to biological mechanisms, such as genetics, hormonal changes, adaptive thermogenesis, and neural factors, which undermine weight loss effects and promote weight regain . TherefoThis study has several limitations. First of all, the retrospective nature of the study and the lack of a control group limit the validity of its findings with respect to controlled trials. Moreover, some possible determinants such as family income or parents’ behaviors were not explored in depth. The possible association of adherence and intervention outcomes with these factors is therefore lacking. Furthermore, the reasons for non-attending and dropouts were not explored. Analyzing these reasons could have given important indications on the acceptance of the intervention. Further research considering these items is needed. Nevertheless, this study reports the results of a treatment program offered to children and adolescents in a geographical area widely affected by childhood obesity and highlights some important points for its progression and for the implementation of further interventions in this context. Moreover, the objective assessment of anthropometric outcomes and the use of bioelectrical impedance analysis to evaluate body composition in the outpatients strengthens the validity of the study.The findings of this study suggest that a multidisciplinary approach to childhood obesity treatment may be feasible to improve anthropometric parameters in children and adolescents with obesity in the local context examined. However, the stability of these outcomes can be obtained through time and with respect to that compliance to the intervention plays a pivotal role. Since a high dropout rate was obtained in the two years observed, it is important to address the outpatients’ attrition by identifying those factors that may hinder their participation. In addition, further research related to the maintenance of weight loss among youths with obesity participating in intervention programs is needed.In this study, lower parents’ educational levels were associated with lower compliance. In a public health perspective, social support is needed to counteract the possible influence of inequalities and other factors on treatment attrition.


Differential diagnosis of Crohn’s disease (CD) and ulcerative primary intestinal lymphoma (UPIL) is a tough problem in clinical practice.Our study identified key differences between CD and UPIL patients and aimed to further establish a scoring model for differential diagnosis.A total of 91 CD and 50 UPIL patients from 9 tertiary inflammatory bowel disease centers were included. Univariate and multivariate analyses were used to determine significant markers for differentiating CD and UPIL. A differential scoring model was established by logistic regression analysis.The differential model was based on clinical symptoms, endoscopic and imaging features that were assigned different scores: intestinal bleeding (−2 points), extraintestinal manifestation (2 points), segmental lesions (1 point), cobblestone sign (2 points), homogeneous enhancement (−1 point), mild enhancement (−1 point), engorged vasa recta (1 point). A total score of ≥1 point indicates CD, otherwise UPIL was indicated. This model produced an accuracy of 83.66% and an area under the ROC curve of 0.947. The area under the ROC curve for validation using the 10-fold validation method was 0.901.This study provided a convenient and useful model to differentiate CD from UPIL. What is known:CD and UPIL have different therapy and prognosisDifferential diagnosis of CD and UPIL is difficultWhat is new hereEndoscopic and imaging indicators significantly improved the ability to differentiate between CD and UPILThis model in our study is useful to differentiate CD from UPIL.Ileocolonic ulcers appear in many clinical conditions such as Crohn’s disease (CD), intestinal tuberculosis (ITB), and primary intestinal lymphoma (PIL) . CD is aThe gold diagnostic criteria for CD and UPIL rely on pathology, but it is difficult to obtain typical pathological manifestations through biopsy specimens for both diseases. A recent article reported a potential model for the differential diagnosis between CD and PIL . HoweverTo enhance the differential diagnostic efficiency and reduce the misdiagnosis rate, we analyzed the key differences in the clinical, endoscopic, and imaging characteristics between CD and UPIL patients. Furthermore, we evaluated the diagnostic value of different markers and established a scoring model for differential diagnosis.A total of 91 CD patients and 50 UPIL patients were enrolled in this study between 1 January 2004, and 30 December 2018. These patients were diagnosed and treated at nine centers, namely, the Peking Union Medical College Hospital, the Sixth Affiliated Hospital of Sun Yat-sen University, the First Affiliated Hospital of Sun Yat-sen University, the Xijing Hospital, the Sir Run Shaw Hospital, the Shanghai Renji Hospital, the Shanghai Tenth People’s Hospital, the Affiliated Hospital of Anhui Medical University, and the Wuhan Union Hospital. Clinical, endoscopic, and imaging data were collected from all patients. The Institutional Review Board of Peking Union Medical College Hospital (S-K1100) approved the study.The inclusion criteria are as follows: (1) clinically or pathologically confirmed CD or pathologically confirmed PIL; and (2) clinical, endoscopic, and radiographic data were available for the majority of the patients. Endoscopic and imaging data include the original images and reports. For each item, the proportion of missing cases was lower than 20%.The exclusion criteria are as follows: (1) PIL with fungating or other non-ulcerative lesions; and (2) PIL with post-surgery or treatment data (patients with data before the surgery or treatment could be included).All patients were diagnosed with CD according to the European Crohn’s and Colitis Organization (ECCO) guidelines and Chinese consensus based on clinical manifestations, endoscopic features, and imaging or pathological features , 7.All patients were diagnosed with PIL by histological results according to Dawson’s criteria .Demographic and clinical data included the sex, age at the onset of gastrointestinal symptoms, clinical manifestations, intestinal complications, extraintestinal manifestations (EIMs) , past, and personal history of the patient shown in 2. Skin Endoscopic indicators included lesion locations, segmental lesions, ulcer morphology , number of ulcers , ulcer diameter , inflammatory polyps, mucosal bridges, and cobblestone signs Figure 1Two experienced endoscopic physicians independently read all the endoscopic data. If their opinions were inconsistent, the final diagnosis was made after discussion.Imaging items included the length of the longest lesion segment, the thickness of the lesion, enhancement degree, homogeneous hyperenhancement, asymmetric mural hyperenhancement, polypoid lesion of the mucosal surface, fibrofatty proliferation, and engorged vasa recta Figure 2Two radiologists independently reviewed all the imaging data. When their opinions were inconsistent, the final diagnosis was made after discussion.Continuous variables following an apparently normal distribution were summarized by the mean [standard deviation (SD)]; otherwise, they were summarized by the median and interquartile range. Categorical variables were presented as proportions. Univariate analysis was conducted using logistic regression with one independent variable. Receiver operating characteristic (ROC) curve analysis was used to determine the threshold value for continuous variables presenting a linear assumption, otherwise Lowess smoothing function was used. A multivariate logistic regression model was built after univariate analysis, and a further variable selection procedure was conducted, and a final multivariate model was developed by incorporating variables with statistical significance  variables. Variables with marginal statistical significance  were also included in the final multivariate model due to their clinical significance.A scoring system was built based on the final multivariate model. Taking the variable with the minimum regression coefficient as 1 point, the scores of other variables were obtained by dividing their regression coefficients with the minimum regression coefficient and rounding to the nearest integer. The Youden Index was used to determine the cutoff value of the scoring model. The total risk score of each patient was the sum of all the scores of predictors assigned to him or her.Evaluating the predictive performance (AUC) of the fitted model using all cases from the original analysis sample tends to result in an overly optimistic estimate of the performance. Therefore, a 10-fold cross-validation procedure was employed to calculate a more realistic estimate of predictive performance . To calcAll the data were analyzed by SAS9.2 .Among the 50 UPIL patients, 17 lymphomas (34%) were of B-cell origin, and the rest of the cases  were of NK-cell and T-cell origins. The details are shown in As shown in The clinical data Table 2 The endoscopic characteristics Table 4 The imaging data Table 5 To comparatively analyze the diagnostic value of clinical symptoms and various endoscopic and imaging indicators in CD and UPIL, we performed multivariate and ROC curve analyses of the clinical symptoms individually, clinical symptoms combined with endoscopic indicators, and clinical symptoms combined with endoscopic and imaging indicators to select the model with the best differential diagnostic power.First, we included clinical symptom indicators that produced P <0.05 with the univariate analysis in the multivariate logistic regression analysis. We found that the indicators with statistical significance were intestinal bleeding and EIMs. The AUC for differentiating CD and UPIL based on these two indicators was 0.726. We then performed a multivariate logistic regression analysis of clinical and endoscopic indicators that produced a P <0.05 in the univariate analysis. These indicators included intestinal bleeding, EIMs, segmental lesions, and cobblestone signs. Based on these four indicators, the AUC for differentiating CD and UPIL based on these four indicators was 0.918. Finally, we performed a multivariate logistic regression analysis of clinical, endoscopic, and imaging indicators with a P <0.05 in the univariate analysis, which included intestinal bleeding, EIMs, segmental lesions, cobblestone signs, homogeneous enhancement, mild enhancement, and engorged vasa recta Table 6.Therefore, including endoscopic and imaging indicators significantly improved the ability to differentiate between CD and UPIL.The differential diagnostic scoring model for CD and UPIL was ultimately established based on the logistic regression model of clinical symptoms combined with endoscopic and imaging features. According to the previous multivariate analysis, we got the scores of each variable using the method shown in the statistical analysis subsection Table 6.The above results were validated using a 10-fold validation method. The AUC for 10-fold validation was 0.901 Figure 5Approximately 30 to 50% of extranodal lymphomas primarily involve the gastrointestinal tract, two-thirds of which are classified as ulcerative lesions . PatholoIn this study, we established a differential model using multivariate logistic regression that could robustly differentiate between CD and UPIL. This scoring model identified the most meaningful variables based on clinical symptoms and imaging and endoscopic characteristics. A total score ≥1 point indicates a diagnosis of CD, and less than 1 point indicates UPIL. Our predictive model produced an accuracy of 83.66% and an area under the ROC curve of 0.947, which will be conductive and helpful in clinical practice for differentiating between CD and UPIL.In this study, demographic and clinical characteristics were compared between CD and UPIL patients. From univariate analyses, the results indicated that onset age, perianal lesions, intestinal perforation, intestinal bleeding, and EIMs appeared significantly different between CD and UPIL. It was significant that UPIL patients had an older age at onset, which was consistent with the results of the large-sample epidemiological studies of lymphoma . EIMs anAlthough endoscopic evaluation plays a key role in the diagnosis of CD and UPIL, there was no consensus on typical endoscopic features for UPIL; some cases depicted a diffuse or irregular ulcer that indicated UPIL, and others did not exhibit any specific characteristic , 13, 19.In terms of imaging, there are few comparative studies on CD and UPIL. Many studies show that the enhancement of gastrointestinal lymphoma is homogeneous, which mean it is equal to or lower in attenuation than the normal tissues . NecrosiTo comparatively analyze the diagnostic value of clinical symptoms, endoscopic and imaging features in CD and UPIL, ROC curve analyses based on different multivariate analyses were performed. The AUCs for differentiating CD and UPIL were 0.726 based on clinical manifestations, 0.918 based on combined clinical manifestations combined with endoscopic features, and 0.947 based on the clinical manifestations combined with endoscopic and imaging features. Statistical analysis showed that the last AUC was significantly higher than the other two AUCs (P <0.05)  data according to the coefficients of logistic regression analysis and established a diagnostic scoring model for CD and UPIL. The results suggest that the combination of clinical symptoms, CTE, and endoscopic features can robustly differentiate CD and UPIL. The AUC obtained from 10-fold cross-validation of this model was 0.901, indicating that it has strong predictive power for distinguishing CD and UPIL. It is worth noting that the indicator “cobblestone appearance” did not attain statistical significance in the scoring system. But the cobblestone sign is deemed the “colonoscopic marker” of CD, and it is visualized by multiple deep ulcers with elevated edematous mucosa interconnecting the ulcers. According to the published references, the cobblestone sign may not be very specific for CD, and it may also occur in other diseases like infection, but it is rare in UPIL. We therefore think the cobblestone sign is of great value in excluding UPIL. Furthermore, a label of statistical significance (P <0.05) does not mean or imply that an association or effect is highly probable, and many statisticians think that we should re-examine the meaning of P-value and move forward to a world beyond “P <0.05” . So we iThis is the first study to provide a combined clinical, endoscopic, and imaging-based model for differentiating UPIL from CD. However, the first notable limitation of this study is that there were various pathological types of lymphoma included, which could have affected the diagnostic model efficiency and the ultimate prediction accuracy. Secondly, 10-fold cross validation belongs to internal validation, and the objectivity is indeed inferior to external validation, which needs a larger sample size. We have tried our best to collect enough patients for external validation in this multicenter study. Unfortunately, UPIL is uncommon in clinical practice, and we did not collect enough patients to perform external validation. Because of the limited sample size, a ten-fold validation was performed, which verified the robustness of the model at present and had a lower variance than a single hold-out set estimator. However, it is still essential to further collect data for external verification, which is our future work plan; Thirdly, some markers like lactate dehydrogenase that are sensitive to the diagnosis of UPIL were excluded from this study. Fourthly, patients in the CD group suffered from a heavy level of activity restriction (moderate to severe), which may not represent the full spectrum of CD patients. Fifthly, this study was a retrospective with a small sample size, and future studies with larger populations must validate these results in full.In conclusion, our results suggest that the combination of endoscopy, imaging features, and clinical symptoms is of great value for differentiating of CD and UPIL. The inclusion of more different subtypes of UPIL in the future will help establish a more accurate and meaningful differential model.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.HY and JQ: Study design, data collection and analysis support, and critical revision of manuscript. HZ: Data collection and analysis and drafting the manuscript. WL, BT, TG, XG, RF, KW, QC, ZR, ZL, NH, LZ, YL, and CW: Data collection. WH Data analysis. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This work was supported by the National Nature Science Foundation of China [81570505 and 81970495], the Beijing Municipal Natural Science Foundation [7202161], the Health Research & Special Projects Grant of China [201502005], and the CAMS Innovation Fund for Medical Sciences (CIFMS) [2016-I2M-3-001 and 2019-I2M-2-007].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.


Carotid intima-media thickness (CIMT) was measured at the distal wall of the common carotid artery proximal to the bifurcation point along a plaque-free segment 10 mm long on each side by B-ultrasound. The mean of the common CIMT was used bilaterally in this study. In the cross-sectional analysis, large NC was associated with the presence of abnormal CIMT. Logistic regression analysis was used to assess the relationship between NC tertiles and CIMT. The multivariable-adjusted odds ratio was 1.76  for the highest tertile versus the lowest tertile and was 1.07  per 1 standard deviation increment in NC. Among steelworkers in North China, relatively large NC level is associated with elevated odds of subclinical atherosclerosis.The purpose of this study was to determine whether neck circumference (NC) is associated with subclinical atherosclerosis among Chinese steelworkers in North China. A cross-sectional survey was conducted among steelworkers in northern China ( Cardiovascular disease (CVD) is the leading cause of death in China, accounting for 40% of deaths in the Chinese population . About 2Obesity is associated with risk factors for CVD such as dyslipidemia and hypertension, promoting the development of atherosclerosis . HoweverNeck circumference (NC) is considered a relatively easy anthropometric measure to predict upper body fat distribution ,14. CompTherefore, the NC as an indicator of upper body adiposity is beginning to show diagnostic value in evaluating atherosclerosis. To the best of our knowledge, the results of previous studies on NC and atherosclerosis were inconsistent ,18. AddiThis cross-sectional study reported the results of a baseline survey of steelworkers in 11 steel production sectors of HBIS Group’s Tangsteel Company in North China. All employees of the company underwent statutory annual physical examination from February to June 2017, and a total of 7661 participants were recruited. Overall, 4084 workers voluntarily completed carotid ultrasound examinations. After excluding 297 workers with incomplete questionnaire information and 320 workers with incomplete body measurement index data, a total of 3467 workers were included in the final analysis. The age ranges were 23 to 60 for male workers and 28 to 60 for female workers. The study was approved by the ethics committee of the North China University of Science and Technology (Ethic ID: 16040). Written informed consent was obtained from all participants.2). WHR was calculated as WC (cm) divided by HC (cm). BMI ≥ 25 kg/m2 [NC, WC, and hip circumference (HC) were measured three times by a plastic belt, and the average value of the measurement was taken. NC was measured horizontally from the midway of the neck, between the middle of the cervical spine and the middle of the anterior neck, with the head erect and eyes facing forward. The WC was measured at the midpoint between the lower edge of the rib and the upper edge of the iliac crest on the mid axillary line. HC was measured at the level of the maximum posterior extension of the hip in the horizontal plane. To avoid measurement bias, there was only one staff assigned to measure NC, WC, and HC all through the survey. The height and weight data that were ultimately used for analysis were accurate at 0.1 cm and 0.1 kg. BMI was defined as body weight (kg) divided by the square of the body height  ,22,23. CCarotid artery ultrasound scanning was carried out using a high-resolution B-mode topographic ultrasound system . It was conducted by two trained ultrasound doctors who were blinded to clinical presentation and laboratory data. According to the 2007 European Society of Hypertension/European Society of Cardiology hypertension guideline recommends, we defined a CIMT > 0.9 mm as an abnormal CIMT .Covariates mainly included age, sex, educational level, smoking status, drinking status, physical activity, dietary approaches to stop hypertension (DASH) score , dyslipit-test or analysis of variance (ANOVA) were used for comparison among groups. Otherwise, the median (upper quartile–lower quartile) and Kruskal–Wallis test were used to describe and compare non-normal distribution continuous variables. The classification data were presented as numbers and percentages, and the χ2 test method was used for comparison among groups. Pearson correlation analysis was used to calculate the correlation coefficient between WC, NC, and metabolic parameters. Logistic regression analysis was used to assess the association between NC and CIMT. NC was included in the logistic regression analysis as a categorical variable divided into three groups by tertiles and as a continuous variable. Model 1 was unadjusted. Model 2 was adjusted for age and sex. Model 3 further adjusted education level, smoking status, drinking status, physical activity, DASH score, diabetes, dyslipidemia, and elevated blood pressure. We conducted a subgroup analysis by BMI, AO, sex, and age, to examine whether the relationship between NC and CIMT is reliable in the presence of potential confounding factors. All data were analyzed using SAS V.9.4  and MedCalc 19.6.0 . A two-tailed p < 0.05 was considered statistically significant.The measurement data were statistically described using mean and standard deviation if the normal distribution was followed. Student’s p < 0.001). The demographic, clinical, and lifestyle characteristics of the participants according to CIMT status are shown in p < 0.05) even after adjusting for age, sex, educational level, smoking status, drinking status, physical activity, DASH score (The results of the Pearson correlation depicted that WC and NC was significantly correlated with systolic blood pressure (SBP), diastolic blood pressure (DBP), FBG, total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL). The association was still significant (SH score .p for trend <0.001) after adjusting for age and sex (Model 2). After adjustment for educational level, smoking status, drinking status, physical activity, and DASH score, dyslipidemia, elevated blood pressure, and diabetes only slightly reduced the magnitude of the odds for abnormal CIMT  (Model 3). The overall OR (95% CI) of abnormal CIMT was 1.07 (1.04 to 1.10) per 1-SD increment of NC when NC was considered as a continuous variable . Analyses stratified by sex indicated that there were significant associations between the highest NC tertile and abnormal CIMT in male  and female . As for age, in age 50 to 60, compared with those the lowest NC tertile, the highest NC tertile had increased odds of abnormal CIMT . Each of the variables were observed with no interaction .The associations between NC tertiles and the odds for abnormal CIMT stratified by BMI, AO, sex, and age are presented in Subsequently, by constructing the areas under ROC curves (AUCs), the predictive value of NC and other body measurement indexes for abnormal CIMT was evaluated. Considering that there are various age and sex groups, we assessed the AUCs of NC and other body measurement indexes for CIMT by age and sex groups. For sex groups, the AUCs of NC were 0.564 in male and 0.630 in female. The AUCs in male and female were the highest in WC (0.576) and WHR (0.679), respectively. For age groups, the age group of 23 to 39 had the highest AUCs value of NC both in male and female  .Considering the main occupational hazards exposed to workers in steel enterprises such as dust, high temperature, noise, and carbon monoxide see , we furtRare studies have explored the potential value of NC as a predictor of abnormal CIMT among the occupational population in China. In this cross-sectional study of steelworkers, the prevalence of abnormal CIMT was 20.8%, and a positive association was observed between relatively large NC and CIMT. In addition, similar results were obtained by sensitivity analysis and the association remained robust after further adjustments for occupational hazards, such as dust, high temperature, noise, and carbon monoxide. Our research shows that higher neck fat accumulation was also associated with metabolic dysregulation, characterized by elevated blood pressure and fasting blood glucose. Overall, these findings suggest that the excessive accumulation of neck fat in steelworkers was of great significance for predicting the prevalence of subclinical atherosclerosis.Previous studies have reported that central obesity, hypertension, hypertr-iglyceridaemia, and impaired fasting glucose were associated with abnormal CIMT . In our To evaluate the predictive value of NC and other body composition indicators for CIMT, ROC analysis was used to calculate AUCs, and the results showed that NC has a low AUC value and may not be a good predictor of CIMT. However, none of the current studies provide data disaggregated by age group. Our results showed that, in the 50–60 age group, NC had the highest predictive value in comparison with other body measurement indexes in both sex groups. Similarly, stratified analysis of age was observed, with the highest tertile of NC positively associated with abnormal CIMT in the 50–60 age group. Previous research reported that age is an independent risk factor for CIMT progression, and older age is associated with a higher CIMT . MoreoveIt is well established that obesity is commonly known to be a heterogeneous disease. Differences in body fat distribution result in specific cardiovascular disease . PreviouThe limitations of our study should be noted. First, the nature of the cross-sectional study limited our ability to infer causal relationships between NC and CIMT to some extent. Second, we used NC to assess subcutaneous fat in the neck, but we cannot quantify the fat and muscle content. Therefore, the proportions of fat and muscle are unknown. Third, our data are based on steelworkers, most of whom are male in northern China, so the ability to generalize the conclusions to the general population is limited. Fourth, compared with workers who did not take carotid ultrasound, those who did were older, less were male, and they had higher SBP, DBP, and FBG levels . These wIn conclusion, large NC is associated with elevated odds of subclinical atherosclerosis in steelworkers. Measurement of NC may provide a more complete understanding of subclinical atherosclerosis risk with variation in fat distribution.


The purpose of this study was to clarify the incidence, risk factors, and clinical outcomes of septic acute kidney injury (AKI) in cancer patients with sepsis admitted to the intensive care unit (ICU).n = 279) and the AKI group (n = 77). The clinical data after ICU admission were compared between the above two groups, and the risk factors and the clinical outcomes of septic AKI in the ICU were identified.A total of 356 cancer patients admitted to the ICU due to sepsis from January 2016 to October 2021 were analyzed retrospectively. According to the incidence of septic AKI, all patients were divided into the non-AKI group . LASSO regression and logistic regression all showed that lactate, sequential organ failure assessment (SOFA) score and septic shock were closely related to the occurrence of septic AKI. In terms of clinical outcomes after ICU admission, the rate of mechanical ventilation (MV) and continuous renal replacement therapy (CRRT), MV time, hospitalization time and 28-day mortality in the ICU were significantly higher in the septic AKI group than in the non-septic AKI group. Among the three subgroups of septic AKI , the mortality of patients in the subgroup of AKI combined with septic shock was significantly higher than others. CRRT has no significant effect on the short-term outcome of these patients.Lactate level, SOFA score and septic shock were closely related to the occurrence of septic AKI in the ICU. The clinical outcomes within 28 days after ICU admission of cancer patients with septic AKI were worse than those without septic AKI. The short-term outcome was worse in patients with septic AKI complicated with septic shock. CRRT does not have any significant effect on the short-term prognosis of cancer patients with septic AKI in the ICU. Acute kidney injury is considered as one of the serious comorbidities in critically ill patients. AKI may have higher short-term and long-term mortality, and the use of medical resources is considerably increased. AKI is characterized by a sudden decrease in glomerular filtration rate (GFR), resulting in the accumulation of nitrogenous waste and the inability to maintain the homeostasis of body fluids and electrolytes . AlthougThe most common cause of AKI in critically ill patients is sepsis. Cohort studies indicate that the incidence of septic AKI ranges from 19 to 48%, while the mortality of patients with septic AKI fluctuates from 22 to 70% –12.Because the immune system of cancer patients with sepsis cannot cope with the initial injury, pathogen invasion emerged on the basis of malignant cell transformation. Compared with non-cancer patients, cancer patients with sepsis had a 2.5-fold higher in-hospital mortality rate due to sepsis. Cancer patients with sepsis have a worse prognosis , 14. Then = 279) and the AKI group (n = 77) in terms of the occurrence of septic AKI , and all patients provided written informed consent for the treatment of sepsis and related scientific research purposes A total of 356 cancer patients with sepsis were retrospectively screened out of 3,362 patients admitted to the ICU in Peking University Cancer Hospital from January 2016 to October 2021, according to the inclusion criteria. Inclusion criteria: (1). Patients with sepsis aged >18 years; (2). Diagnosis satisfying the definition of sepsis 3.0. Exclusion criteria: (1). CKD stage 3 and above; (2). After kidney transplantation; (3). Incomplete clinical data. All the included patients were divided into the non-AKI group (ptic AKI .The diagnosis of septic AKI: (1). Clinical judgment of AKI has a positive correlation with sepsis; (2). AKI refers to the definition and diagnostic criteria from kidney disease improving global outcomes (KIDGO) in 2012.Demographic characteristics and baseline data , infection site and etiological data, some laboratory test results within 24 h after ICU admission, the first SOFA scores, and other complications related to sepsis, including septic shock, septic cardiac dysfunction (SCD), and acute respiratory failure (ARF), were collected from all the included patients. The short-term clinical outcomes of all patients in the ICU were recorded, including mechanical ventilation (MV), continuous renal replacement therapy (CRRT), MV time, length of stay in the ICU and 28-day mortality in the ICU.“survival,” “surviviner,” “glmnet,” “pROC”) were used for statistical analysis. Continuous variables with normal distributions were expressed as means ± SD; otherwise, they were expressed as medians (IRQ). Categorical data were expressed as numbers (proportions). categorical variables were reported as frequency or percentage (%). Continuous variables with a normal distribution were compared by unpaired independent t test, continuous variables with a skewed distribution were compared by the Mann–Whitney U test, and the classified data were compared using the χ2 test or Fisher’s exact probability method. Logistic regression and LASSO regression were utilized to compare and screen out the significant risk factors of septic AKI. The number of septic AKI related variables of non-zero parameters was controlled by adjusting the Lambda(λ) value in the LASSO regression. 1se (the dashed line on the right side) was taken as a reference, the method of ten-fold cross-validation was utilized to obtain the minimum number of variables for the optimal model. The Kaplan–Meier method was used to analyze the short-term clinical prognosis of patients with septic AKI. The ROC curve was used to determine the predictive value of relevant risk factors for septic acute renal injury. Bivariate correlation analysis is applied to the comparison of critical variables. For all the above tests, a two-tailed P < 0.05 was regarded as statistically significant.SPSS 26.0  and R language   .2.P = 0.032, P = 0.002, P = 0.001, P = 0.005, P = 0.001) , brain natriuretic peptide (BNP), and SOFA scores after ICU admission between the septic AKI group and the non-septic AKI group (= 0.001) .3.P = 0.001, P = 0.001, P = 0.041)  were more likely to occur in the septic AKI group than in the non-septic AKI group (= 0.041) .4.LASSO regression was used to screen the important risk factors of septic AKI: All the variables in 5.P = 0.001, P = 0.001, P = 0.009)  .6.P = 0.04) , a positive correlation between septic shock and SOFA score , and a positive correlation between lactate and SOFA score .The drawing of ROC about important variables that affect the occurrence of septic AKI: Lactate, SOFA score, and septic shock were screened out with the intersection of Wayne diagram adopted from the combination of Lasso regression and logistic regression. The union ROC (lactate combined with SOFA score and septic shock) showed that the performance in predicting septic AKI  is better than the predictive performance of each variable  ( = 0.04) . Bivaria7.P = 0.004, P = 0.001, P = 0.006, P = 0.004, P = 0.001)  .8.P < 0.001) (P = 0.005)   . In the = 0.005) ; However = 0.34) , 8.9.P = 0.19)  .Septic AKI is a life-threatening complication characterized by an abrupt deterioration in renal function, manifested as elevated serum creatinine levels, oliguria, or both. It closely relates to infection or sepsis. Septic AKI is one of the earliest focal manifestations in patients with sepsis. Current estimates suggest that septic AKI affects 10–67% of patients with sepsis , 15. HowWe found that there may be a definite relationship between septic AKI and cancer type. Regroup analysis showed that sepsis patients with retroperitoneal and urinary tumors were more vulnerable to septic AKI. For the two types of cancer patients, we analyzed the reasons. The mechanism of retroperitoneal and urinary tumors with septic acute kidney injury may include the following: Firstly, the tumor has oppressed or invaded the urinary system, causing local obstruction or postrenal obstruction, resulting in impaired renal function. Secondly, most patients with retroperitoneal and urinary tumors have undergone surgery, and there is a risk of low organ perfusion during the operation. Some patients may undergo single nephrectomy, and patients may be complicated with abdominal infection, paralytic intestinal obstruction, intra-abdominal hypertension after surgery . In addiP < 0.001). This result shows that septic shock may have higher levels of blood lactate, and both of which are positively correlated with the severity of the disease, that is, SOFA score.Our study also concluded that lactate, SOFA score and septic shock were closely related to the occurrence of septic AKI with LASSO regression and Logistic regression. Serum lactate levels in the septic AKI group were significantly higher than those in the non-septic AKI group. The serum lactate level is a sensitive but non-specific indicator of metabolic stress . As a prIn our study, rates of MV and CRRT for the septic AKI group were significantly higher than those of the non-septic AKI group, and the MV time and the ICU stay time were also significantly prolonged. There was a major difference in the 28-day mortality between the above two groups. The 28-day mortality was also significantly increased when septic AKI was combined with septic shock. We compared the effect of CRRT on the prognosis of patients with septic AKI. CRRT cannot prolong the short-term survival time of patients with septic AKI, so CRRT did not improve the short-term prognosis of septic AKI. These conclusions are in agreement with most studies , 28.Our study on septic AKI is of definite clinical significance. Firstly, the group of this study focused on cancer patients with sepsis, and we found that septic cancer patients of retroperitoneal and urinary tumors were more likely to have septic AKI. The group studied and this conclusion are not common in previous studies. Secondly, we screened out three variables with the intersection of Wayne diagram adopted from the combination of Lasso regression and logistic regression. The prediction of the combined ROC based on the three variables for the occurrence of septic AKI has good performance. Later, it can be modeled and verified after increasing the sample size. If the predictive ability of the model is reliable, it can be adopted in clinical application to judge the prognosis of septic AKI at an early stage. Finally, we understand that if cancer patients with sepsis have septic AKI at the same time, the short-term outcome will be poor, and CRRT cannot effectively improve the prognosis. The above aspects are helpful for us to understand the risk factors of septic AKI in cancer patients with sepsis, which play a good reference role in the diagnosis, treatment, and prognosis of septic AKI in cancer patients.However, our study has its limitations. Firstly, this study was a retrospective study, and our data were taken from single-center studies, so the incidence and severity of septic AKI may be biased. Secondly, for all patients with septic AKI, we focused on the short-term outcomes within 28 days after ICU admission and lacked 90-day or longer follow-up data on cancer patients with sepsis. The lack of awareness of the long-term survival and physical and mental health of patients with sepsis is also something that needs to be improved in future research. In addition, in view of the small number of CRRT treatments, a total of 24 cases, we did not conduct a subgroup analysis, but only to explore the overall prognostic differences. If patients with septic AKI were graded to different subgroups according to the KIDGO criteria, and the prognostic value of CRRT in each subgroup is compared, different results may be obtained, which also represents one of the limitations of this study.Lactate level, SOFA score and septic shock were closely related to the occurrence of septic AKI in the ICU. The clinical outcomes within 28 days after ICU admission of cancer patients with septic AKI were worse than those without septic AKI. The short-term outcome was worse in patients with septic AKI complicated with septic shock. CRRT does not have any significant effect on the short-term prognosis of cancer patients with septic AKI in the ICU. This study was a preliminary exploration of the incidence, influencing factors and clinical outcomes of septic AKI in cancer patients with sepsis, which has certain guiding significance for the diagnosis, treatment and prognosis of septic AKI.The raw data supporting the conclusions of this article will be made available by the authors for a reasonable purpose, without undue reservation.The study was approved by the Ethics Committee of Peking University Cancer Hospital and all patients provided written informed consent for the treatment of sepsis and related scientific research purposes.YY and JD designed, analyzed, and drafted the manuscript. XC and RC collected and interpreted the patients’ data. HW administered and revised the manuscript. All authors read and approved the final manuscript.