The outcomes measured were as follows: a 10-point visual analogue scale pain score; Vancouver scar scale for scar vascularity, height, pliability and pigmentation; ultrasound measurement of scar thickness; Jebsen−Taylor hand function test; grip strength; Perdue pegboard test; and the Michigan hand outcomes questionnaire. The change in the score from baseline to post-treatment was compared between the two groups. ESWT improved the pain score (p = 0.001), scar thickness (p = 0.018), scar vascularity (p = 0.0015), and improved hand function . The other measured outcomes were not different between the two groups. ESWT is effective in decreasing pain, suppressing hypertrophic scarring, and improving hand function. Postburn hypertrophic scarring is a common complication in burn injuries to the hands, often associated with impaired hand function. We evaluated the effects of extracorporeal shock wave therapy (ESWT), compared to a sham stimulation therapy, on hypertrophic scars of the hand caused by burn injury and investigated its effects on hand function. This was a double-blinded, randomized, controlled trial of 48 patients with a burn to their dominant right hand. The parameters of ESWT were as follows: energy flux density, 0.05–0.30 mJ/mm Hypertrophic scarring is a common complication after a burn. Hypertrophic scars result from excessive tissue formation during the wound healing process . The mecExtracorporeal shock wave therapy (ESWT) is effective in the treatment of orthopedic diseases and neuropathic pain and has also been used in regenerative medicine of the skin , with neThis was a double-blinded, randomized, controlled trial of 48 patients  recruited from the Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, Korea, between November 2019 and April 2020. Our study was approved by the Ethics Committee of the Hangang Sacred Heart Hospital (HG2018-047) and registered in ClinicalTrials (NCT04138355). All patients provided written informed consent. Each of the 48 patients enrolled in the study were ≥18 years old and had sustained a deep partial-thickness (second-degree) burn or a full thickness (third-degree) burn involving only the right hand, which had been treated with a split-thickness skin graft (STSG) after the thermal injury, <6 months prior to enrollment. At the time of the study, all the patients were in the re-epithelialization phase of wound healing and had been transferred to the rehabilitation department, after acute burn treatment, to improve hand and wrist stiffness due to painful retracting scarring. The criteria for exclusion from the study were as follows: left-hand dominance; musculoskeletal diseases  of the right dominant hand; pregnancy; or potential for additional damage to the skin if exposed to ESWT and conventional occupational therapy. The first 50 burn patients who met our inclusion/exclusion criteria were randomly allocated, using a computer program, to either the ESWT (n = 25) group or to the sham (n = 25) group. While all participants in the sham group completed the trial protocol, two patients in the ESWT group dropped out of the study because they did not want to undergo serial evaluations. Thus, 23 patients were ultimately included in the ESWT group, and 25 were included in the sham group . Patients in both groups received standard rehabilitation treatment for burn injuries to the hands, including medication, scar lubrication, massage therapy to the scars, and occupational therapy to improve hand function. Occupational therapy treatment consisted of 20 sessions  for four weeks. Every effort was made to provide the same exercise rehabilitation for both groups and to adapt the level of difficulty of the exercises prescribed to each patient’s performance. Patients received one ESWT or sham treatment session per week for four weeks. 2, an energy flux density (EFD) of 0.05 to 0.30 mJ/mm2, and a frequency of 4 Hz. Between 1000 to 2000 impulses were administered per session, for four sessions held at one week intervals. In the sham group, the same shock wave equipment, with the same-shaped adapter, as in the experimental group was used, but with no energy emitted , with an electromagnetic cylindrical coil source used to focus the shock wave . ESWT wa emitted .In order to evaluate the effect of ESWT, we compared the change in the severity of pain, scar thickness, and hand function between the ESWT and sham groups, from baseline measures taken immediately before the intervention and measures taken immediately after session 4. The 10-point visual analogue scale (VAS) was used to measure self-reported pain severity, with ratings from 0 (no pain) to 10 (unbearable pain). The Vancouver scar scale (VSS), an observer-dependent scale of the macroscopic appearance of scarring, was used to measure changes in the scar over the four week period of treatment . The VSSp-value < 0.05 was deemed significant. The pre- to post-treatment scores were evaluated between the two groups using the Mann−Whitney or independent t-test, as appropriate for the variable type and distribution, with a p-value < 0.05 deemed significant. Statistical analyses were performed using SPSS, version 23 . Fisher’s exact test was used to evaluate the homogeneity of the distribution of sex and burn types between the two groups before treatment, and the independent t-test was used to evaluate the homogeneity of distribution of the total burn surface area (TBSA), scar thickness, total VSS, dominant-hand and bilateral PPT scores, and the score for picking up small objects subtest of the JTT. A between-group p > 0.05 for all comparisons; p > 0.05 for all comparisons; There were no differences between the two groups in terms of demographic and clinical characteristic before treatment (p = 0.001) and vascularity VSS score (p = 0.0015) (p = 0.018) for the ESWT group over the sham group (p = 0.19), pliability (p = 0.78), height (p = 0.66), and the total VSS score  and picking up small objects (p = 0.004), with no between-group differences in the change score for the remaining subtasks , both hands (p = 0.97), and assembly ; activities of daily living, ADL (p = 0.51); work (p = 0.12); pain (p = 0.45); esthetics (p = 0.06); and satisfaction (p = 0.15). More reductions were found in the ESWT group than in the sham group for the pre- to post-treatment change in the VAS score ( 0.0015) . There wam group . HoweverWe evaluated the effectiveness of ESWT on the hypertrophic scars of hand burns that required STSG. Therapeutic effects were evaluated by the change in scar pain, thickness, esthetic characteristics, and hand function after a four week period of treatment. The ESWT treatment of hypertrophic scarring after a burn injury to the hands provided significant benefits in improving hand function, decreasing pain, and suppressing hypertrophic scar growth. 2; frequency, 4 Hz; and three sessions at one week intervals). The authors proposed that measured improvement in pain control with ESWT had resulted from a decrease in the number of unmyelinated nerve fibers; inhibition of nociceptors from repeated stimulation; regulation of neuroinflammatory molecules, such as substance P; and increased blood flow, facilitating tissue regeneration via an increase in endothelial nitric oxide synthase (eNOS). Joo et el. applied ESWT to burn scars with severe pruritus, using the same protocol as described by Cho et al., and found ESWT to be effective in reducing the severity of pruritus and improving ADLs [2; a frequency of 4 Hz; and a volume of 1000 pulses) suppressed EMT by inhibiting the EMT inducer [2) in suppressing hypertrophic scar formation through inhibition of α-SMA expression [2), reduced the need for surgery and decreased scar formation during the six month follow-up period [Cho et al.  have reping ADLs . Epitheling ADLs . Seo et ing ADLs  identifipression ,20. Meirp period . 2, frequency 4 Hz) increased the perfusion at remote sites via an increase of the NO and of vascular endothelial growth factor (VEGF) [In our study, we also identified a significant benefit of ESWT in improving vascularization of the scar tissue, measured using the VSS. Previous research has investigated the mechanisms underlying the mechanosensitive feedback between ESWT and stimulated cells . Nitric r (VEGF) . Davis er (VEGF) , althougr (VEGF) ,13. Over2, frequency 4 Hz) applied to a knee as a treatment for osteoarthritis reduced neuropeptide expression, which was associated with improved pain and gait function [ESWT is known to be effective for reducing pain and improving function on orthopedic injuries . Substanfunction . More sufunction . This evfunction ,31,32. 2; frequency, 6 Hz; two sessions per week for five weeks) was effective in significantly improving VSS scores, scarring pain, and the range of movement of the hand. These clinical benefits of ESWT were thought to be mediated by stimulation of dermal fibroblasts, neoangiogenesis, and improvement in the parallel organization of collagen fibers within the skin. Similarly, a beneficial effect of ESWT has been reported for the treatment of trigger finger complaints, resulting from enhanced repair and healing of the degenerated tendon [ESWT has been widely used in treatment of various tendinopathies in upper limbs. Steroids limit tenocyte function by reducing proteoglycan and collagen synthesis, which reduce mechanical strength. Unlike steroid therapy, ESWT studies have shown that ESWT affects tenocyte regeneration, leading to an improvement in muscle strength. The effectiveness of ESWT compared with that of local steroid injections showed that ESWT had favorable effects on resolution of pain and improvement of grip strength ,34. In od tendon . This study requires cautious interpretation of the data, for reasons of small sample size, a short follow-up period, and the absence of detailed measurement of range of motion in the affected hand. Future studies with a longer time frame and more detailed assessment are needed to confirm our findings. Continued basic research into the mechanisms underlying the clinical effects of ESWT are needed to determine optimal parameters for the clinical management of hypertrophic scars.In making the comparison of ESWT with a sham stimulation therapy for the treatment of hypertrophic scarring of the hand after a burn injury, we identified a clinically beneficial effect of ESWT in promoting hand function, improving scarring, and alleviating scar-related pain. This indicates the clinical usefulness of the intensity and frequency parameters of ESWT that we used in our study. It is important to point out that the optimal frequency and intensity of ESWT for the treatment of hypertrophic scars of the hands after a burn remain to be determined. Our findings, however, do provide experimenters with the option to use ESWT for its potential to improve the management and treatment of hand burn scars after STSG.


The presented results were obtained in a scientific trial, in which the addition of camelina, flax, and sunflower seeds to Ross 308 broiler diets was tested in terms of improvement of production efficiency, health status parameters, and quality of poultry meat. The results of the research showed that the tested full-fat seeds can be considered good dietary ingredients with a positive effect on the poultry production process and, consequently, on the dietary value of poultry meat.p < 0.05) in average body weight and a decrease (p < 0.05) in the ether extract content and energy digestibility of the diets. Moreover, the best carcass quality with a high proportion of muscles and low abdominal fat content (p < 0.05) was noted in broilers fed flax- and sunflower-enriched diets. The treatments with the oil seeds reduced the ether extract content and the calorific value of breast and drumstick muscles. The flax seeds contributed to an increase in the Fe content in drumstick muscles. Additionally, some blood parameters were influenced by the flax seed supplementation, e.g., the level of hemoglobin declined (p < 0.05) and the iron level in plasma increased (p < 0.05). It can be concluded that the camelina, flax, and sunflower seeds can be regarded as good dietary components with positive effects on the dietary value of poultry meat.The study determined the effect of the addition of 15% of camelina, flax, and sunflower seeds to iso-caloric and iso-nitrogenous diets for broiler chickens during 21–42 days of age on the nutrient digestibility, production traits, slaughter analysis parameters, hematological indices, blood mineral elements, and dietary value of breast and drumstick meat. Two hundred one-day-old broiler chickens were assigned to four groups (treatments) with five replicates . The experiment lasted 6 weeks. Broiler chickens receiving diets supplemented with camelina and flax seeds exhibited an increase ( The primary aim of animal production is to provide high nutritional and dietary value of meat, which mainly depends on its chemical composition. Currently, attention is paid not only to the content of essential nutrients but also to the content of minerals and biologically active substances ,2. The qThe major focus in the literature on the supplementation of birds’ diets with flax, camelina, or sunflower seeds is placed on reduction of the ratio of n-6/n-3 fatty acids in poultry products ,11,12. SOilseeds also influence the digestive tract and digestion processes in poultry. This is connected with the relatively large amounts of dietary fiber in oilseeds, a significant part of which (ca. 1/3) dissolves in water, forming highly viscous solutions. The high viscosity of digesta may limit the digestion and absorption of nutrients in young birds ,15,16. CGiven such diverse information on the potential nutritional application of camelina, flax, and sunflower seeds in poultry production, it seems advisable to conduct further research in this field. Moreover, there is little information in the literature on the effect of seeds administered in feed mixes to chickens on the content of macronutrients and micronutrients in their meat.Therefore, the aim of the study was to analyze the impact of the addition of raw full-fat camelina, flax, and sunflower seeds to diets for broiler chickens on the basic production parameters, nutrient digestibility, hematological profile, and the nutritional and dietary quality of meat and the basic nutrient and mineral profile.Camelina sativa L. Crantz) Luna cv., flax (Linum L.) Opal cv., and dehulled sunflower (Helianthus L.) Lech cv. were purchased in a specialist store  as a locally produced certified plant material originating from crop harvesting in 2017. The oilseeds were grown in areas located in southern and eastern Poland. The chemical composition of the seeds is shown in Full-fat unprocessed camelina  on a poultry farm . One-day-old broiler chickens Ross 308 (200 birds) were randomly assigned to 4 dietary treatments with 5 replicate cages per treatment . The body weight of the 1-day-old broiler chickens was 42.6 ± 0.1 g. The experiment was carried out for 6 weeks. The broiler chickens were reared in 1-mry house . Vaccinary house .The experimental feed diets were based on cereal meal middlings (wheat and corn) and post-extraction soybean meal . Three tFor each cage, the body weight (BW) of the broiler chickens and the average daily feed intake (ADFI) were recorded at 21, 35, and 42 days of life. The body weight gains (BWGs) and feed conversion ratio (FCR) were calculated in the grower and finisher periods. The mortality rates were recorded daily. The weight of dead broiler chickens was included to calculate the average weight gain, feed intake, and FCR.Feed digestibility was evaluated using the indicator method  . The anaOne female and one male broiler chicken with the body weight close to the average value were selected from each cage for dissection. Selected chickens were not given feed 10 h before slaughter, whereas constant access to water was ensured. The slaughter was carried out by decapitation. After the slaughter, a simplified dissection analysis was performed. Liver, gizzard, heart, breast, and drumstick muscles, and abdominal fat were collected. The tissues were weighed, packed in specially marked bags, and frozen at −25 °C until chemical analyses .The chickens selected for the slaughter were also assigned for blood sampling (two broiler chickens/cage). The blood sampling and hematological analyses of red blood cells (RBCs), packed cell volume (PCV), hemoglobin (HGB), mean cell volume (MCV), mean cell hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were described in a previous article . The conThe content of basic nutrients, dry matter Method 925.09), crude ash (Method 923.03), crude protein Method 920.87), ether extract (Method 920.39), and crude fiber (Method 962.09), in the oil seeds and diets was determined by AOAC .Tocopherols were chemically determined in the oilseeds by extracting 0.5 g of the sample with 5 mL hexane containing 20 mg/L DYN .The details of the method for determination of xanthophylls and total phenolic content in oilseeds were presented in an earlier publication by Kiczorowska et al. .The amino acid contents in the experimental diets were determined using an automatic amino acid analyzer  after previous acid hydrolysis with 6 M HCl (method 994.12) . CysteinThe contents of Ca, Mg, P, Cu, Fe, and Zn in the seeds as well as Ca, Mg, and P in the diets were measured (three replicates of each sample) using flame atomic absorption spectrophotometry (FAAS) . Calcium was determined at λ = 422.7 nm, magnesium at λ = 285.2 nm, copper at λ = 324.8 nm, iron at λ = 248.3 nm, and zinc at λ = 213.9 nm . Total PThe contents of moisture (Method 925.09), crude ash (Method 923.03), crude protein Method 920.87), and ether extract (Method 920.39) were determined in breast and drumstick muscles .87, and . The eneThe contents of Ca, Mg, P, Cu, Fe, and Zn in the chicken muscles were determined using flame atomic absorption spectrophotometry (FAAS) as described in All analyses were performed in triplicate and all data were expressed as means.p < 0.05). Statistica software  was used for the calculation of the mean values and the SEM. The cage was used as a statistical unit. The normality of data and homogeneity of variances were tested using the Shapiro–Wilk and Brown–Forsythe tests, respectively. Significant differences between the means were determined by the Tukey’s honestly significant difference (HSD) post hoc test:ij is the measured variable, μ is an overall mean, ai—the dietary inclusion of the full-fat oilseeds (treatment), and eij—the random error.The data were analyzed using one-way analysis of variance  were used to determine the direction and intensity of the relationships between the basic nutrients and minerals in the oilseeds  and broiler chicken muscles .p = 0.038), was achieved through the supplementation with the camelina and flax seeds. Another positive effect, i.e., an average 5% reduction (p = 0.042) of the feed intake (ADFI) compared with the control, was noted after administration of the camelina and sunflower seeds in the diets. An equally important achievement of the use of oilseeds was the decline (p = 0.026) in chicken falls throughout the grower and finisher periods in comparison with the control treatment. The addition of the oilseed blends (p < 0.05) also improved the slaughter analysis parameters. Bird carcasses from the full-fat oilseed treatments were characterized by higher breast muscle content (p = 0.037) and greater gizzard weight (p = 0.044) as well as a smaller proportion of abdominal fat (p = 0.028), compared with the control treatment. The analysis of both the grower and finisher periods (day 21–42) in the nutrition experiment showed that the basic production parameters of the broiler chickens fed with mixtures containing the tested oilseeds did not differ significantly. Only the feed conversion ratio (FCR) value in experimental groups supplemented with camelina and flax seed mixtures was significantly higher than in the control group (p = 0.035).The basic productivity parameters of the broiler chickens, i.e., body weight (BW), average daily feed intake (ADFI), body weight gains (BWG), and feed conversion ratio (FCR), observed in the first rearing period did not differ between the groups . The addp = 0.038) and finisher periods , compared to the control group. The lowest digestibility of fat, even by 14% compared to the control treatment, was detected in the CAM broiler chickens. All chickens from the full-fat seed treatments were also reported to have reduced gross energy digestibility (p = 0.033) in the grower period. The digestibility of the other nutrients in the feed did not differ significantly between the full-fat seed treatments and the control treatment.The present study also consisted of an analysis of the digestibility of basic nutrients . The 15%p = 0.024) and approximately 34% in drumstick muscles (p = 0.037), in comparison with the control (p = 0.042) calorific value in comparison with the muscles of chickens fed the standard diets. The largest decrease in the fat content and calorific value was recorded in the muscles of chickens fed with the addition of the flax and sunflower seeds. Additionally, the content of crude ash was lower (p = 0.038) in the breast muscles of the CAM, FLA, and SUN chickens than in the control. No significant differences were found in the content of the other nutrients in the poultry muscles.The addition of the oilseeds to the broiler chicken diet reduced the ether extract content on average by 21% in breast muscles ( control . The drup = 0.038) the content of Fe in drumstick muscle by approximately 11%, compared with the control group  between basic nutrients and some minerals in the oilseeds as well as the breast and drumstick muscles of chicken broilers supplemented with CAM, FLA, and SUN are presented in p < 0.05).There were mainly strong correlations between the contents of the basic nutrients and elements in the seeds and in the breast and drumstick muscles. High positive and negative correlations (r > 0.6) were observed mainly between the nutrient content in the chicken muscles and camelina seeds: Ca, Mg, P, Cu, Fe, Zn, and fat, in the chicken muscles and flax seeds: Ca, Mg, P, Cu, Fe, Zn, fat, and crude ash, and in the chicken muscles and sunflower seeds: Ca, Mg, P, Cu, Fe, Zn, and fat .In the experiment, selected hematological indices were determined to evaluate the health status of the birds . The CAMp < 0.001). The addition of the flax seeds to the diet increased the plasma iron concentration in the broiler chickens, compared with the control, CAM, and SUN treatments (The present study showed an influence of FLA on the iron content in the blood plasma of the broiler chickens (eatments .p = 0.048), but the differences between the other treatments were not statistically significant.There was a higher plasma level of magnesium in the FLA treatment than in CAM . Flax seeds contain water-soluble and insoluble NSP forms. In these seeds, over 46% of NSP are represented by the water-soluble fraction . As repoIt was found in the present study that the inclusion of oilseeds into broiler chicken feed mixtures reduced the fat content in their muscles (breast and drumstick). This may have been caused by the reduced digestibility of fat in the diet. The lower fat accumulation in the muscles was also observed by Rebolé et al.  in the mThere is no information in the literature about the impact of nutrition supplemented with full-fat seeds on the mineral composition in chicken muscles. The higher Fe concentrations detected in the muscles of the FLA broiler chickens can be associated with the high blood level of the element, which to some extent reflects its concentration in the organism. The level of iron in the body largely depends on the diet and gastrointestinal absorption . In the The present study also involved analysis of the relationships between basic nutrients and mineral elements in the oilseeds in mixtures for broilers and their breast and drumstick muscles. The values and trends of the correlation coefficients obtained for the components are probably associated with their physicochemical properties, antagonistic or synergistic interactions, bioavailability, as well as coexistence and co-involvement in metabolic and physiological processes with other ingredients.Hematological indices are useful in assessment of the potential toxicity of feed, especially in the case of feed components that can affect blood parameters and animal health. The values of the analyzed blood indicators corresponded to the reference values specified for this species ,50. SimiIn the present study, the reduction in the HgB level induced by the FLA treatment may have been associated with the content of cyanogenic glycosides  and enzymes  involved in the hydrolysis of cyanogenic glycosides and release of hydrocyanic acid . HydrogeBlood serum and plasma often serve as a biological matrix for assessment of the proper supply of elements and their transformations in the organism. Their content in the body is a result of a dynamic balance of the demand, supplied quantity, and availability ,57. The Brassicaceae plants [Oilseeds contain a substantial amount of minerals, in particular phosphorus, magnesium, iron, zinc, and calcium, which, however, are characterized by reduced bioavailability. These seeds also contain substances with anti-nutritional properties, which may exert a negative effect on the organism, e.g., by limitation of the absorption of nutrients or even toxic effects. The main anti-nutrients found in oilseeds are phytic acid, tannins, cyanogenic glycosides in flax seeds, as well as glucosinolates and sinapine mainly in seeds of e plants ,59. The e plants ,61. The e plants ,62, whicThe positive effect of the use of the 15% camelina, flax, and sunflower seed addition in the diets at 21–42 days of age improved the average body weight, average daily feed intake (in the finisher period), and some slaughter parameters in the broiler chicken. The inclusion of oilseeds into the mixture for broiler chickens, especially camelina and flax, had a positive effect on the dietary and nutritional value of chicken muscles. The negative effect of the flax seed diet was reflected in the weakened fat digestibility. An equally disturbing effect was the decrease in the hemoglobin blood content in chickens fed the flax diet. Based on the production results obtained so far, camelina, flax, and sunflower seeds seem to be good diet components as they exert positive effects on the dietary value of poultry meat. However, there is still a need for research to elucidate the mechanisms associated with the ability of oilseeds to potentiate the retention of elements and their impact on the health status of birds.


Penstemon is an emerging model for the study of continental adaptive radiation. We report here the first complete plastome sequence for this genus. The P. fruticosus  plastome is 152,704 bp in length with a quadripartite structure consisting of a large single-copy region  and a small single-copy region  that are separated by two inverted repeats . The plastome contained 24 tRNA genes, 8 rRNA genes, and 83 protein-coding genes for a total of 115 unique genes. Phylogenetic analysis of whole chloroplast sequences shows that the nearest relatives of P. fruticosus are the Plantago and Veronica genera in the Plantaginaceae family.The genus  Penstemon (Mitchell) is native to North America with a distribution that reaches from the Arctic Circle to the tropics of Central America. This genus is an emerging model for continental adaptive radiation with over 270 species that are adapted for specialized ecological niches of North America  Greene [Plantaginaceae]), is native to the United States Intermountain West, and is found within Penstemon’s most basal clade  have been deposited in the Stanley L. Welch Herbarium (BRY), Brigham Young University, Provo, UT, USA. DNA was extracted using a modified CTAB method . We identified 20 simple sequence repeat (SSR) loci of which 9, 2, and 9 were mono-SSR, tri-SSR, and tetra-SSR loci, respectively. A total of 22 forward and 32 palindrome repeats were identified; however, no reverse complement repeats were identified.The plastome of bush penstemon was 152,704 bp in length with a quadripartite structure, consisting of a large single-copy region  and a small single-copy region  that are separated by two inverted repeats , and an average CG content of 37.9% (GenBank accession number MG201976). The average sequence coverage was 9449P. fruticosus within the order Lamailes, we constructed a ML phylogeny with 1000 bootstrap replicates using plastome alignments of 12 Lamailes species, with Solanum lycopersicum as an outgroup (Penstemon genus is an outgroup to the sister clades formed by the Plantago, Veronica, and Veronicastrum genera of the Plantaginaceae family. The complete plastome of P. fruticosus provides genetic data critical for the study of evolution and systematics of Penstemon as a model for continental adaptive radiation.To determine the phylogenetic position of outgroup . Our phyoutgroup  and multoutgroup . The Pen


Sarcopenia is defined as an age-related loss of skeletal muscle and is associated with several health disorders. Causes of sarcopenia, which included physical inactivity, alcohol, dietary habits, and smoking, have been researched. The present study was undertaken to examine the association between reproductive span and sarcopenia in Korean women. Data obtained from 2008 to 2011 Korea National Health and Nutrition Examination Surveys (KNHANES) were analyzed. We defined sarcopenia based on the cut-off values of the Foundation for the National Institutes of Health (FNIH) sarcopenia project criteria: ASM/BMI < 0.512 for women. Reproductive span was defined as years from menarche to menopause, and we divided the 3970 study subjects into three groups by reproductive span tertile. Multivariate logistic regression analysis was used to determine adjusted ORs for the relation between reproductive span and sarcopenia. The prevalence of sarcopenia in the study was 17.7% (704 of 3970). Multiple logistic regression analysis was performed using weighted populations. After adjusting for covariates, reproductive span was found to be inversely associated with the risk of sarcopenia . Sarcopenia was first described by Irwin Rosenberg in 1989, and is characterized by age-related loss of skeletal muscle mass, strength, and function . SarcopeMenarche and menopause are two indicators of reproductive history, and associations between them and sarcopenic status have been well investigated ,7,8,9,10Although many studies have addressed relations between reproductive indicators and muscle in women, no study has previously investigated the relation between reproductive span and sarcopenia. Accordingly, in the present study, we aimed to identify the association between reproductive span and sarcopenia in Korean women using data obtained during the 2008–2011 Korean National Health and Nutrition Examination Surveys (KNHANES).KNHANES surveys have been conducted annually using a cross-sectional, rolling sample and stratified cluster design by the Division of Chronic Disease Surveillance of Korea Center for Disease Control and Prevention since 1998. The following exclusion criteria were applied: subjects with incomplete answers about social and medical histories; incomplete answers about reproductive history ; a history of cervical cancer or total hysterectomy, and lack of blood pressure (BP), weight, height, waist circumference (WC), or laboratory marker data. From all survey participants in the 2008–2011 KNHANES surveys, 3970 postmenopausal women aged above 40 years were recruited for this study. All participants provided written informed consent and data were recorded anonymously.We used the International Physical Activity Questionnaire short form (IPAQ-SF) to estimate the overall physical activity (PA) amount of a participant by the duration (in hours) and number of days (in a week) of engagement in three types of activities  in the past 7 days ,14. We mWe measured the amount of smoking by unit, pack-years, and the amount of alcohol based on grams per week. Total energy  consumptions were calculated using a food composition table produced and validated by Rural Development Administration .2 (m2). BP was measured by well-trained observers using a mercury sphygmomanometer  after subjects had rested for 5 min in a seated position. Final BP values were calculated by averaging the second and third measurements. Height was measured (in centimeters) using a wall-mounted measuring scale, and weight was measured (in kilograms) using a calibrated electronic scale with subjects wearing light clothing without shoes. Body mass index (BMI) was calculated using weight (kg)/heightHypertension was defined according to JNC-8 as systolic BP of >140 mmHg or diastolic BP of >90 mmHg or treatment with antihypertensive medication . Diabete2 < 5.4 [Dual-energy X-ray absorptiometry  was used to measure body compositions. Several definitions of sarcopenia have been proposed. We used BMI-adjusted appendicular skeletal muscle mass (ASM), which was calculated by dividing ASM (defined as summed muscle mass of arms and legs) by BMI. We defined sarcopenia based on the cut-off values of the Foundation for the National Institutes of Health (FNIH) sarcopenia project criteria: ASM/BMI < 0.512 for women . Further2 < 5.4 .We excluded subjects with menarche age <10 years and menopause age >60 years to reduce effects of outliers. Reproductive span was calculated from age at menarche to age at menopause for each of the study subjects, which were divided into three groups based on reproductive span tertiles.Statistical analysis was performed using SPSS ver. 20.0 . To calculate the total population represented by the 3970 study subjects, we employed the stratification variables and sampling weights. The aim of the sampling weight usage was to ensure that calculated estimates or results are truly representative of the Korean population . Samplinp-values of <0.05 were considered statistically significant.Data distributions were found to be normal, which allowed the use of parametric tests. Continuous variables such as age, BP, and laboratory markers, were analyzed by one-way ANOVA followed by Tukey’s multiple comparison. For categorical variables, the chi-square test was used to compare frequencies between groups followed by the multiple comparison of Benjamini–Hochberg. Binary logistic regression analysis was performed to examine odds ratios (ORs) of sarcopenia covariates. Multivariate logistic regression analysis was used to determine the adjusted ORs of reproductive span for sarcopenia. 2 were greatest in the longest reproductive span group (tertile 3). Furthermore, the prevalence of sarcopenia was highest in the tertile 1 group. Subjects in tertile 3 had the following characteristics when compared to those in tertile 1 or 2: young age, high ratio of hypertension and dyslipidemia medication, high BMI, high diastolic BP, low white blood cell (WBC) count, high total energy and protein intake.A total of 3970 women, who were estimated as a population of approximately 16 million people after weighting, were included in this study. The general characteristics of study subjects classified by reproduction span tertile are summarized in Binary and multiple logistic regression analyses were performed using the weighted population. The weighting values that were applied in this study were calculated by KNHANES. Univariate logistic regression showed that the risk of sarcopenia as defined by FNIH  increaseWe selected covariates significantly associated with the risk of sarcopenia by binary logistic regression analysis . Age-adjp < 0.001) and ASM/BMI  and ASM/BMI  were strengthened  than those aged 46 to 70 at menopause . Tom et Menopause is characterized by many hormonal changes, especially estrogen changes . When men = 20,547), 12.2 for the 1970s (n = 6568), and 12.2 for the 1980s (n = 281), respectively, and the overall average age at menarche was 12.6 years [The average ages at menarche were 16.74, 16.31, 16.18, 15.47, 15.13, and 14.39 for Korean women born in 1940–1944, 1945–1949, 1950–1954, 1955–1959, 1960–1964, and 1965–1969, respectively . Accordi.6 years . The ave.6 years . Our sub.6 years , and somIn the present study, an older age at menarche was associated with the risk of sarcopenia . In a crWith aging in menopausal women, it was reported that atrophy and denervation of type II fibers occurred ,28. WidrMoreover, reproductive span could be considered to reflect cumulative exposure to sex hormones like estrogen, which are known to have systemic anti-inflammatory effects . Direct To the best our knowledge, this study is the first large-scale study analyzing the association between reproductive span and sarcopenia in Korea. Furthermore, the weighting exercise indicates that it well represents the Korean population, and we adjusted for several confounders, such as age, socioeconomic status, smoking, physical activity, and medical history. Nevertheless, the study has some limitations. First, because of its cross-sectional nature, the causal relationship between reproductive span and sarcopenia could not be accessed. Second, the 2008–2011 KNHANES only measured muscle mass using a DXA, but did not measure strength and performance. Future study is needed to analyze the association of reproductive indices with sarcopenia diagnosed by a broader definition. Third, the study is subject to recall bias because ages at menarche and menopause were collected using self-reported questionnaires, although previous studies have shown the validity and reproducibility of self-reported age at menopause and menarche are fairly good ,41. FourCollectively, we conclude that a longer reproductive span is significantly associated with a lower risk of sarcopenia. We believe that better understanding of the association between reproductive history and muscle mass is likely to lead to better management of sarcopenia and early menopause in women, and suggest prospective studies be undertaken to determine the effects of reproductive span on sarcopenia and to elucidate the physiologic mechanisms responsible. Furthermore, in the viewpoint of public health, our study proposed women’s reproductive indices such as ages at menarche and menopause and their integrative index (reproductive span) that are easily obtained from a questionnaire as the early screening markers for sarcopenia.


Introduction: Spermatic cord sarcomas represent a rare genitourinary malignancy with a challenging diagnostic and therapeutic pathway. Different histotypes have been described and prognostic factors remain poorly defined due to the paucity of data presented in literature.Methods: Retrospective chart review of 22 adult patients treated for spermatic cord sarcoma in a single institution in the last 20 years was performed. Clinicopathological characteristics of the tumors were collected with primary and subsequent treatment. Survival analysis was performed in order to identify prognostic factors of disease-specific survival.Results: The median age at diagnosis was 68 years (58–78), the most common histotype was liposarcoma (14/22), and most patients (63.6%) were found to have positive surgical margins after surgery. The 5-year cancer specific survival was 91.3%. Grading (p = 0.480), histotype (p = 0.327), and type of intervention (p = 0.732) were not associated with survival. All patients dead of disease had positive surgical margins (p = 0.172).Conclusion: We report a good prognosis at 5 years. Wide radical resection remains the first and probably the most important step; thus, according also to literature, negative surgical margins should be aimed. Spermatic cord masses represent a challenge in clinical practice, due to their rarity and absence of well-defined, preoperative, diagnostic criteria.Genitourinary (GU) sarcomas account for <5% of all soft-tissue sarcomas and <2% of malignant urologic tumors . Among GA bi-modal age presentation for paratesticular sarcomas has been reported for ages 16–20 and >60. Moreover, in the adolescent and young adult population, rhabdomyosarcoma shows the highest incidence, while in the older aged group, liposarcoma, and leiomyosarcoma are the most common subtypes.The typical presentation is a unilateral inguinal swelling or scrotal mass, which may or may not be painful and is occasionally accompanied by a hydrocele. Occasionally, an initial sign of disease may be acute scrotum due to necrosis or intra-tumoral bleeding , 6. Due In the presence of a scrotal mass, ultrasonography is the first-line imaging test to characterize the location and, thus, to differentiate intratesticular from paratesticular masses but might fail in distinguishing herniated fat from a lipomatous mass. CT and MRI are useful to evaluate the extent of the disease beyond the inguinal ring and to investigate dimensions, topography, and anatomical relationships of the mass .The final diagnosis is achieved by histologic examination of the mass after surgery or after percutaneous biopsy.Given the rarity of these tumors, there is little clinical evidence available on which to base multimodal effective treatment strategies.Radical orchiectomy and wide local resection of surrounding soft tissues has become the accepted standard of management and may be definitive treatment when achieved , 9. If tSeveral studies have examined the role of adjuvant radiotherapy in STSs of the extremity and have concluded that while it may help in reducing local recurrence, it does not impact overall survival or disease-specific survival . The rolWe already presented as a case series our initial experience with spermatic cord sarcoma . In thisRetrospective analysis of clinico-pathological characteristics and surgical outcomes for 22 adult male patients (>18 years of age at the time of diagnosis) treated for primary or recurrent spermatic cord sarcoma from 1996 to 2018 in Padua was performed. All cases were reviewed by a pathologist, and the diagnoses were confirmed and updated to the latest edition of the World Health Organization classification of soft tissue and bone tumors.Data abstracted included age, side of the tumor, date of surgery, histopathologic subtype, other tumor characteristics (grade and stage), site and date of recurrence, additional treatment, and follow-up time. Grading was evaluated according to the Federation Francaise des Centers de Lutte Contre Cancer (FNCLCC) system and staging was assigned according to the American Joint Committee on Cancer (AJCC) TNM staging system. Resections were classified according to the pathological specimen as R0 or R1 depending on the presence of tumor within 1 mm from the inked margin.The study endpoint was cancer-specific survival, and causes of death unrelated to sarcoma were censored.p < 0.05 was considered statistically significant. All analyses were performed using R Statistical Software .Distributions were summarized using frequencies, medians, and interquartile range. Cancer-specific survival rates were estimated using the Kaplan–Meier method and with log-rank test. Given the low number of events, no multivariate analysis was performed. Any Ethics approval was not required because, for the study, we used existing data collections and records that contain only unidentifiable human data.Furthermore, for all retrospective studies involving the only use of anonymized clinical data, the Italian legislation does not provide for the approval of an ethics committee.A cohort of 22 patients with complete follow-up data was analyzed and summarized in Three patients had adjuvant chemotherapy, one patient had adjuvant radiation therapy, and four patients had second surgery. Five patients were treated at our institution after a recurrence of the primary disease; thus, we were unable to retrieve complete staging information for one of these patients.The most common histotype was liposarcoma; in particular, 10 patients had well-differentiated liposarcoma and 5 patients had dedifferentiated liposarcoma. Leiomyosarcoma was found in three cases and four patients had other histotypes, namely, mixofibrosarcoma, epitheliod sarcoma, rhabdomyosarcoma, and one undifferentiated pleomorphic sarcoma. Most patients (63.6%) were found to have positive surgical margins after surgery and 9 (40.9%) presented with G3 disease.Seven patients overall received perioperative therapy. Three patients performed preop/therapy with neoadjuvant intent: one patient (myxofibrosarcoma G2 stage IIb) performed radiotherapy, and two patients  received chemotherapy. Four patients received postop/therapy with adjuvant intent: two did CT  and two did RT .In the context of multidisciplinary treatment, radiotherapy has the role of providing local control of the disease. Preop/radiotherapy is indicated in patients in whom conservative surgery cannot be performed at the time of diagnosis due to the size of the disease, the site of onset, or its close proximity to important structures such as bones, vessels, or nerves. Postop/radiotherapy is indicated in the most aggressive tumor forms in order to reduce the risk of a local recurrence and when we have R1–R2 margins. In the case of localized disease, however, it can be used in the pre-operative phase to reduce the size of the primary tumor or in the post-operative phase in the presence of very aggressive forms, to reduce the risk of local recurrence and/or spread of the disease at a distance .Five patients overall had recurrence; four patients revealed distant metastases .According to the American Joint Committee on Cancer (AJCC) TNM staging system, one patient with undifferentiated pleomorphic sarcoma presented with metastatic disease (Stage IV) and died of disease after 3 months from the diagnosis.The median follow-up of the whole cohort was 66.6 months (18.4–109). Four patients were dead of disease at the end of follow-up. The 5-year CSS was 91.3% .CSS survival was analyzed in relationship with the type of intervention, margin status, grading, histotype, and adjuvant therapy and illustrated in p = 0.480), histotype (p = 0.327), type of intervention (p = 0.732), and adjuvant therapy (p = 0.2075) were not associated with CSS. However, it is noteworthy that all patients dead of disease had positive surgical margins (p = 0.172), while none of those with negative margins died of disease.Grading  in addition to increasing the risk of distant metastases and disease-related death.Additionally, Stojadinovic et al.  reportedWang et al.  performeOur study represents one of the largest and most homogeneous cohort studies of patients with spermatic cord sarcomas, since it is the experience of a single center dedicated multidisciplinary team. Our findings, although not significant, are interesting, and somewhat consistent with previous studies.First of all, we present a cohort with one of the longest median follow-up time reported in literature, exceeding 5 years. Within this follow-up time, we found a 5-year CSS 91.3%, providing evidence of good prognosis for this disease, when adequately managed, even in case of a potential incomplete first resection.p = 0.172). Every patient who died for disease had positive surgical margins, while none of those with negative margins died of disease. Unfortunately, given the low number of events, the test had not enough statistical power to provide a significant p-value. We were unable to demonstrate a relationship between the type of surgical intervention performed and survival; this corroborated the idea that surgical resection should aim for excision of the tumor and surrounding tissues until negative margins are obtained.We found a non-significant trend of relationship between positive surgical margins and disease-specific mortality (p = 0.02) and overall survival (p = 0.081).The need for a wide resection with negative surgical margins is consistent with findings of Goldberg et al.  where heSimilarly, median survival for the patient with metastasis at diagnosis was very poor, emphasizing the need for prompt and accurate diagnosis and treatment. Our experience is consistent with the reported epidemiology, where liposarcoma was the most common histotype (15/23), while rhabdomyosarcoma was present only in one 18-year-old patient.Our study included adjuvant therapies; however, the diversity of radiation and chemotherapy regimens along with the small sample size prohibited any analysis regarding these modalities.p = 0.025) and disease-specific survival, especially in the liposarcoma subgroup (p = 0.043).In the multicenter study by Radaelli et al.  the qualThere are several limitations in our study; most of them are explained by its retrospective design and by the small data set that did not allow for multivariate analysis. Moreover, adjuvant treatments were individualized, and their potential therapeutic effect could not be discriminated from a selection bias related to those with unfavorable pathologic features. Unfortunately, these are limitations shared with the other mentioned studies, and the rarity of these tumors still makes them the only evidence available. Likely, only a collaborative international effort to gather together the clinico-pathological data on these rare tumors might at least in part overcome these limitations.Despite its limitations, this remains one of the largest single-center studies to date and with a considerably long follow-up, related specifically to spermatic cord sarcomas. This specific disease, given its location and atypical presentation, should be distinguished from other GU sarcomas.In conclusion, spermatic cord sarcomas are uncommon tumors with a challenging diagnostic and therapeutic pathway. Our experience showed a good prognosis at 5 years, with most of the localized tumors that can be cured by surgical resection. According to our experience and literature, margin status remains of outmost importance in determining the prognosis; thus, effort should be put in obtaining complete excision of the tumor. We must underline that, most of the time, the first physician who encounters these patients is the urologist, who is usually not familiar with sarcomas. In this setting, with the conclusions of this manuscript, we hope to raise the suspicion of this disease in case of spermatic cord masses, to emphasize the importance of radical intervention, and to provide an overview of the prognosis. It is undoubtable that treatments and prognosis at the individual level should be based on a multidisciplinary discussion. Further studies are required to elucidate optimal adjuvant therapy and appropriate patient selection for it.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The ethical review of human research was not required because, for the study, we used existing data collections and records that contain only unidentifiable human data.MI and SM designed clinical studies. CZ, NL, AG, RC, and PD analyzed the data. MI, SM, and MR wrote the manuscript. TP-G, FZ, and CR performed surgery. MI, AD, and SM reviewed, revised, and approved the final paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objectives: The current study aimed to investigate whether childhood-onset craniopharyngioma patients are impaired in social-cognitive skills, and whether individual differences in task performance are modulated by the neurohormone oxytocin.Study design: We tested 31 adamantinomatous craniopharyngioma patients with and without hypothalamic lesions and 35 age- and gender-matched healthy controls. To test for between-group differences in social-cognitive skills, we experimentally assessed participants' abilities to interpret social signs or dispositions and to understand others' thoughts, feelings, and intentions. Associations between fasting oxytocin saliva concentrations and task performance were analyzed across the whole group of participants.Results: Compared to controls, patients with hypothalamic lesions were significantly less able to identify the correct emotional content of vocal expressions and to understand others' mental states. Judgements of trustworthiness were not different between patients and controls. There were no correlations between the primary measures of task performance and fasting oxytocin saliva concentrations.Conclusions: This is the first study to show that craniopharyngioma patients with hypothalamic lesions are impaired in some aspects of social cognition, which are of high relevance for everyday social interactions. These deficits suggest a disruption of the normal functionality of hypothalamic-fronto-limbic networks and/or additional areas of the social brain, which are at particular risk by hypothalamic location of the tumor and its treatment. The term social cognition refers to psychological processes, which underlie social behavior, enabling individuals to successfully interact with conspecifics and to navigate in social environments. It includes more basic operations, such as recognizing dispositions and emotions of others , and high-level representations, enabling to read others' mental states, such as feelings, beliefs, intentions, and desires . Social Craniopharyngiomas are rare intracranial tumors with an incidence of 0.9-2 cases per million persons per year. 30–50% of the cases are diagnosed during childhood and adolescence . Due to In CP in general, impairments in social-cognitive skills may result from brain changes due to the tumor or its treatment. Even with recent microsurgical methods, frontal, temporal, and limbic areas of the social brain are at risk by commonly employed transcranial surgical approaches via frontal or fronto-temporal routes. Tumor growth may also in some cases compromise the integrity of these brain regions. However, CP with HL are at further risk from adverse changes in hypothalamic-fronto-limbic networks due to the tumor or its treatment. The hypothalamus is known to be essential for basic social-behavioral patterns mediating the satisfaction of drives and urges like mating, sexual behavior, and defensive/attack behavior, which are of vital importance for the survival of the individual and its species . It exerIn addition, tumor- or treatment-related lesions of hypothalamic-limbic networks in CP may induce changes in the production, release, and central receptor binding of the neurohormone oxytocin. Oxytocin is a hypothalamic neuropeptide, which is mainly synthesized in the supraoptic and paraventricular nuclei of the hypothalamus. For peripheral circulation, it is released into the bloodstream via the posterior pituitary gland, and acts as a hormone to affect physical functions. For central circulation, neurons in the paraventricular nuclei project to various limbic structures such as the amygdala, hippocampus, and nucleus accumbens, which have a high density of oxytocin receptors . The oxyCompared to patients without HL, CP with HL have a higher risk for additional brain lesions which compromise the social brain and/or the central circulation of oxytocin. Hence, we hypothesized that CP with HL are impaired in social cognitive tasks when compared to CP without HL or to healthy controls. The current study used three experimental tasks to test participants' ability to interpret social signs and to understand others' thoughts, feelings, and intentions. In addition, we hypothesized that social-cognitive task performance is positively correlated with oxytocin saliva concentrations (OSC) across the whole group of participants.Thirty-one patients and 35 healthy controls participated in the current study. Inclusion criteria for all participants were visual abilities not interfering with task performance and a minimum age of 7 years for the Trustworthiness of Faces task, and 12 years for the two remaining tasks. Additional inclusion criteria for healthy controls were absence of psychiatric or neurological disorders, no substance abuse or use of psychoactive drugs, and a maximum age of 40 years to match the age range of the CP. For CP, a reference-confirmed diagnosis of childhood-onset craniopharyngioma was an additional inclusion criterion. Note that one patient prematurely aborted the experiment and another patient was excluded from final data analyses due to a histological diagnosis of xanthogranuloma, which we learned later. One healthy control was excluded due to stimulant medication use not known before data acquisition, leaving 29 CP and 34 healthy controls for analyses. The study was conducted during an annual meeting of the German Craniopharyngioma Support Group, where all patients and healthy controls willing to participate and fulfilling inclusion criteria, were offered to join the experiments. It was part of a larger study that also investigated CP and healthy controls for (i) OSC before and after a standardized breakfast , and ii. As onlyIn patients, the histological diagnosis of craniopharyngioma was confirmed by reference assessment in all cases. Tumor size was calculated using the formula “1/2 (A x B),” where A, B and C are the maximum dimensions in the standard planes: axial  and coronal . Tumor- or treatment-related HL were assessed based on a previously published grading system  by usingTable 2.The Identification of Emotional Expressions in Voices was tested with verbal stimuli from the Geneva Multimodal Emotion Portrayals (GEMEP) corpus . The subhttp://tlab.princeton.edu/databases/) (Table 3).The ability to assess the trustworthiness of faces was tested with a validated dataset of computer-generated faces  . The databases/) . In everTable 4.To assess cognitive empathy, we used the MASC, a video-based test for the assessment of social-cognitive competencies, which can be used with children ≥ 12 years . The tesTo assess if symptoms of depression or anxiety, which are generally more prevalent in CP compared to controls , modulatFor the primary measures of all experimental tasks, we assessed whether radiation therapy and age at diagnosis were associated with task performance. For the two tasks lasting longer than 15 min , we tested in addition whether patients' performance decreased over time to a stronger extent than that of controls.n = 10 in duplicates and triplicates) were 1.05% at 7.2 pg/ml, 1.94% at 20 pg/ml, and 1.58% at 200 pg/ml. Detection limit (± 2 SD from zero) was typically 0.5 pg/ml and always under 1 pg/ml. We correlated fasting OSC scores with each of the primary task performance measures to analyze associations between OSC and task performance. We also correlated fasting OSC scores with state anxiety and depression scores, respectively, to reproduce the well-known negative associations between these variables . Using The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committe of the University of Oldenburg, Oldenburg, Germany. Written informed consent to participate in this study was provided by the participants or the participants' legal guardian/next of kin.JÖ and CT conceptualized and designed the study. HM and SB coordinated and supervised patient recruitment. JÖ and AM supervised data collection. HM and SB analyzed and interpreted the clinical data. JÖ and AM carried out final data analyses. JÖ drafted the initial manuscript. CT critically reviewed and revised the initial manuscript. All authors approved the final manuscript as submitted.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.


Leukemia is one of the most common cancers. We conducted this study to comprehensively analyze the temporal trends of leukemia mortality during 2003–2017 and project the trends until 2030. We extracted national-level data on annual leukemia mortality from China Health Statistics Yearbooks (2003–2017). We applied the Joinpoint regression model to assess leukemia mortality trends in urban and rural China by sex during 2003–2017. We also produced sex-specific leukemia mortality using the adjusted Global Burden Disease (GBD) 2016 projection model. In urban areas, age-standardized leukemia mortality decreased significantly among females during 2003–2017 . In rural areas, significant decreases of age-standardized leukemia mortality were both found among males  and females  from 2008 to 2017. Rural-urban and sex disparities of leukemia mortality will continue to exist until the year 2030. According to projection, the leukemia mortality rates of males and rural populations are higher than that of females and urban populations. In 2030, leukemia mortality is projected to decrease to 3.03/100,000 and 3.33/100,000 among the males in urban and rural areas, respectively. In females, leukemia mortality will decrease to 1.87/100,000 and 2.26/100,000 among urban and rural areas, respectively. Our study suggests that more precautionary measures to reduce leukemia mortality are need, and more attention should be paid to rural residents and males in primary prevention of leukemia in China. Leukemia, also known as leukemia, is a group of blood cancers that start in blood-forming tissues and result in large numbers of abnormal blood cells in the bloodstream. The main types of leukemia include acute myeloid leukemia, acute lymphoblastic leukemia, chronic lymphocytic leukemia, chronic myelogenous leukemia, and hairy cell leukemia , 2. LeukIn the socioeconomic context of economic growth and urbanization, China has long been characterized by large rural-urban disparities in health care. Leukemia is closely related to ionizing radiation, benzene, formaldehyde, pesticides and infectious agents , and rurLiterature analyzing the mortality trends of leukemia in China is scarce. Although previous studies have reported leukemia mortality trends in China, they either covered a small proportion of the Chinese population in some certain cities such as Tianjin  and KunsWe extracted age-specific crude mortality rates of leukemia by year from China Health Statistics Yearbooks (2003–2017), which cover disease-specific mortality stratified by age and sex in urban and rural populations. The age-standardized mortality rates were calculated by way of the world standard population, and age-specific rates were calculated for age groups of 0–14, 15–34, 35–54, 55–74, and ≥75-years, respectively. According to the China Health Statistics Yearbooks, the urban areas include municipalities under the direct administration of central government and prefecture-level cities. The rural areas include counties and county-level cities, and township health centers and village clinics are included as well. China Health Statistics Yearbooks are annual informative publications that reflect the development of health care and residents' health status in China. The data are collected by the Center for Health Information and Statistics (CHIS) of China through national routine death reporting system and have been recognized as representative of common cancers in China , 14. Thehttps://surveillance.cancer.gov/joinpoint/) was downloaded from the website of the US National Cancer Institute. The software takes trend data  and fits the simplest joinpoint model that the data allow. The user supplies the minimum and maximum number of joinpoints. The program starts with the minimum number of joinpoint  and tests whether more joinpoints are statistically significant and must be added to the model (up to two points). This enables the user to test that an apparent change in trend is statistically significant. The tests of significance use a Monte Carlo Permutation method. The models may incorporate estimated variation for each point or use a Poisson model of variation. In addition, the models may also be linear on the log of the response . The software also allows viewing one graph for each joinpoint model, from the model with the minimum number of joinpoints to the model with maximum number of joinpoints and the user could choose to present the software recommended model  and the average annual percent changes (AAPCs) in leukemia mortality to describe the temporal trends. Joinpoint Regression Program 4.8.0.1 or natural-log space (for other data) and calculate the annual rate of change. Afterwards, a time-based weight matrix is established to add more weight to rate of change in recent years. The weight of rate of change in year t is:T is the last year with available data. The parameter ω was determined with a validity test: we selected the ω that used the first half of available data to predict the second half most accurately.Where Sex and rural-urban disparities will still exist in leukemia mortality until the year 2030. Based on the projections of the leukemia mortality, it is estimated that among the males and females, leukemia mortality will decrease in both urban and rural areas . In 2030This study is an updated systematic analysis and projection of nationwide leukemia mortality rates in urban and rural China by using the latest representative data. From 2008 to 2017, leukemia mortality decreased among the males and females in urban and rural areas. In rural areas, leukemia mortality significantly decreased by 1.7 and 1.6% among the males and females, respectively, from 2008 to 2017. In urban areas, leukemia mortality significantly decreased by 0.9% in the females during 2003–2017. Rural-urban disparities and sex disparities were substantial for leukemia mortality, which will still exist until 2030. In 2030, leukemia mortality is projected to drop to 3.03/100,000 in urban areas and 3.33/100,000 in rural areas among the males. Among the females, leukemia mortality will decrease to 1.87/100,000 and 2.26/100,000 among urban and rural areas in 2030, respectively.p = 0.026). Besides, significant drops in the mortality of adult patients diagnosed with myeloid leukemia were observed from 1994 to 2001 with the APC of −21.22% and from 1994 to 2003 with the APC of −12.86% for males and females, respectively, in southeastern Brazil  can be used for the early diagnosis of leukemia and the judgment of the severity of leukemia  can be found below: HX: conceptualization, funding acquisition, project administration, writing—review, and editing. ZC and YZ: data curation and visualization. BL and HT: formal analysis, investigation, methodology, resources, software, validation, and writing—original draft. YZ and HX: supervision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sleepiness decreases alertness and results in decrements in performance. This is especially problematic in the healthcare field due to restricted sleep from shift-work. Sleepiness increases medical errors, but it also affects emotions and interpersonal interactions. Empathy in physicians is a desirable trait which is associated with increased patient recovery rates and patient satisfaction, and decreased use of pain medication. Shift-work may alter empathy in physicians and affect patient outcomes, but the effects of sleepiness on empathy are unknown. Empathy, which is related to burnout, declines during medical school, while incidence of burnout increases. This study assessed the effect of sleepiness from time of day (TOD) and 12 h shifts on empathy and burnout in medical students. Participants were tested on sleepiness and empathy prior to and immediately following a 12 h Emergency Medical Technician shift. Burnout was assessed following each shift to determine if it was affected by sleepiness, empathy, and shift. TOD affected empathy, with empathy highest in the evening. Sleepiness from working 12 h shifts resulted in decreased empathy and increased burnout, with females showing higher rates on the exhaustion component of burnout. This research demonstrates that TOD affects empathy, and sleepiness decreases empathy and increases burnout in medical students. Fatigue due to sleepiness is common in modern society, due in large part to working rotating and night shifts in our 24/7 society. Fatigue, due to sleep deprivation, has been shown to be one of the main factors related to many types of accidents, including medical errors . FatigueSleepiness has a detrimental effect on performance, including reducing reaction times, decreasing vigilance, and increasing cognitive and perceptual distortions . The cogWhile sleepiness-related errors are problematic in a variety of professions, they are especially concerning in healthcare. Numerous studies demonstrate that cognitive performance suffers in healthcare professionals who are sleep deprived, including decreases in memory, vigilance, and spatial abilities . The cliMedical students have limited access to clinical settings, but sleepiness may affect their performance, too. In an attempt to adjust to their workload and schedule, medical students often reduce their sleep during medical school, and almost 60% of medical students have poor sleep quality . This poEmpathy is the experience of “feeling” what another is feeling, essentially bridging the gap between the experience of self and the experience of others . EmpathyPhysician engagement and empathy is considered necessary for mutual physician-patient satisfaction ,18 and tWhile sleepiness can affect cognition and performance, there are numerous studies to demonstrate that it can also affect our perception and emotional regulation. Sleep loss and poor sleep quality adversely affect mood, leading to increased frustration, a tendency to blame others for problems, and anger rumination with a lower indication for forgiveness ,22. SleeSleepiness has also been shown to be associated with the experience of burnout, where empathy may be protective against the experience of burnout . BurnoutBurnout has three main components: a state of emotional exhaustion, depersonalization or cynicism and lower personal accomplishment . PhysiciWhile sleep loss has been shown to affect some aspects of empathy ,37,38, GThirty-three first-year medical students  participated in this study, but three were excluded due to incomplete data, resulting in 14 male and 16 female final participants. Nineteen of the participants worked day shifts, and 11 worked night shifts. Ages of the students ranged from 22 to 38 years, with a mean age of 24.76 (standard deviation 3.35).Descriptive statistics for the variables of sleepiness , empathy , and burnout  by time of day, shift and gender can be found in F = 6.71, p < 0.05. The 12 h shift itself did not have an effect on empathy, separate from time of day and sleepiness. There was no significant effect of shift on burnout.A 2 (Shift) × 2 (Time of Day) × 2 (Gender) mixed multivariate analysis of variance assessed the effects of shift (day/night), time of day of testing (am/pm) and gender  on sleepiness, empathy, and burnout. Shift and time of day were tested within-subjects, and gender was a between-subjects analysis. All requirements for Analysis of Variance were met. As expected, sleepiness (as reported by the SSS) was higher after completing the 12 h night shift than after the 12 h day shift, F = 7.497, p < 0.01, indicating an interaction between time of day and shift. Time of day did not have a significant effect on burnout.Time of day was grouped as AM (between the hours of 0500 and 0900) and PM (between the hours of 1700 and 2100). These times corresponded to the beginning and ending of the 12 h shifts, which was when data collection occurred. Time of day affected empathy levels, with the PM time showing higher levels of empathy, but only prior to the 12 h shift  = 7.71, p < 0.01  = 3.87, p < 0.05. However, males were more fatigued after completing a shift, regardless of time of shift, than females, F = 4.69, p < 0.05. There was no significant difference in empathy levels between males and females.Gender was classified according to participant choice as either male or female. Gender had a significant effect on burnout, specifically on the personal exhaustion category of burnout. Females had significantly higher levels of personal exhaustion than males, refer to . In addir(30) = 0.444, p < 0.01. The sleepier the person, the more likely they were to report a feeling of depersonalization, but only after completion of the shift. Burnout and empathy were also related. The personal accomplishment subset of the MBI was directly related to pre-TEQ empathy scores. The higher the sense of personal accomplishment, the higher the empathy score prior to the shift, r(30) = 0.387, p < 0.05 (refer to r(30) = −0.480, p < 0.01 , time of day , and gender  on sleepiness, empathy, and burnout. As predicted, working a 12 h night shift resulted in enhanced sleepiness as compared to a 12 h day shift. This is not surprising, given that the medical students typically attend classes and/or study during the day. What was new and notable was that the sleepiness associated with the shift resulted in differences in empathy. The sleepier the participant after working the 12 h shift, the lower their emotional empathy score. This represents the first known work to demonstrate that sleepiness due to shift-work impacts emotional empathy levels.In addition, empathy scores were different depending upon time of day in both within and between subject analyses, with PM time of day showing higher levels of empathy. However, empathy levels were affected by time of day only prior to working a 12 h shift. Once the shift was worked, empathy levels were no longer significantly affected by time of day. This demonstrates that working a 12 h shift, in addition to sleepiness, results in a decrease in empathy.While time of day was only assessed at two time points, which is not ideal, it demonstrated two distinctly different levels of empathy in medical students. Future research should focus on time of day and look to see if empathy is at all related to biological rhythms fluctuating with circadian rhythmicity. Kleitman (1938) demonstrated a systematic link between cognitive performance and core body temperature over 75 years ago . It is pMany studies show that women tend to be better at recognizing facial and body expressions of emotion, as well as showing higher cognitive and affective empathy . While tEmpathy and burnout were related, where people who scored higher on personal accomplishment had higher empathy scores, and people who had higher exhaustion levels had lower empathy scores. Both of these subsets of the burnout inventory were affected with shift-work, such that shift-work lowered personal accomplishment and elevated exhaustion levels, both of which lowered empathy levels.This study was limited by the small sample size (34) and incomplete data from some of the subjects. Subjective sleepiness, as assessed by the Stanford Sleepiness Scale, was used to determine sleepiness/alertness in medical students, but no physiological factors were assessed. Since self-report is notoriously unreliable, future research should include objective measures of sleepiness in addition to self-report.This study represents the first known research to demonstrate that sleepiness due to shift-work and time of day affects emotional empathy. In addition, this research furthers the work by Guagdani , Minkel (2010), and Kahn (2013) that demonstrates that sleep loss and sleep deprivation affect emotional interpretation ,24,25,39Thirty-four first-year medical students from a southern, urban medical school in the United States were participants. Four participants did not complete all requirements within the time frame required for the study, so their data were excluded. As a part of their medical school curriculum, the students complete Emergency Medical Technician (EMT) training prior to time spent on undergraduate medical education. During their first two years of medical school, the students are expected to participate in monthly 12 h EMT shifts that they work concurrently their classroom and testing requirements. These shifts can be day shifts, starting at anywhere from 0500 to 0800, or night shifts, starting at anywhere between 1700 and 2000 . The shifts were worked during the medical school year, overlapping with required duties of the students .Sleepiness was assessed using the Stanford Sleepiness Scale (SSS). The SSS is a self-report Likert scale in which participants are asked to indicate which level of sleepiness/alertness best describes their current state . The optThe Toronto Empathy Questionnaire (TEQ) is made up of 16 questions that cover a variety of attributes associated with empathy . Items oBurnout was measured using the Maslach Burnout Inventory Student Scale (MBI-SS) . The MBIInstitutional Review Board approval was obtained from University of South Carolina (IRB#Pro00084476) to conduct research with the medical students. Participants were asked to volunteer to participate in the study through email recruitment, and all students who consented to participate received a link for participation. All data were collected using RedCap (Research Electronic Data Capture) on an electronic device. All participants were required to complete the tasks within one hour prior to the start of their shift and within one hour of the end of their shift. Any participant who failed to complete the survey within the hour had their data excluded.Participants were assessed on empathy (using the TEQ) and sleepiness (using the SSS) prior to and following their shift, and they were assessed on burnout following the shift only (using the MBI-SS). Participants were not tested twice on the MBI-SS because, although it has high test-retest reliability ,50, ther


Improvement effects were detected in all post-intervention tests . As a main conclusion, it is indicated that an alternative sports-based program improves physical ability and motor skills in individuals with intellectual disabilities.The first aim of the present work was to examine the effects of a physical activity sports program, specifically Kin-Ball, within a group of individuals with intellectual disabilities, on decreasing sedentary behavior and improving basic physical skills. The second aim was to evaluate social validity and acceptability of the intervention. In this pre-experimental study, 47 individuals participated  with an average age of 29.85 (SD = 10.41). All participants were administered an intervention program based on the alternative sport of Kin-Ball. BMI was calculated for body composition and age-related Z-scores were interpreted with the tables provided by the WHO. Endurance was measured through a modified six-minute test, speed was analyzed using a 50 m test, and strength was estimated according to a hand-grip dynamometer. Likewise, balance and coordination were examined in line with adaptations proposed by the scientific literature. Results indicated that all cases experienced statistically significant differences following the intervention program ( Intellectual disabilities (IDs) are understood as those conditions characterized by significant limitations in both intellectual functioning and adaptive behaviors. Depending on the level of intellectual disability, there is a consensus that describes delays in motor functioning . For a dAs is logical, the characteristics presented by populations with IDs are accentuated with increasing age and add to those that are derived from aging ,7. Thus,Regular engagement in physical activity (PA) is one of the factors which has been seen to demonstrate quality of life improvements within the general population. Such practice is importance for the maintenance of health in all of its dimensions ,11,12. NThese studies are corroborated by authors such as Boddy et al.  or PérezVan Schijndel-Speet et al. , adminisA particularly useful sport in this regard is Kin-Ball . This sport stands out because of its dynamic characteristics and emphasis on teamwork, cooperation, and the sporting spirit of those involved. Studies such as those performed by Hall et al. , demonstPhysical education teachers of students with special educational needs need to know about the active strategies that they can use with the class as a whole. This is important as the majority of implementation programs are undertaken as case studies or with individual students. Although research on this topic is highly limited, some authors ,39 have The legal guardians of participants gave informed consent for participation and the procedure applied was approved by the Committee of Research Ethics at the 1230/CEIH/2020. A total of 47 individuals  participated in this pre-experimental study. Participants were attending a Special Education Centre and had an average age of 29.85 years (SD = 10.41), with age ranging from 12 to 55 years. The Special Education Center has 13 units of Basic/Primary Education and four relating to the Training Program for Transition to Adult Life and Work. All participants attended 12 sessions, with data being collected at the beginning and end of the program. Participants were referred to the program by supervisors and workers at the aforementioned center as part of the physical activity plan they were receiving. Inclusion criteria for the present study stipulated that participants must have been diagnosed with an intellectual disability; however, all other center users were also invited to participate in a voluntary way. Participant flow through the phases of the intervention program is shown in The first adaptation involved two sessions which sought to increase knowledge and initiate contact with students, those responsible for their physical education and support staff. This ensured that these individuals had initial contact with this sporting modality. Likewise, informal meetings were held at the end of each session with the main working and auxiliary staff. Here, queries were raised around those questions that could be improved or changed. This helped to clarify ideas and establish new tasks and additional activities which would lend greater adaptability to the sport.A second adaptation was made in which the traditional 8 weeks were extended to 12 weeks in order to enable greater familiarity with the activities and contents of this modality. Each session lasted 1 h in real time, with participants arriving 20 min prior to session initiation and leaving after 1 h of the activity had passed.Program exercises were adapted for the first few sessions but later, and then throughout the program, a sequencing of this sport modality was developed . The medThe study was centered on health-related components of physical aptitude and followed the categories proposed by the American College of Sports Medicine (ACSM), i.e., body composition, muscular strength, and endurance . FlexibiBMI was calculated as body weight measured in kg divided by height in meters squared. Age-related Z-scores were calculated for BMI according to growth charts stipulated by the WHO. Then, these Z-scores were classified as underweight when zBMI was <2 SD. For children younger than 6 years, overweight was classified when zBMI was >2 SD and obesity was determined in cases in which zBMI was >3. For those aged between 6 and 18 years, zBMI scores >1 were classified as overweight and >2 as obese . The WHOEndurance was measured through a modified 6 min test which has been validated within populations with intellectual disabilities . Speed wBoth pre- and post-intervention tests were conducted individually in a sports hall, with each session following a fixed order, i.e., weight, height, manual dynamometry, coordination, balance, speed, and endurance. Participants were evaluated by the same professionals for the pre- and post-intervention tests. Specifically, the supervision and evaluation team included occupational therapists, physical education graduates, and physical therapists. This sequence meant that the easiest tests (body composition and dynamometry) were completed at the start, progressing towards the most difficult test which was resistance. A rest was allowed between performance of the various tests. A 12-week intervention program (one session per week) was developed. All individuals participated on the same day, although they were divided into three groups according to age groups. Two of the groups had a total of 16 participants, while the other group had 15 participants.Evaluators explained activities to each participant individually and performed demonstrations. Participants were encouraged to do their best at all times and to complete tasks in the correct fashion. No standardized instructions were given, because each student had their own personal preferences and communication styles. Instead, instructors were permitted to use their judgement with regard to if the participant had understood the way in which they were expected to perform the tests, with maximum effort and in accordance with the protocol. All instructors had prior experience with the testing procedures and were experts working with children with intellectual disabilities.d) interpreted as follows: null (0–0.19), low (0.20–0.49), moderate (0.50–0.79), or high (≥0.80) [p ≥ 0.05).A descriptive analysis was carried out in order to describe participants’ characteristics. Pre- and post-intervention test differences among groups were determined through Chi-square and Pearson analysis, whereas independent t-tests were used for interval data. Results for a number of the tests were shown through descriptive statistics. The magnitude of differences (effect sizes) was obtained while using the standardized measure Cohen’s d ( (≥0.80) . A confin = 25) and 46.8% males (n = 22)) with an average age of 29.85 years (SD = 10.411). Average fat mass was 21.51 kg (SD = 9.97), fat-free mass was 47.25 kg (SD = 8.45), and total water mass was 33.14% (SD = 6.12). With regards to the initial data obtained (pre-intervention stage), the following results were obtained in the various conducted tests: BMI (M = 25.22 and SD = 4.46), strength (M = 19.38 and SD = 6.10), speed (M = 11.25 and SD = 2.09), endurance (M = 478.73 and SD = 76.81), coordination (M = 70.57 and SD = 19.14), and balance (M = 24.31 and SD = 19.74).r = −355).Following this, correlations among variables collected in the pre-intervention stage were examined see . It was p = 0.000), with improvements being detected in all of the post-intervention stage tests (Finally, analysis of data designed to uncover the effects of the intervention program based on Kin-Ball indicated that statistically significant differences were found in all cases (ge tests . Cohen’sThe present study indicates that individuals with intellectual disabilities have low levels of health-related physical aptitude. However, the 47 participants who participated in a physical activity intervention program through Kin-Ball experienced improvements in their physical abilities.Other studies delivered with similar samples around the world have obtained positive values similar to those reported by the present study and have had positive effects on motor development ,50, althInitial baseline data, collected in the first stage prior to any intervention, showed similar values to those found in studies such as those conducted by Bazzano et al. , Harris A moderate correlation was found between speed and balance, i.e., those with better balance employed less time to complete the speed test. This agrees with the fact that an individual with an intellectual disability occasionally suffers problems in relation to balance, musculoskeletal issues, and decreased muscle tone . This imPhysical activity programs for individuals with intellectual disabilities are fairly abundant and consider certain aspects to be highly positive. Over recent years, aerobic ,58, mindImplementation of the program revealed improvements in all post-intervention stage tests. This establishes that, when performed in a continuous way, Kin-Ball is beneficial for the physical and social development of those with intellectual disabilities ,61. IndeIn relation to intervention, effects based on this sporting modality have demonstrated improvements in intention, motivation, and attitude, with these all being important psychological factors considered by the model proposed by Van der Ploeg et al. .Despite the fact that the individuals with intellectual disabilities who participated in the present study had some type of musculoskeletal and physical-sporting problem , it was Limitations of the present research study exist, by the fact that it was developed from within a group of participants formed by 82 children and adolescents who were identified has having moderate to severe disabilities. Nonetheless, the sample size included only 47 participants as participants abandoned some tests, in some cases as a result of a lack of adaptive behavior or poor motor development. Future studies should include larger samples and consider the socioeconomic status and background of individuals. This is important given that previously conducted studies have demonstrated that these variables are also associated with a good physical state ,67. The The main conclusions obtained through evaluation of the adequacy of a physical activity program based on Kin-Ball are that all participants increased their speed, endurance, strength, coordination, and balance. Participants also reported high levels of satisfaction and motivation towards this alternative sport.