Low bone mineral density (osteoporosis) is associated with vertebral and nonvertebral fractures in postmenopausal women. Tibolone is a low-risk hormone replacement therapy alternative to estrogen therapy, effective in the treatment of menopausal symptoms and prevention of bone loss, but the evidence is controversial. This systematic review with meta-analysis summarizes the clinical trials of the tibolone effect on percentage change of bone mineral density in the lumbar spine, femoral neck, and total hip in postmenopausal women. The results show that tibolone 2.5 mg dose increases the percent change in bone mineral density compared with non-active controls at 24 months in lumbar spine and femoral neck, regardless of the scanner used to evaluate the bone mineral density. No difference was observed when 2.5 mg tibolone dose was compared with estrogen therapy at 24 months, and both treatments have a positive effect on the bone mineral density. In conclusion, tibolone increases bone mineral density compared to non-active controls, and there was no difference when it is compared to estrogenic therapy; thus, tibolone is an alternative treatment for menopausal symptoms and bone protection.Low bone mineral density (BMD) on postmenopausal women causes bone fragility and fracture risk. Tibolone seems to prevent bone loss. Therefore, this systematic review with meta-analysis synthesizes the tibolone effect on BMD percent change in lumbar spine (LS), femoral neck (FN), and total hip (TH) in postmenopausal women. Controlled trials that provided tibolone evidence on the efficacy of tibolone in preventing loss of BMD were included. Regarding the included studies, a pooled mean difference (MD) with 95% confidence intervals (95%CI) was estimated to determine the BMD percentage change. Eleven studies were identified and eight were included in the quantitative analysis. Tibolone at a dose of 2.5 mg increased BMD compared with non-active controls at 24 months in LS ; and FN , with Hologic and Lunar scanners, respectively. No difference was observed when tibolone 2.5 mg dose was compared with estrogen therapy (ET) at 24 months, LS , FN , and TH . Therefore, tibolone increases BMD in LS and FN compared to non-active controls, and there was no showed difference with ET. Osteoporosis is characterized by a reduction in bone mass and micro-architectural deterioration of bone tissue, that cause an increase in bone fragility and susceptibility to fracture risk. In postmenopausal women, osteoporosis is the most frequent primary form of the pathology observed after the fifth decade due to bone loss caused by estrogen deficiency that increases bone turnover with an imbalance between bone formation and resorption ,2.Different treatment options are recommended in postmenopausal women with osteoporosis, such as selective estrogen receptor modulators (SERMs), bisphosphonates, peptides of the parathyroid hormone family, denosumab, romozumab and other pharmacological intervention to prevent bone loss, like hormone therapy (HT) .HT prevents the accelerated bone turnover and bone loss at all skeletal sites and is considered effective to prevent postmenopausal osteoporosis and reduce the risk of vertebral and non-vertebral fractures regardless of baseline bone mineral density (BMD) . FurtherOtherwise, tibolone, a synthetic steroid with a structure different from estrogens and SERMs , acts diTibolone is a treatment for climacteric complaints; moreover, it could be a therapeutic option to prevent BMD loss and consequently reduce the risk of fractures in postmenopausal women. Therefore, this systematic review with meta-analysis was performed to (1) summarize the effect of tibolone on BMD change in lumbar spine, femoral neck, and total hip in postmenopausal women; (2) assess the quality of identified trials with current available tools; and (3) evaluate the safety of tibolone therapy.This research was designed and reported in accordance with PRISMA guidelines , and theA systematic literature search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ScienceDirect, Scopus, Epistemonikos, Lilacs, SciELO, IMBIOMED and Medigraphic databases. In addition, a grey literature search was conducted in ScienceDirect conference abstracts, Scopus conference paper, Proquest and TESIUNAM. Searches were carried out in July 2020. In the search, we did not restrict the language and it was limited to studies in humans. The search strategy was built using the following MeSH terms and keywords: “tibolone”, “bone density”, “bone”, “osteoporosis” or “osteoporosis postmenopausal”. The strategy was adapted to each of the databases .Two reviewers (L.C. and O.D.C.) independently assessed all titles and abstracts to identify studies that potentially meet the eligibility criteria. The reviewers were blinded to each other’s decisions. Disagreements were resolved through discussion and consensus with one additional review author (M.A.S.). Studies were included if they met the following criteria: (1) randomized or non-randomized controlled trial; (2) participants were postmenopausal women, defined as women with a surgical or natural menopause with at least 12 months of amenorrhea; (3) intervention was tibolone at any dose compared to non-active controls  or an active treatment with estrogens or combined hormone therapy; (4) outcome measured as the BMD percent change in lumbar spine (LS), femoral neck (FN) and total hip (TH); (5) BMD determination was performed by quantitative computed tomography (QCT) or by dual energy X-ray absorptiometry (DXA) Lunar or Hologic densitometers; and (6) follow-up at 12, 24 or 36 months. Studies that included women with unilateral or bilateral oophorectomy, osteoporosis diagnosis, previous fractures, and breast cancer, were excluded.Eligible studies were reviewed by two authors, data extraction was performed by one investigator (L.C.) and then checked independently for accuracy by the other investigator (O.D.C.). The following data were extracted: first author, year of publication, study design, characteristics of participants, interventions doses, follow-up, type of comparator, bone mineral density results and adverse events (AE). For BMD, the following data were extracted: the mean percent change, standard deviation, and number of participants in both the tibolone and comparator group. Where the standard error of the mean percent change (SEM) was only reported, standard deviation (SD) was calculated with the formula: SD = SEM × square root (n), where n is the number of subjects. When the percent change was reported in figures to accurately measure the mean and standard deviation in the graphs, the image was enlarged to interpolate the data with a drawn line. If necessary, the authors were contacted via e-mail for more information about the study design and results.Two review authors independently evaluated the risk of bias in the included studies. For randomized studies, the recommendations of the Cochrane risk of bias tool was used ; each ca2 statistics were performed, considered not important if the value is 0% to 40%, as moderate between 30% to 60%, as substantial if the value is 50% to 90%, and 75% to 100% represents considerable heterogeneity [Meta-analysis was performed using Review Manager software version 5.3 from the Cochrane Collaboration . For theogeneity . PublicaA total of 696 citations was found, the study selection process is illustrated in A total of 1529 participants were included in 11 studies. The mean age of women in most of the selected studies was between 49 and 55 years ,21,22,23Four studies were non- or semi-randomized ,16,19,20In most of the randomized studies in the systematic assessment of bias an unclear or high risk of bias was observed with respect to allocation concealment, blinding of outcome assessment and selective reporting bias a,b.Regarding the random sequence generation and allocation concealment (selection bias), a low risk of bias was estimated in three studies because their participants were allocated by a random system. Three studies classified by an unclear risk of bias had no information about the generation of a random sequence and one did not specify the block selection process. Besides, all the selected studies were accounted with an unclear risk of bias because they did not provide information about allocation concealment.With respect to blinding of participants and personnel (performance bias) and blinding of outcome assessment (detection bias), a low risk of bias was considered in four studies double-blind; unclear risk of bias was estimated in two studies without information about blinding participants and/or personnel; and one study, rated with a high risk of bias, was an open study. Moreover, all studies were classified with an unclear risk of bias, if they did not provide enough information for blinding of outcome assessment.With relation to completeness of follow up (attrition bias), there were dropouts in four studies, the intention to treat analysis was applied so that we considered a low risk of bias. In contrast, three studies describe the dropouts, but there is no comparison with the total number of participants assigned to the groups, which we rated with an unclear risk of bias.On selective reporting (reporting bias), an unclear risk of bias was considered in all studies. They pre-specified the outcomes reported, according to the procedures, and it is mentioned that the equipment was calibrated, but it is not clear whether it was by the same operator who carried out the measurements, or whether the operators were standardized or certified by the International Society for Clinical Densitometry (ISCD).Additionally, in the domain of other potential sources of bias, most of the selected studies were rated with a low risk of bias. Finally, most of the randomized studies were considered with an unclear risk of bias.In non-randomized studies, a moderate or serious risk of bias was observed. In the domains addressing issues before the start of the interventions (confounding and selection of participants in the study) and in the domains covering issues after the start of interventions (bias due to deviation from an intended interventions and selection of the reported result) c,d.Regarding the bias due to confounding, two studies were considered with moderate risk, women with hormone treatment were randomly assigned to the treatment groups. Two studies were classified with serious risk; in one, women were able to choose their treatment and in the other, the baseline variables were different.Bias in the selection of study participants. The selection may have been related to the intervention and the outcome; three studies were classified with moderate risk as the authors used appropriate methods to adjust for the selection bias and one study with severe risk, as this could not be adjusted for in the analyses.Bias in classification of interventions: a low risk of bias was considered in three studies with the intervention status well-defined, and one study with some aspects of the assignments of intervention status determined retrospectively was considered to have a moderate risk of bias.Bias due to deviations from intended interventions: concerning the effect of assignment to intervention, and the effects of starting and adhering to interventions, there were deviations from the usual practice and deviations from the intended interventions, respectively; but the effect on the outcome is expected to be slight; therefore, three studies were classified as being at moderate risk. In one study, the analysis was not appropriate to estimate the effect of adhering to intervention.Bias due to missing data. Three studies with proportions of missing participants were similar in the intervention groups, they were classified as being at low risk. In one study, a moderate risk of bias was considered because the proportions of missing participants do not differ considerably across intervention groups and the analysis possibly could not have removed the risk of bias arising from the missing data.Bias in measurement of outcomes. A low risk bias in all studies was considered, and methods used to evaluate intervention group outcomes were comparable, with the possibility of the influence of the knowledge of interventions types on the participants.Concerning bias in the selection of the reported results, all studies were classified with a moderate risk of bias, and the outcome measurements and analyses are consistent with an a priori plan. Finally, most of the studies present one domain with a serious risk of bias; therefore, the overall risk of bias judgement for non-randomized studies is serious.2 = 0%, p = 0.81; and MD 7.35%, 95%CI: 2.68 to 12.01, 152 participants; I2 = 68%, p = 0.08, for Hologic and Lunar densitometers, respectively ; likewise, the BMD percentage change increases after 24 months . With regard to FN, the results at 12 and 24 months were MD 1.81%, 95%CI: 0.79 to 2.82, 196 participants; I2 = 0%, p = 0.93, and MD 3.34% 95%CI: 1.81 to 4.87, 196 participants; I2 = 40%, p = 0.19, respectively.In the LS, tibolone 2.5 mg dose ,19,21,24ectively . In the ectively . No stud2 = 80%, p < 0.0001  0.625 mg  and estr< 0.0001 . In FN, p = 0.32 . Moreovep = 0.32 . The sen2 = 0%, p = 0.96 , and five of them had different objectives such as bone loss or fracture prevention, without describing the effect on BMD . BesidesIn this study, most of the available data were derived from a comparison with non-active controls. For both densitometers, the increase in BMD is observed for 12 months, with the percent change being greater at 24 months in the lumbar spine and femoral neck, especially with a 2.5 mg tibolone dose. At menopause, both trabecular (cancellous) and cortical bone may be affected, but loss of trabecular bone is more clearly associated with the abrupt decline of the ovarian function at menopause. Trabecular bone consists of 20% of the total bone, which is in the flat bones and in the ends of long bones, and it has ten times the surface/volume ratio of cortical bone. Sex steroids contribute to maintain bone mass mainly by decreasing osteoclastic bone resorption in the trabecular bone, and in this way it suppresses the rate of bone remodeling . In thisAccording to the comparison between tibolone and estrogens, the information about the 1.25 mg tibolone dose compared with estrogen therapy is scarce . The mos4 tibolone). About 80% of the total oral dose of tibolone circulates as an inactive sulfated form , then in locally tissues, the sulfatase enzymes desulfated the metabolites into active estrogenic molecules [Consistently, tibolone is an antiresorptive drug, a synthetic steroid analogue of the progestin, norethynodrel, and structurally different from estradiol and SERMs, with unique tissue-specific effects. Tibolone influences the synthesis and metabolism of estrogens, progesterone and endogenous androgens; for example, in the breast it regulates enzymes, in the endometrium the metabolism is tissue-selective, and in bones it acts via activation of estrogen receptors ,31. The olecules .In contrast, VMS described by women as hot flashes or night sweats represent the most bothersome symptoms of menopause and the most common reason women seek medical care . BesidesIn this way, a meta-regression of published trials concluded that greater improvements in DXA-based BMD is strongly associated with greater reduction in fracture risk, particularly for spine and hip fractures. For example, if tibolone increases the BMD at 2% of the lumbar spine, it could be associated with a 28% reduction in spine fracture or 22% hip fracture, whereas 4% improvement in femoral neck could be associated with a 55% reduction in spine fracture or 32% hip fracture, according to the meta-regression published . MeanwhiIn addition, our analysis supports that tibolone is associated with a lower rate of vaginal bleeding compared to estrogen therapy, and it is suggested that if 47% of women taking combined hormone therapy experience unscheduled bleeding, between 18% and 27% of women taking tibolone will do so . MoreoveIn women with a history of breast cancer, tibolone increase the risk of cancer recurrence and, in women over 60 years of age, it may increase the risk of a stroke. Concerning other long-term adverse events, there is no evidence that tibolone increases the risk or that it differs from estrogen therapy with respect to long-term safety . In relaThis analysis focused on preventing bone decline with tibolone; however decision-making also incorporates side effects and other measures to improve bone health such as aging, appropriate physical activity, lifestyle, environmental factors, good nutrition, adequate intake of calcium and vitamin D. It is possible to prevent osteoporosis and therefore avoid the intervention of antiresorptive medications or stimulators of bone formation to treat this disease, such as bisphosphonates, demosumab, romosozumab, teriparatide and abaloparatide . ConsideThe findings of this systematic review suggest that tibolone is useful to prevent the decrease in BMD. However, some limitations need to be considered when interpreting the results of this study. First, the evidence from this research cannot be extrapolated to women with osteoporosis or previous fractures, because this population has a greater increase in BMD in response to antiresorptive agents. Second, there are no recent studies, and much of the evidence included was unclear or had a high risk of bias in more than one domain. Third, according to the ISCD, the region of interest in spine BMD measurement is L1–L4. Finally, the comparison and pooling of Hologic and Lunar BMD values is difficult. To solve this problem, raw BMD could be standardized with equations; however, the percentage difference between these two systems could be reduced but not eliminated.The strengths of this systematic review over meta-analysis is that it is the only one that reports a percentage change in BMD with current available tools and that assesses the quality of identified trials. The specific data of the mean difference in percentage change in BMD could be useful in monitoring bone health, in addition to the possible prediction of fractures. Moreover, the evidence from this systematic review may be valuable in clinical decision-making to treat bothersome menopausal symptoms, with the benefit of bone loss prevention.The present meta-analysis provides quantitative data of tibolone improvement of BMD percentage change and demonstrates no difference with estrogen therapy. Quality evidence was unclear or had a serious risk of bias; in addition, tibolone has been shown to have fewer adverse events than estrogen therapy.


Vitiligo is a disfiguring skin disease with profound psychosocial impacts, such as anxiety, but the reported effect sizes of associations vary. We aimed to conduct a meta-analysis to quantify the strength of association between anxiety and vitiligo and to estimate the prevalence of anxiety among individuals with vitiligo.  A systematic literature search was performed in five online databases  from inception until March 20, 2020. All of the eligible studies were comprehensively reviewed, and all of the available data were analyzed according to our predefined criteria. I2 = 30.1%). The pooled prevalence of anxiety in female patients was significantly higher than that in males . Subgroup analysis showed that the pooled prevalence of clinical anxiety disorder and anxiety symptoms was 12%  and 34% , respectively. No publication bias has been detected by Begg's funnel plot and Egger's test.  Twenty-one studies involving 3259 patients in 11 countries were included in this meta-analysis. Compared with the healthy control group, patients with vitiligo often had concomitant anxiety , findings should be interpreted with caution. Vitiligo is an autoimmune skin disease characterized by depigmented macules, which result from progressive melanocyte destruction in the epidermal area . It is eHowever, the evaluation of the mental health state in individuals with vitiligo has not been well demonstrated. On the one hand, most dermatologists focus on the treatment of skin lesions and ignore the potential mental symptoms. On the other hand, the majority of vitiligo patients reject the proposal for referral to a psychiatrist due to the stigma associated with psychosis . RecentlRecently, numerous studies in this area have been published. Therefore, an up-to-date meta-analysis is essential to analyze the relationship between anxiety and vitiligo.This meta-analysis was based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines . We follOriginal articles matched the following inclusion criteria: (1) cross-sectional, case-control, or cohort study design; (2) a sample of patients clinically diagnosed with vitiligo; (3) anxiety was clinically diagnosed or evaluated by specific questionnaires; (4) sufficient raw data were available for analysis; and (5) manuscript in English or Chinese. Exclusion criteria were as follows: (1) reviews, conference abstracts, letters, or case reports and (2) duplicated or overlapping data. The process of article selection was conducted by two researchers (Jiani Liu and Rui Tang) independently. Any discrepancies were resolved by mutual discussion.Two independent researchers (Jiani Liu and Rui Tang) extracted data from the included studies. The following baseline information were extracted: first author's name, year of publication, study design, country, race of participants, number of participants, gender information, age, anxiety scales, and quality assessment score. To accurately evaluate the quality of each eligible study, all of studies were evaluated by the Newcastle–Ottawa Scale (NOS) , 15. TheI2 statistics were applied to identify heterogeneity among studies. A fixed-effects model was applied to estimate the pooled effect size in the case of no significant heterogeneity (I2 < 50% or P > 0.1); otherwise, the DerSimonian–Laird random-effects model was employed [All of the data processing and analysis were performed using Stata version 15.0 . The association between anxiety and vitiligo was estimated by the odds ratio (OR) for dichotomous data and standard mean differences (SMDs) for continuous data, with their corresponding 95% confidence intervals (CIs). The chi-squared test and employed . To explemployed .A total of 533 publications were identified from the primary online search . Three additional articles were included through reference tracking. Next, 140 duplicates were removed. 337 articles were excluded due to irrelevant topics after screening of the titles and abstracts. After a meticulous full-text review of the remaining articles, 38 articles were excluded. Eventually, 21 studies involving 3259 cases were included for meta-analysis. Details of the online search strategy are presented in n = 20) or retrieved from the online database (n = 1). The sample sizes of participants ranged from 24 to 1432 people, and gender information was also presented. The mean age in all of the studies except for that by Ucuz et al. [The main information of the 21 included studies is presented in z et al.  ranged fP < 0.001), which demonstrated the association between anxiety and vitiligo. No significant heterogeneity has been revealed  (z | = 0.707), Egger's test (P > ∣t | = 0.514), and the funnel plot illustrated that no publication bias was detected  . Begg's detected .P = 0.003) with no heterogeneity  (z | = 1.000), Egger's test (P > ∣t | = 0.826), and the funnel plot detected no publication bias (P = 0.001) suggested that female patients were more susceptible to social anxiety . No publication bias was detected by Begg's test (Pr > ∣z | = 1.000), Egger's test (P > ∣t | = 0.983), and the funnel plot  . Begg's ion bias . Moreove anxiety . No hetenel plot .P > ∣t | = 0.060) and the funnel plot did not indicate any publication bias  was observed for the pooled prevalence of anxiety, subgroup analysis was performed based on outcome measurement tools. The pooled prevalence of clinical anxiety disorders based on clinical diagnostic criteria among 9 studies [I2 = 76.3%; P < 0.001), and that of anxiety symptoms based on valid screening scales among 10 studies [I2 = 94.7%; P < 0.001).Nineteen studies , 26–35 rion bias . As cons studies , 33, 34  studies –32, 35 wSensitivity analysis was conducted to confirm the stability of all of the analyses with respect to the comorbidity of vitiligo and anxiety. The pooled results of all of the analyses were not significantly changed after the removal of any specific studies .Compared with the relevant study by Osinubi et al. , we firsPlenty of clinical studies have reported the viewpoint that patients with vitiligo are susceptible to anxiety disorders. We first conducted a quantitative assessment of the susceptibility of anxiety in vitiligo patients. Several hypotheses may explain the increased prevalence of anxiety disorders among individuals with vitiligo. In some regions, skin depigmentation may be regarded as a sign of low social status, and patients with skin depigmentation suffer from more discrimination in daily life . PatientSubgroup analysis was conducted to evaluate the influence of different cultures on the prevalence of anxiety among participants with vitiligo. Although the results did not achieve statistical significance, an interesting appearance was that the pooled prevalence of anxiety increased from 15% for studies conducted in Asians to 23% for that in the Middle East. This diversity might be related to different levels of vitiligo acceptance between different cultures . HoweverMost viewpoints assumed that vitiligo patients with dark skin (Fitzpatrick skin phototypes IV-VI) are more susceptible to anxiety, depression, and other psychological diseases because of greater notable depigmented patches and the stigma , 39. HowThis association between vitiligo and anxiety can partly be explained by molecular biological mechanisms. Both the skin and the brain originate from the ectoderm during embryogenesis and are regulated by many of the same hormones and neurotransmitters . O'SulliAs far as we know, this study is the first meta-analysis to clarify the female predominance of anxiety in vitiligo patients. According to our data, females have a higher risk of anxiety and develop more severe social anxiety, which may be related to greater cosmetic awareness and lower self-confidence . GeneralWe have observed notable heterogeneity between studies with respect to the pooled prevalence of anxiety, which may be due to the fact that different anxiety-specific scales and clinical diagnostic criteria were utilized in different studies. Six clinical diagnostic criteria  and 10 different validated screening scales were separately applied in the included studies, of which two scales (ACS-SAA and LSAS) were aimed at evaluating social anxiety. Therefore, we conducted a subgroup analysis to identify whether the difference in outcome assessment tools would be a potential heterogeneity source. Our results indicate that the prevalence identified by clinical criteria was significantly lower than that identified by screening scales. This can be explained by the fact that the purpose of screening scales is to identify as many anxiety symptoms or subclinical anxiety emotions as possible and to rate these manifestations; however, the purpose of clinical criteria is to accurately diagnose clinical anxiety disorders and to conduct medical interventions in a timely manner. In the subgroup analysis, the heterogeneity between studies was slightly lower. Differences in measurement standards among various screening scales were among the confounding factors that cannot be avoided. An interesting problem is that thresholds applied to screening scales to define anxiety symptoms also differed between studies. Even if the same scale was used, like HADS-A, the measurement thresholds to define outcomes differed between studies , 31. A uAdditionally, depression, phobia, adjustment disorder, and somatoform disorder also occur in patients with vitiligo , 46, 47.The limitations of our article are worth discussing. For example, the case-control studies comparing the prevalence of anxiety in vitiligo patients and healthy controls are limited. Only a small number of studies reported the prevalence of anxiety in female and male patients separately. Although no heterogeneity has been observed in these analyses, more related studies with more candidates are required to support our conclusion. Moreover, the high heterogeneity in the analysis of the prevalence of anxiety in vitiligo patients cannot be ignored. Besides the measurement tools, other factors might be taken into consideration for the heterogeneity, such as the study design and age of participants. Therefore, more results based on those confounding factors would be helpful to our further research.In conclusion, comorbidity of anxiety and vitiligo is common in the clinic. Patients with vitiligo have an enormous burden due to anxiety, with female predominance. Dermatologists and psychiatrists should be vigilant to the presence of anxiety, apply appropriate interventions to reduce the psychological impacts in a timely manner, and thus promote recovery in vitiligo patients. A better designed case-control study and larger sample sizes are warranted for future studies. Moreover, in the field of psychodermatology, a uniform scale to measure anxiety in vitiligo patients is urgently needed.


Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development.A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI).n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced . When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased . When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher .A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development.CRD42019142842.PROSPERO The online version contains supplementary material available at 10.1186/s13017-021-00381-0. Injury remains the leading cause of death and disability , 2 and iIn recent decades, there has been a decrease in injury mortality rates as a result of comprehensive legislation pertaining to road safety and injury prevention campaigns . FurtherA designated trauma centre/major trauma centre is a multi-specialty hospital that offers multiple levels of care for trauma patients. Trauma centres are often the first step in the implementation of a trauma system. While there is no agreed definition of a mature trauma system , it is wThe different characteristics of trauma systems have been highlighted in prior reviews , 17. CliThis study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses checklist for systematic reviews . This reStudies were included if they involved non-randomised control trials, observational studies, interrupted time series studies, controlled and non-controlled before and after studies, and prospective and retrospective cohort studies. Only peer-review population-based articles were included, and grey literature was excluded in this review. Articles for which full text was unavailable were excluded.Traumatic injury individuals from all age groups, gender, and ethnicity with all causes of injury  were included. All levels of severity of traumatic injury patients, from relatively minor to severe, were included. Articles that dealt with ‘trauma/injury’ as a whole were included in this study as well as articles that focused on three or more injury types. Articles that focused on a specific type of injury such as whiplash or two or fewer specific types of injuries were excluded from this study and reflects that the majority of published trauma system evaluation studies represent all injury patients rather than focusing on a specific type of injury. Further, excluding studies that focused on a specific type of injury enhanced the ability of the review to generalise the study findings across all traumatic injury patients.Studies about the effectiveness of trauma care services in reducing mortality with sufficient data were included.Studies were eligible if they compared mortality rates for trauma patients treated at non-trauma centres and trauma centres, mortality rates between pre and post system implementation, as well as studies that evaluated system improvements made after the initial introduction of the trauma system. The timeframe included any period following initial establishment until the system was operating in a stable way. Noting that there is no agreed definition in the literature for system maturation , the opeThe primary outcome of this study was the mortality rate of injured patients treated in the three different stages of trauma system development.The search strategy was based on the recommended Joanna Briggs Institute (JBI) three-phase search progress . An initIncluded studies were limited to studies written in English, human-related studies, and published from January 1, 2000, to December 31, 2020. Since clinical healthcare and systems have evolved dramatically in the last three decades , and resCitations identified through the search strategy were imported into Covidence systematic review software . The Covidence software removed duplicate studies. Two independent reviewers (RA and SS) assessed the eligibility of every study by title/abstract screening and full-text screening. Any disagreement was resolved by a third reviewer. Articles that matched the study criteria were included in data extraction.Data extraction was performed by two independent authors (RA and SS). Disagreements were resolved through discussion and, if consensus could not be reached, by a third reviewer. Data extraction included author names, publication year, country of data origin, data collection period, source of data, design, sample size, characteristics of the study population, stage of trauma system development  and years of operation, cause and type of trauma, level of injury severity, and mortality rate. No authors were contacted to clarify or obtain missing data or information.The risk of bias of included studies was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool . The too. For analysis calculation, inverse variance (IV) random effects models were used, effect sizes were expressed as odds ratios (OR) for dichotomous data, and their 95% confidence intervals (CI) for the data were explored. Given that the majority of studies in this field report an OR [I2 values of 25%, 50%, and 75% correspond to low, moderate, and high, respectively [Included studies were pooled using statistical meta-analysis statistical software, Review Manager (RevMan) Version 5.4. rt an OR , 17, 23,rt an OR  and in crt an OR . The degThe results were synthesised in three different groups  according to the trauma system stage of development. A trauma centre is usually the first stage of system development. In group A of this review, studies were included that evaluated mortality rates for patients treated at non-trauma centres compared to trauma centres. Group B included studies reflecting the development of a network cooperating to establish a trauma system. In this group, studies that compared mortality rates between pre and post system implementation were included (second stage). In group C, mature trauma systems, studies were included that evaluated improvements after the initial introduction of the trauma system.As factors that have been identified as predictors of mortality in a previous review , subgrouA total of 6897 records were identified from the database search and 30 through reference list and author searching for a total of 6927 records. There were 4445 that were included after 2482 duplicates were removed. Following title and abstract review, a further 4277 records were excluded resulting in 168 papers eligible for full-text review. Of the 168 records, 52 articles met the study inclusion criteria and were included in the systematic review –77. Of tThe characteristics of included studies are shown in supplementary file, Appendix The risk of bias assessment is shown in Fig. n = 74,930) including patients in all 52 studies. Among patients in group A, 8.94% died in non-trauma trauma centres compared to 9.14% in trauma centres; an increase of 0.2% in the mortality rate was observed. When comparing mortality within group B, 6.56% died in non-trauma systems compared to 5.3% in trauma systems, while in group C, 8.59% died in early stage trauma systems compared to 5.36% in mature systems; a reduction by 1.26% and 3.23% of mortality rates was observed, respectively.A total of 52 studies, with combined 1,106,431 traumatic injury patients, were included in this systematic review. Of 1,106,431 patients, 6.77% died . The degree of heterogeneity among group A was moderate with p < 0.001; RR = 0.76 or ARR = − 0.02). However, when patients were treated in a non-trauma system compared to a trauma system, the odds of mortality increased (group B), a difference that was statistically significant . Similarly, when patients were treated in an early stage system compared to a mature system (group C), odds of mortality increased with a difference that was statistically significant .The meta-analysis results for groups A, B, and C are shown in Fig. p < 0.05; RR = 2.42 or ARR = 0.03), among road trauma patients , and among severely injured patients with ISS ≥ 15 .The results of the subgroup analysis are shown in Fig. Publication bias was assessed visually with three funnel plots as shown in Fig. This systematic review of 52 studies involving over a million traumatic injury patients is to our knowledge the first meta-analysis examining the effect on mortality of trauma systems at different stages of development. The majority of included studies reported mortality rate as their primary outcome. For all patients in this study, the overall mortality rate was 6.77%. The mortality rate for patients treated in non-trauma centres or non-trauma systems was 7.7% compared to 7.1% for patients treated in a trauma centre or trauma system. With the inclusion of group C, early stage trauma system compared to mature systems, the mortality rate decreased from 7.83 to 6.73%. This pattern of progressive reduction in mortality rates highlights the importance of trauma system development and maturation.p value when we interpreted the data using OR, RR, or ARR among all group analyses. There was a significant reduction of absolute mortality risk of traumatic injury patients, particularly when considering the treatment of severely injured patients (ISS ≥ 15) in a mature system compared to care in an early stage system. This result reflects the effectiveness of prehospital triaging of such patients to a higher level of trauma care. The difference between pre event mortality rates across groups A, B, and C of trauma system development stages and post event mortality rate among paediatric patients was determined to be statistically significant, 0.75% and 0.28%, respectively. This suggests that trauma system development is as important for children as it is for adults. Road trauma mortality reduction was also observed following trauma system implementation and maturation. The degree of injury severity (ISS > 18) among road trauma patients was identified as a mortality predictive factor in a previous review [In this analysis, the interpretation of the OR was frequently consistent with the other matrices used to analyse the data including the RR and ARR. There were no changes in the ts ISS ≥ 5 in a maThe results of our study indicate that patient treatment at an institution that is part of a trauma system was observed to improve patients’ survival rates in the current study. Prior research has also determined trauma system care reduced prehospital time , reducedTrauma service centralisation is usually the first phase in the development of a trauma system. This approach was seen in many high-income countries such as in North America , Europe Although the current study did not find a reduction in mortality rates between trauma centres and non-trauma centres, logistically, this is a first and important step toward organising a regional trauma system. This is particularly important for LMICs, where limited resources can be a barrier to establishing a state-wide/national wide trauma system. While the difference was determined to be statistically significant, the clinical significance of this difference is relatively small, as patients with more severe injuries are likely to be treated at trauma centres than non-trauma centres. Our results provide evidence to justify and prompt healthcare providers and trauma system policymakers’ commitment to continual refinement of trauma systems and shape ongoing government investment in system development. Understanding the effectiveness of trauma systems at different stages of development provides support for LMICs, where system development is still emerging.This meta-analysis has several limitations. First, our search strategy was limited to peer review published articles and excluded grey literature; thus, some healthcare providers and government reports would have been excluded. Second, some studies reported adjusted risk mortality while others reported unadjusted risk and the variation could lead to statistical differences in our meta-analysis. Third, our study found that when patients were treated in a non-trauma centre compared to a trauma centre, the odds of mortality were reduced. However, these statistical differences could be primarily related to selection bias as patients with more severe injuries were more likely to be treated at trauma centres than non-trauma centres. Finally, some subgroup’s analyses were not possible due to the high level of heterogeneity or absence of data pertaining to these predictor variables. Among the included studies, moderate heterogeneity was found for group A; however, groups B and C presented with low degree of heterogeneity.This comprehensive literature review and meta-analysis summarises the findings of trauma system improvement over the last two decades. Management of traumatically injured patients, particularly patients with high injury severity, in a mature trauma system was associated with decreased mortality compared with management of these patients in a non-trauma system. The results of this review provide evidence to support efforts to implement such a system in LMICs and encourage countries with existing systems to further invest in system development.Additional file 1: Supplemental file, Appendix 1.Additional file 2: Supplemental file, Appendix 2.Additional file 3: Supplemental file, Appendix 3.


Background: Chronic obstructive pulmonary disease (COPD) is a public health challenge globally. The burden of COPD is high in never-smokers but little is known about its causes. We aimed to find the prevalence and correlates of COPD in never-smokers, with a special focus on solid fuel exposure.Methods: We conducted a cross-sectional study in Western China. COPD was defined by FEV1/FVC < lower limits of normal (LLN). Descriptive statistics and multivariable logistic regression were used for analyses.Results: Six thousand two hundred and seventy one patients were enrolled between June 2015 and August 2016. The prevalence of COPD in never-smokers was 15.0% . The common independent predictors of COPD in never-smokers included age ≥60 years, exposure to solid fuel, living in a rural area and a history of tuberculosis. Participants with solid fuel exposure were 69% more likely to have COPD  than those without such exposure. In addition, we found a positive association between small airway dysfunction and solid fuel exposure .Conclusions: This study confirmed the substantial burden of COPD among never-smokers and also defined the risk factors for COPD in never-smokers. Furthermore, we found a positive association between solid fuel exposure and COPD or small airway dysfunction. Chronic obstructive pulmonary disease (COPD) is a public health challenge globally, with high prevalence, morbidity and mortality , 2. CigaThe World Health Organization (WHO) estimates that about half of the global population depends on solid fuel for domestic cooking or heating . BurningNumerous studies have been carried out to evaluate the prevalence and risk factors of COPD, while fewer studies have focused solely on never-smokers. In a recent nationwide cross-sectional study in China, more than half of the COPD patients were never-smokers . In TibeWe performed a cross-sectional study on the prevalence and determinants of COPD among people living in Xinjiang and Tibet, China. Xinjiang and Tibet are the largest and second largest provincial-level autonomous regions in China, located along the western border of China. The Institutional Review Board and ethics committee of Beijing Hospital (2013BJYYEC-042C-01) approved the protocol of this study.Detailed methods of the study have been described previously . BetweenWe included permanent residents (who had lived at their current residence for 1 year or longer) aged ≥15 years for this analysis. Exclusion criteria were as follows: pregnancy; myocardial infarction or cerebrovascular accident experienced during the previous 3 months; heart rate >120 beats/min or blood pressure >180/120 mmHg; and being physically incapable of undergoing a spirometry test, such as due to recently undergoing thoracic, abdominal, or eye surgery, or retinal detachment. Each participant received detailed information about the study and study methods, and provided written informed consent before data collection.TM Pneumo PC spirometer  before and 20 min after the administration of 400 μg of salbutamol through a 500 ml spacer. Each spirogram was centrally reviewed and scored based on the American Thoracic Society and European Respiratory Society (ATS/ERS) acceptability and reproducibility criteria criteria . Moreovecriteria , define Never-smokers were defined as a participant who has never smoked, or who has smoked <100 cigarettes in his or her lifetime . PassiveParticipants were considered to have: (1) chronic cough if they have a cough for most of the day for as much as 3 consecutive months during a year; (2) chronic phlegm if they bring up phlegm for most of the day for as much as 3 consecutive months during a year; (3) recurrent wheezing if their chest (lungs) ever sounded wheezy (whistling sound); (4) dyspnea in daily life if they were troubled by shortness of breath when hurrying on level ground, walking up a slight incline, walking at their own pace on level ground or being breathless when dressing/undressing or going out; and (5) at least one symptom if they had at least one of either chronic cough, chronic phlegm, recurrent wheezing or dyspnea in daily life.t-test and χ2 test for continuous and categorical variables, respectively. We performed univariable logistic regression to determine the distribution of the study subjects by the independent variable of interest and to see crude association. Meanwhile, we used multivariable logistic regression analysis adjusted for sex, age, body mass index (BMI), education, education, residence, history of tuberculosis, exposure to solid fuel, exposure to passive smoking, and exposure to dust or chemicals in the workplace with adjusted odds ratio. In the sensitivity analyses, we applied a fixed cut-off to determine COPD.Descriptive statistics such as count and percentage for categorical variables and mean and standard deviation for continuous variables were determined separately for men and women. We conducted independent Student's www.r-project.org). For all tests, the p-value was set to <0.05 to determine significance.All statistical analyses were performed using R with ggplot2, forestplot and ordinal packages  between men and women. The age-specific prevalence of COPD rose significantly with increasing age  in the never-smoking population aged 15 years or older . There wP < 0.05). We also performed a sensitivity analysis using an age-specific fixed cut-off to define COPD. The overall prevalence of spirometry-defined COPD was 10.6% (95% CI 9.9–11.4). Men had a higher prevalence  than women   vs. 10.0% (95% CI 8.7–11.5);  0.0001) . The age 0.0001) .Participants with solid fuel exposure tended to be older, women, less educated and living in rural areas compared with those without such exposure . On averParticipants with solid fuel exposure were more likely to have COPD than those without such exposure. The adjusted OR and 95% CI for the association between solid fuel exposure and COPD was stronger in women  than in men  .Participants with solid fuel exposure were more likely to have chronic cough, dyspnea in daily life and at least one symptom than those without such exposure . ParticiP < 0.001)  . The sex< 0.001) .In this study, we analyzed the prevalence of COPD and its risk factors among never-smokers in Xinjiang and Tibet, with a special focus on solid fuel exposure. Both COPD prevalence and solid fuel exposure were significantly high among never-smokers. The factors independently associated with COPD were age ≥60 years, exposure to solid fuel, living in a rural area and a history of tuberculosis. In addition, we found a positive association between solid fuel exposure and respiratory symptoms or small airway dysfunction. Our results highlight the substantial burden of COPD among never-smokers and confirm the increasingly acknowledged impact of solid fuel on respiratory health.Based on BOLD and other large scale epidemiological studies, it is estimated that the global prevalence of COPD is about 11.7%, which increased 68.9% between 1990 and 2010 . AlthougAbout 3 billion people worldwide use solid fuel for cooking or heating . DespiteThe small airways are the major and earliest site of airflow limitation. Pathological studies suggest that loss of small airways prior to the development of abnormal spirometry or emphysema in COPD patients , 30. RecOur study emphasizes the importance of solid fuel reduction strategies, as public health intervention, which can reduce the burden of COPD. Previous studies showed that the adoption of clean fuel may be beneficial for preventing COPD . MeanwhiPrevious pulmonary tuberculosis was reported to be associated with airway fibrosis, and may lead to lung scarring and airway damage , 39. TheLiving in a rural area and increasing age were associated with a higher rate of COPD in our study, which is consistent with previous findings. For example, rural residence was previously reported to be an independent risk factor for COPD among never-smokers . The assThere are some limitations to our study. First, these data were cross-sectional and we are unable to draw firm conclusions in terms of causation and measure other potential risk factors. Second, some analyses were limited by the design of the questionnaire, which was intended to be comprehensive and easy to administer, but in some cases prevented optimal detailed data collection. We were unable to quantify direct exposure to solid fuel beyond self-reported questionnaires. Third, with a male-to-female ratio of 1 to 2 in our study sample, one may argue that the results could not be generalizable to men. However, in the gender-specific analysis , we found no evidence of heterogeneity. Fourth, the diagnosis of small airway dysfunction in this study was entirely based on spirometry, which could be less accurate than pathological examination and imaging techniques. Finally, those with asthma were not excluded from the study population, which might cause an over-estimate of COPD prevalence in younger age groups.In conclusion, this study confirmed the substantial burden of COPD among never-smokers. Our data suggested that, apart from exposure to solid fuel, history of tuberculosis, living in a rural area and older age are associated with an increased risk of COPD among never-smokers. Furthermore, we found a positive association between solid fuel exposure and COPD or small airway dysfunction.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Institutional Review Board and Ethics Committee of Beijing Hospital (2013BJYYEC- 042C-01). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.HL, ZX, and YG conceived the study. HL, ZX, DC, WL, YT, YW, YM, JC, and MP collected data. HL, ZX, DC, and WL analyzed and interpreted data. HL and ZX drafted the manuscript. HL, ZX, and YG revised the manuscript. YG obtained funding and supervised the study. All authors contributed to the article and approved the submitted version.This study was supported by National Key Research and Development Program of China (2018YFC1315101), Beijing Hospital Clinical Research 121 Project (BJ-2018-199).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.


By gender, the boys recorded higher scores for ASI and lower ones for DSS (p < 0.01). The Spearman’s rho value revealed significant relationships between the presence of sexual double standards and that of romantic myths and ambivalent attitudes (p < 0.01). Conclusions: Adolescents commonly express romantic love myths, sexist attitudes and sexual double standards. These three factors, which are significantly correlated, influence the presence of violence in dating relationships. Background: For school medical services and the staff responsible for sex education for adolescents, it is important to understand the factors that may influence gender violence. The aim of this study is to determine whether the presence of sexist attitudes, double standards and/or romantic myths contributes to the risk of gender violence. Methods: This cross-sectional study was carried out at five secondary schools in the province of Malaga (Spain). In total, 879 adolescents aged 12–18 years were included, studying years 1–4 of compulsory secondary education. Their attitudes were measured on the following scales: Ambivalent Sexism Inventory (ASI), Double Standard Scale (DSS) and Romantic Love Myths Scale (EMA). Results: Significant differences were observed among the age/year groups for the mean scores obtained on each of the above scales (DSS,  For health educators and school medical services, it is important to understand the factors that may influence sexual health and gender violence in adolescence. Intimate partner conflicts can become violent, and relationships between adolescents may also present this behavior . Many naAggression in society and intimate partner violence have become increasingly common, as overexposure and banalization have led to violent behaviors seeming less aberrant. This trend is provoking great concern among health education policymakers and practitioners . AccordiThe term teen dating violence refers to any form of violent behaviors , including harassment and threats, by adolescents towards their partners . GeneralGender violence is strongly related to sexist attitudes, romantic love myths, and sexual double standards, which are often used to justify and explain attitudes of control or jealousy (rather than condemning them), since they are held to be associated with masculine attributes based on the predominance of men over women or with manifestations of bonding ,11. AddiToday the term ambivalent sexism, coined by Glick and Fiske , is usedLikewise, another important factor in the sexual education of adolescents is the impact of romantic love myths or the set of socially shared beliefs about the supposed true nature of love. These beliefs can form solid patriarchal foundations and become firmly and unquestioningly established in the mindset. Indeed, they may even be present, albeit indirectly, in the health education received . The assWith these considerations in mind, those responsible for sex education and the promotion of healthy sexual behaviors should be aware of the influence of these factors on gender violence among adolescents, and on differences in perceptions according to gender. Our main study aim is to analyze the presence of romantic love myths among adolescents, their expressions of sexist attitudes, and sexual double standards towards women. The specific objectives are to describe the differences in the cited variables based on the sociodemographic characteristics of the sample and to analyze the interrelationship between these variables. The scientific hypothesis of the present study is that the three variables that influence gender violence  are correlated with each other.This cross-sectional study , part ofp = q = 0.5, a precision of 5% and a replacement rate of 30%. The inclusion criteria applied were that the students should have attended the class in which the questionnaires were distributed, that their parent or guardian had authorized their participation and that their participation in the study was completely voluntary. Any students (n = 6) who had difficulty in reading and/or understanding the questionnaires, due to language reasons or due to impaired cognitive abilities, were excluded. The study had a response rate of 95% of the participants.The reference population was composed of adolescents living in the province of Malaga. The sample size required  was calculated assuming a confidence level of 99%, An ad hoc questionnaire was used to collect the sample’s sociodemographic variables. The data collected were age, gender, school year, place of residence, sexual orientation, having a partner or not, and age they were when they had their first sexual relationship.The following validated scales were used:Ambivalent Sexism Inventory (ASI), designed by Glick and Fiske  and adapDouble Standard Scale (DSS), designed by Caron et al. , adaptedRomantic Love Myths Scale , designed by Bosch et al. , validatParticipants in this study were recruited non-probabilistically by quota sampling, conducted in secondary schools in the province of Malaga. To ensure an appropriate sample size, five schools were selected, differentiating between urban and rural, since this might be a confounding variable. If any school declined to participate, another from the same area was randomly selected. Once they accepted the Secondary Schools, they were passed to all the students of all the classes that belonged to ESO. The data collection process was strictly confidential and participation in the study was voluntary in all cases.Authorization was requested from the School Councils of the Secondary School in which the questionnaires were to be approved. Written authorization from parents was requested, as well as oral authorization from adolescents. Classrooms were attended during class time, and each student was given a booklet with the paper questionnaires. They took approximately 15 min to complete the questionnaires.The study was carried out in accordance with the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of the University of Malaga (9-2021-H). The protection and confidentiality, contained in Organic Law 3/2018, of December 5, on the Protection of Personal Data and guarantee of digital rights, was guaranteed. In addition, authorization was requested from the School Councils of the secondary schools, as well as the signed consent of the parents and students.Descriptive analyses were performed to obtain the corresponding mean values and standard deviations or percentages, according to the nature of the variables. The Kolmogorov–Smirnov test was used to analyze the normality of the sample data distribution, and relationships between the variables were determined by the Spearman bivariate correlation test. The Kruskal–Wallis and Mann–Whitney U tests were used to confirm the significance or otherwise of the differences in the mean scores obtained from the questionnaires. We conducted data analysis on SPSS 25.0 .We carried out this research in secondary schools. In total, 53 students (6.03%) were studying in their first year of Compulsory Secondary Education (Educación Secundaria Obligatoria (ESO), Spanish initials), 136 (15.47%) were in their second year, 347 (39.48%) were in the third year and 343 (39.02%) were in their fourth year. The descriptive analysis of the variables is reflected in The sample was sub-divided by sociodemographic characteristics in order to analyze the attitudes and beliefs professed. p = 0.007; EMA: p = 0.007; EMAi: p < 0.001; EMAa: p < 0.001; ASI: p = 0.021; ASIb: p = 0.032; ASIh: p = 0.014). The Kolmogorov–Smirnov test showed that none of the questionnaire results met the normality criterion (DSS: p < 0.01); EMA, H = 45.70, df = 3 (p < 0.01); EMAi, H = 22.03, df = 3 (p < 0.01); EMAv, H = 92.98, df = 3 (p < 0.01); ASI, H = 57.14, df = 3 (p < 0.01); ASIb, H = 54.50, df = 3 (p < 0.01); ASIh, H = 35.53, df = 3 (p < 0.01). The Kruskal–Wallis test adjusted with the Bonferroni correction was carried out, to see the differences between matched school grades  in DSS (Z = −4.816), EMAa (Z = −3.819), ASI (Z = −3.135), ASIb (Z = −3.135), and ASIh (Z = −9.153). Based on relationship status, there were significant differences only for EMA  and EMAi . Relative to location, there were significant differences (p < 0.01) in DSS (Z = −4.829), EMA (−6.507), EMAi (Z = −4.384), EMAa (Z =−8.377), ASI (Z = −4.090), ASIb (Z = −4.050), and ASIh (−3.543).Finally, the Mann–Whitney test was performed to verify the differences according to gender, relationship status and location. According to gender, there were significant differences  among the presence of sexual double standards, romantic love myths and sexist attitudes. The DSS was found to have a significant inverse correlation with excess scales, indicating that the lower the sexual double standards, the greater the romantic myths and sexism (benevolent and hostile). Likewise, if adherence to romantic myths increases, ambivalent sexist attitudes are reversed.These results highlight the existence of significant relationships  to describe the differences in the above variables as a function of the sociodemographic characteristics of the sample and (2) to analyze the interrelationship between these variables. The three variables of ambivalent sexism, sexual double standards and romantic love myths were expected to be correlated with each other.p < 0.01) according to gender, with boys (49.94%) presenting more sexist attitudes (both hostile and benevolent), greater adherence to the romantic love myths , and greater acceptance of sexual double standards. These results are consistent with those found in previous research, both in the context of the adolescent population and in the general population [Regarding the first specific objective, the results obtained reflect significant differences  and EMAi (p < 0.01) scales. These results could be explained by the fact that when one person is in a couple, especially in adolescence, romantic love is idealized and the differences in sexual moral freedoms are intensified according to gender. There are other studies, such as those by Lara et al. [In our study, adolescents who had a partner (64.16%) presented greater adherence to double sexual standards, romantic love myths and the subscale of the idealization of love, with significant differences in the EMA . When analyzing the effect size of the correlations, it can be observed that they were between medium and large, with regard to those occurring between the youngest compared to the oldest. These results may reflect the fact that sex education programs are taught in the last years of ESO. The programs are carried out by health personnel such as nurses and doctors, mainly through lectures and educational interventions [Regarding school grades, younger students and those in the first years of ESO  were significantly more likely to present romantic love myths, sexist attitudes and sexual double standards (ventions . These pventions  in childp < 0.01)—EMA: −0.242; ASI: −0.493; ASIb: −0.431; ASIh: −0.446). This could indicate that gender-differentiated sexual freedom measures very different constructs from sexism and romantic love myths, although at first it seems that they could be concordant. On this basis, they should be studied in future research as separate and inverse constructs. On the other hand, the presence of romantic love myths was directly associated with sexist attitudes, both benevolent and hostile (Spearman’s Rho for EMA (p < 0.01)—ASI: 0.415; ASIb: 0.432; ASIh: 0.296). The correlation between romantic love myths  and sexist attitudes is in agreement with the study of Rodriguez-Domínguez et al. [Regarding the correlations between sexual double standards, romantic love myths, and ambivalent sexism, the stronger the presence of sexual double standards, the weaker the presence of romantic love myths and sexist attitudes (Spearman’s Rho for DSS (z et al. ; hostilez et al. ,39,40. IThe strengths of this study include the fact that it was conducted under optimal conditions of relaxation and concentration for the participants, without the imposition of authority. To our knowledge, this study is one of the few that examines a wide range of factors that, individually or together, may influence gender-based violence among such a young population, taking into account their relationship history. The study also has certain limitations. First, it is cross-sectional in nature and may be subject to selection bias resulting from the non-probability sampling conducted. In addition, the sample population was local. The study could be extended to secondary education and vocational institutions to determine whether extended higher education influences the study variables considered. In future research, moreover, we believe that longitudinal studies of these issues should be conducted and that educational interventions focused on these factors should be designed, tested, and implemented by specialists in the field of sexual health.Among the implications of this study, we would like to highlight the importance of knowing that gender differentiating factors are still present and how they are interrelated. It is important to take them into account, especially in order to promote the healthy psychosocial development of young people, both individually and as couples, since distorted ideas influence their development . LikewisThe adolescents in our study population presented romantic love myths, sexist attitudes and sexual double standards, a pattern that was especially evident among the male population. There were significant correlations among these three factors, all of which may influence the appearance of gender violence. To address this problem, it is important for adolescents to receive appropriate sexual education, addressing among other questions the parameters that may induce violence against women in intimate relationships.


Inborn errors of immunity (IEI) are a heterogeneous group of disorders, affecting different components of the immune system. Over 450 IEI related genes have been identified, with new genes continually being recognized. This makes the early application of next-generation sequencing (NGS) as a diagnostic method in the evaluation of IEI a promising development. We aimed to provide an overview of the diagnostic yield and time to diagnosis in a cohort of patients suspected of IEI and evaluated by an NGS based IEI panel early in the diagnostic trajectory in a multicenter setting in the Netherlands.We performed a prospective observational cohort study. We collected data of 165 patients with a clinical suspicion of IEI without prior NGS based panel evaluation that were referred for early NGS using a uniform IEI gene panel. The diagnostic yield was assessed in terms of definitive genetic diagnoses, inconclusive diagnoses and patients without abnormalities in the IEI gene panel. We also assessed time to diagnosis and clinical implications.For children, the median time from first consultation to diagnosis was 119 days versus 124 days for adult patients . The median turn-around time (TAT) of genetic testing was 56 days in pediatric patients and 60 days in adult patients . A definitive molecular diagnosis was made in 25/65 (24.6%) of pediatric patients and 9/100 (9%) of adults. Most diagnosed disorders were identified in the categories of immune dysregulation , antibody deficiencies , and phagocyte diseases . Inconclusive outcomes were found in 76/165 (46.1%) patients. Within the patient group with a genetic diagnosis, a change in disease management occurred in 76% of patients.In this cohort, the highest yields of NGS based evaluation for IEI early in the diagnostic trajectory were found in pediatric patients, and in the disease categories immune dysregulation and phagocyte diseases. In cases where a definitive diagnosis was made, this led to important disease management implications in a large majority of patients. More research is needed to establish a uniform diagnostic pathway for cases with inconclusive diagnoses, including variants of unknown significance. Inborn errors of immunity (IEI) are a heterogeneous group of inherited disorders affecting different components of the immune system , 2. ClinNext-generation sequencing (NGS) has proven to be useful in the diagnostic evaluation of different diseases –6. In thAlthough NGS is widely used in the evaluation of IEI, its overall diagnostic yield and optimal timing in the diagnostic work up still have to be determined. Moreover, prospective data on the extent of changes in clinical management and prognosis are still lacking. In 2017, consensus was reached among all Dutch genome diagnostic laboratories to adopt a uniform IEI gene panel, based on updates from the International Union of Immunological Societies (IUIS), for nationwide use in the evaluation of IEI , 19. TheWe performed a prospective observational cohort study in patients referred for evaluation of an inborn error of immunity (IEI).We selected data from 165 patients who had a suspicion of an IEI and were referred by a clinical immunologist for next-generation sequencing (NGS) within one of seven Dutch academic medical centers from 2017 to 2020, irrespective of age and sex. Patients were selected when a clinical suspicion of IEI existed, based on clinical manifestations, severity of infections, severity of immune dysregulation and/or laboratory abnormalities. After inclusion, patients were subsequently categorized according to International Union of Immunological Society (IUIS) classification  .In short, 65/165 samples were sequenced using a WGS approach, with a mean coverage depth of 30x . For theA total of 100/165 samples were sequenced using a WES approach, with a mean coverage depth of >50 to >75x, depending on the genome diagnostic center where sequencing was performed . For theA uniform IEI gene panel was designed by the three participating diagnostic centers. During the study period, and following international reporting on IEI related genes, the panel was updated by three-monthly consensus meetings, primarily based on annual updates of the IUIS classification  and on cVariant interpretation was performed according to the ACMG guidelines  and variVariants classified pathogenic (class 5) and likely pathogenic (class 4) were reported to the referring clinician. The variants of unknown significance (class 3) were reported based on clinical relevance. The relevance of the variants of unknown significance was discussed in center based multidisciplinary meetings with clinical laboratory geneticists, clinical geneticists, immunologists, physicians and other experts as required based on the clinical situation. For analysis purposes, we divided the genetic findings into one of the following three categories: conclusive genetic diagnosis, inconclusive outcome , or no abnormalities in IEI panel.A genetic diagnosis was defined as the presence of one heterozygous (likely) pathogenic variant in diseases with autosomal dominant inheritance or when a (likely) pathogenic hemizygous variant was identified in case of X-linked (recessive) inheritance. In case of diseases with a recessive inheritance, a genetic diagnosis was considered confirmed if homozygosity or compound heterozygosity for the (likely) pathogenic variants were found.Risk factors were defined as variants that might contribute to the disorder in a multifactorial context. These variants are not the only cause of the disorder and do not display a monogenic inheritance pattern. This is the case when the frequency of variants in the unaffected general population exceeds the expected frequency for a rare monogenic disorder. They are also referred to as variants with reduced penetrance .Carrierships were defined as the presence of one (likely) pathogenic variants in diseases with autosomal recessive inheritance that are unlikely to contribute to the phenotype of patient. This also includes cases in which a second variant was missed due to technical issues.A VUS was defined as variant with unknown clinical significance. For analysis purposes, we clustered all VUS separately from other inconclusive outcomes.When no (likely) pathogenic variants or variants of unknown significance were identified by the clinical laboratory geneticists, the outcome was categorized as ‘no abnormalities in IEI gene panel’. Incidental findings were reported when identified.After bioinformatic analysis, filtering and subsequent classification of the variants, the potential causative gene variants were reported to the referring clinician.The time to diagnosis was defined as the time between the first consultation for the suspicion of IEI and the genetic diagnosis. We also measured turn-around time (TAT) for NGS based IEI panel diagnostics, which was defined as the time between the arrival of the blood sample in the laboratory and the result of the genetic evaluation.First, we assessed the number of patients that were provided with a conclusive genetic diagnosis, an inconclusive outcome and a genotype without abnormalities in the gene panel. Next, we categorized these patients in IEI subcategories using the IUIS classification. In the conclusive genetic diagnosis group, we reported on the clinical implications for each specific patient.For continuous variables that were normally distributed, mean and range were reported. Median and interquartile range were used in data with a skewed distribution. A Mann-Whitney U test was performed to compare differences in continuous variables between the groups with and without a conclusive genetic diagnosis, and between WES and WGS. A chi-squared test was applied to compare diagnostic yield between patients referred for WES or WGS. Analyses were performed by SPSS software version 26.0 .Overall, 165 patients were enrolled in the study between 2017 and 2020 Table S2Patients were clustered according to their clinical presentations in one of 11 IEI categories based on the IUIS classification . Most pa2(1) = 0.262; p = 0.609).In 65/165 patients, the sequencing data used for the IEI panel analysis were generated using a WGS based approach, versus 100/165 patients using a WES based technique. Of the patients with a conclusive genetic diagnosis, 11 out of 65 (16.9%) were sequenced by WGS, and 14 out of 100 (14%) were analyzed by WES based approach , with a lower mean time to diagnosis in patients under the age of 18 (119 vs 124 days). The range of time to diagnosis was 6 to 2314 days in children and 33 to 6801 days in adults. The overall median TAT was 59 days (IQR 42 days). Median TAT was lower in children (56 days) than in adults (60 days), ranging from 6 to 94 days and 23 to 96 days, respectively. A Mann-Whitney U test did not show a statistically significant difference between children and adults in time to diagnosis  and turn-around time . The median TAT was lower in WES  than in WGS . Differences in turn-around time between WES and WGS were not statistically significant .As shown in PRF1, UNC13D, and STX11, respectively  type 2 , type 3  and type 4 , based on homozygotic pathogenic variants in ectively Table S3PIK3CD, BTK and AICDA, respectively.Patients with a conclusive diagnosis from the antibody deficiency category were diagnosed with activated PI3K-delta syndrome (APDS1) , X-linked agammaglobulinemia (XLA)  and AID deficiency , based on pathogenic variants in NCF1, G6PD and MKL1, respectively.The diagnoses clustered within the phagocyte diseases consisted of autosomal recessive chronic granulomatous disease (AR-CGD) , G6PD deficiency  and MKL1 deficiency , based on pathogenic variants in G6PD variants, that did not fully explain the clinical phenotype of the specific patient  of patients in whom a conclusive genetic diagnosis was made. In cases without a direct change in disease management, the NGS outcome led to confirmation, continuation and/or optimization of existing therapy. As shown in  patient Table S3In 9/25 (36%) of cases with a conclusive diagnosis, the genetic diagnosis led to an HSCT indication. This was the case for 6 patients with FHL, and for patients with MKL1 deficiency (n=1), APDS (n=1), and X-linked lymphoproliferative syndrome (n=1). In one patient, a referral for HSCT was recalled based on the outcome of the genetic evaluation. This patient proved to have Ataxia Teleangiectasia, which led to the decision to defer from HSCT. In the patients with ADA2 deficiency and G6PD deficiency, disease specific consultation was initiated.Risk factors were identified in 13/165 patients (7.9%) Table 1.TNFRSF13B. Seven of these patients had a clinical diagnosis of common variable immunodeficiency disorder. TNFRSF13B variants in CVID patients were interpreted as contributing to clinical manifestation, and not as genetic diagnosis. Variants in this gene were also identified in one patient in the immune dysregulation group and once in the autoinflammatory disease group. Two patients were diagnosed with a risk factor in TLR3. Both patients were categorized in the combined immunodeficiencies group.Nine patients were diagnosed with a variant of TCIRG1 variant in a patient with pancytopenia, an IL36RN variant in a patient with refractory eczema, and in a UNC13D variant in a patient with hemophagocytic lymphiohistiocytosis. No additional evaluations  were performed in these cases, and a definitive diagnosis could not be made in these patients.Carrierships were identified in 25/165 patients (15.2%) and were predominantly found in the categories of antibody deficiencies , combined immunodeficiencies  and immune dysregulation . In three cases, the phenotype of the patient matched the disease for which carriership was detected, raising the suspicion of a second variant on the other allele, which was however not detected by NGS. Specifically, this was the case for a The other carrierships identified in the study cohort were not compatible with the clinical manifestations and were therefore not explicitly mentioned as such.RAB27A variant with a clinical diagnosis of FHL. An NFKB1 variant was found in a patient with recurrent autoimmune hemolytic anemia, antibody deficiency and splenomegaly and a TRAF3 variant was found in a patient with antibody deficiency.In 38/165 (23%) patients, one or more heterozygous variants of unknown significance in autosomal recessive diseases were reported. In this group, no second pathogenic variants were found and the clinical manifestations were not matching. At the start of the study, there was no consensus on the reporting of VUS within the diagnostic trajectory. Therefore, the number of patients with a reported VUS might be an underrepresentation of the number of patients were a VUS was detected. In four patients, potentially relevant VUS were reported. This was the case for a patient with a homozygous NFKB1 (n=1) and TRAF3 (n=1) were designated as matching with the clinical manifestations. Follow up testing was not performed, and no alterations in clinical management were noted.In the patients with inconclusive outcomes, SNP arrays were performed in one patient with a risk factor, in three patients with carrierships and in two patients with a VUS. Results revealed a negative outcome. Variants in In 64/165 patients (38.8%), no genetic explanation for the clinical manifestations was found during our study Table 1.In patients without abnormalities identified in the gene panel, the result of the IEI panel did not have specific clinical implications. Clinical management was unchanged and in some cases additional testing was performed, that did not involve further immunological evaluation. Within this group, in two patients, the outcome resulted in the end of the immunological diagnostic trajectory and follow up.In this study we evaluated a prospective cohort of 165 patients with a suspicion of an inborn error of immunity (IEI) and assessed the outcomes of NGS as an early routine diagnostic tool. Introduction of uniform NGS based IEI diagnostics in The Netherlands resulted in a diagnostic yield of 24.6% in pediatric patients and 9% in adults, resulting in an overall diagnostic yield of 15.2%. This yield varied from 0-42%, depending on immune deficiency disease category, with highest yields found in the disease categories immune dysregulation and phagocyte diseases. In all cases with a conclusive genetic diagnosis, this result had direct clinical implications.Patients presenting with severe clinical manifestations and life-threatening complications were more likely to receive a conclusive molecular diagnosis, compared to patients with a less severe phenotype. Conclusive genetic diagnoses led to referral for hematopoietic stem cell transplantation (HSCT) in 9 out of 25 (36%) patients, including those with a diagnosis of hemophagocytic lymphohistiocytosis (FHL) and X-linked lymphoproliferative syndrome (XLP2). Especially within these IEIs, adequate and early diagnosis is important, as timely diagnosis and earlier initiation of HSCT is associated with improved outcome , 24–30. We observed that antibody deficiencies represented the majority of our study cohort, with a total of 55/165 33.3%) patients. This is consistent with previous findings as they comprise the most prevalent symptomatic category of IEI , 33 and .3% patieIn many cases, the outcome of NGS remained inconclusive despite the presence of variants in genes known to be associated with IEIs, as was the case for different VUS, carrierships and risk factors. Guidelines for the interpretation of germline variants are available , but intG6PD variants. The G6PD variants reported in our study could have been designated as incidental finding. Nevertheless, G6PD has been classified as related to IEI and was therefore included in the IUIS classification , are currently made as diagnostic yields may increase and become more precise with this technique . To makeThe diagnostic yields of 24.6% in children and 9% in adults are comparable to the percentages found in other publications, including a study by Arts et al. published in 2019 . By contAll Dutch genome diagnostic centers have implemented NGS-based diagnostic tools . DiffereWe took different steps to make the process of NGS based IEI diagnostics uniform and feasible across all genome diagnostic centers. First, a uniform NGS based IEI panel was used to evaluate all patients. Prior to the implementation of this technique as part of the standard evaluation in patients with a clear suspicion of IEI, different NGS based IEI panels were offered in the participating university hospitals. At introduction of the technique in the standard work up, a uniform IEI panel was agreed upon, based on the IUIS classification at that moment. In three-monthly consensus meetings, this panel was expanded for all participation genome centers from 360 genes to 426 genes at the end of the study. We further performed a national external quality assessment  to ensurGATA2 variant that was considered to be somatic, as we did not detect it in other tissues tested in this patient. Theoretically, a WGS based approach could yield higher percentages of conclusive diagnoses compared to WES based approach, as it enables the detection of non-coding variants , Leiden, NetherlandsSchölvinck, EH Department of Pediatric Infectious Diseases and Immunology, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, The NetherlandsSimon, A. Department of General Internal Medicine, Radboud University Medical Center, Nijmegen, The NetherlandsStol, K. Department of Pediatric Infectious Diseases and Immunology, Amalia’s Children Hospital, Radboud University Nijmegen Medical Centre, Nijmegen, The NetherlandsVervenne RML. Department of Genome Diagnostics, Amsterdam University Medical Center, Amsterdam, The NetherlandsWe state that the co-authors have performed the following tasks for the paper: KE: Data collection, overall writing the paper. MH: Generation of data, making it ready to analyse, education of the PhD student on interpretation variants, and co-writing. IH: Generation of data, making it ready to analyse and co-writing. AS: Generation of data, making it ready to analyse and co-writing. EZ-H: Generation of data, making it ready to analyse and co-writing. LV: Generation of data, making it ready to analyse and co-writing. HL: Inclusion/selection patients, entering data, co-writing. SH: Inclusion/selection of patients, entering data, co-writing. MD: Inclusion/selection of patients, entering data, co-writing. FV: Inclusion/selection of patients, entering data, co-writing. JP: Inclusion/selection of patients, entering data, co-writing. DB: Inclusion/selection of patients, entering data, co-writing. VD: Inclusion/selection of patients, entering data, co-writing. CV: Inclusion/selection patients, entering data, co-writing. AV: Inclusion/selection patients, entering data, co-writing. AL: Responsible for the process of handling incoming samples, co-writing. KA: Generation of gene panel, co-writing. PH: Inclusion/selection patients, co-writing. GB: Inclusion/selection patients, co-writing. TK: Inclusion/selection patients, co-writing. GF: Co-writing. MG: Supervision, education of KE on sequence variants, overall guidance and writing. JM: Supervision, overall guidance and writing. All authors contributed to the article and approved the submitted version.This study is part of the Genetics First: next-generation sequencing for cost-effective PID diagnostics project. This project is funded by ZonMw (grant number 846002001).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.