Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC.Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology.p = 0.1) or the combination of MH, US, and UC (94.9%) . The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations .In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients. Non-muscle invasive bladder cancer (NMIBC) is present in approximately three-fourths of patients diagnosed with bladder cancer, and it is estimated that 20–40% will be at high risk of disease recurrence and progression . The risSurveillance after the initial resection is an integral part of the management protocol and should reflect the individual patient’s degree of risk. In most guidelines, it is agreed that follow-up should be done every 3–6 months in the first 2 years and then every 6 months to 1 year for the next couple of years and then yearly thereafter , and morIn addition to cystoscopy, urine cytology (UC) has a pivotal role notably in high-grade disease and might improve surveillance accuracy ,12. BesiTo combat the FC limitations, and for the sake of improving the patient experience during follow-up, we aimed to prospectively compare the performance of a combination of three daily used, non-invasive measures, namely microscopic hematuria (MH), abdominal ultrasonography (US), and UC, and as possible substitutes for FC in patients undergoing surveillance for T1-low-grade (T1-LG) NMIBC.A retrospective analysis for prospectively collected data was conducted for patients undergoing surveillance after TURBT for T1-LG NMIBC in a tertiary referral center over a period of 12 months. The protocol of the study was approved by the institutional review board before patient enrollment, and written informed consent was taken (Mansoura Faculty of Medicine IRB: MS/15.08.68). The authors confirm the availability of, and access to, all original data reported in this study. All patients who underwent TURBT with initial pathology of T1-LG disease and were scheduled for surveillance were included. Grading was evaluated according to the WHO 2004 grading system. Patients with biopsy-proven high-grade or muscle-invasive disease, carcinoma in situ, gross hematuria, persistently positive urine culture, or had contracted bladder were excluded. All of our patients received immediate intravesical instillation of Epirubicin. Maintenance intravesical instillation was continued in due patients according to the EUA guidelines.Demographics included age, gender, associated comorbidities, body mass index (BMI), and the time since the last TURBT. Urine clean catch samples were withdrawn before and after FC to assess the incidence of UTI. Patients with positive urine culture received the appropriate antibiotics, and the culture was rendered negative before the procedure. For the assessment of patients’ experience, a visual analog score (VAS) was obtained during FC, and a question was asked (satisfied/unsatisfied). Additionally, IPSS data before and 1 week after FC were collected.Initially, patients underwent urine analysis for MH followed by referral to a dedicated uro-radiologist for transabdominal pelvic US, and then an appointment was scheduled to undergo outpatient FC during which UC was obtained. Patients with negative findings of all the tests were discharged and considered negative, while inpatient cystoscopy and biopsy were performed if any of the test results were positive.Urine samples were collected and examined for hematuria by microscopic examination of the urine sediment. For cytological evaluation, urine samples were collected by bladder washing with saline before FC and were sent for cytology. Urine was centrifuged, cyto-spinned, and stained with Papanicolaou stain and examined by an academic pathologist. The US was performed by a dedicated radiologist who was blinded to the findings of the other tests, and changes in the lining mucosa were described. Then, patients were subjected to FC by a dedicated experienced urologist. In the indicated patients, rigid cystoscopy under anesthesia was then carried out, and biopsy from any suspicious area and multiple random biopsies from the rest of the bladder mucosa were taken and sent for histopathology.The research question was how much negative MH, US, and UC were accurate in excluding the presence of bladder cancer and consequently might ameliorate the need for FC. Hence, we compared primarily the negative predictive value (NPV) of MH, UC, and US and their relative combinations in comparison to FC for the detection of recurrent bladder cancer. Positive test results were considered for MH if ≥3 RBCs/HPF was present as suggested by the AUA guidelines , and forhttp://www.r-project.org) with the package DTComPair.All data were prospectively collected and maintained in an electronic database. The sensitivity of a test is defined as the percent of patients with the disease for whom the test is positive . A comparison of sensitivity between the two measures was performed using the McNemar test. The negative predictive value (NPV) is defined as the percent of individuals in whom the test is negative, and the disease is not present [true negative/test negative  × 100]. Statistical differences of NPV were calculated with the generalized score statistic test. Specificity and PPV were not the primary targets of the study. Wilcoxon signed-rank test was used for paired comparison of non-parametric variables. Statistical analysis was performed using IBM v.25 statistical software and R programming language v. 3.6.3 (p = 0.01). Thirty-six (17%) patients showed positive urine culture following FC. The median (IQR) VAS was 7 (4–8), and 87% of the patients were not satisfied regarding the FC experience. A total of 218 patients, 202 males representing 92.6%, were included in the study. The median (IQR) IPSS score before FC was 11  and has increased to 14  1 week after the FC . Two lesions (pTa) were missed being in the trigone close to the bladder neck in elderly patients with a bulging median lobe. Another lesion (pT1) was located in the anterior wall close to the bladder neck. These lesions were detected by ultrasound examination as focal intraluminal growth and two were tested positive for MH. On the other hand, the combination MH/US was falsely negative in five patients; all were small (<1 cm) papillary lesions (3 pTa and 2 pT1) and were detected by FC. The addition of UC to the MH/US combination excluded one of these patients.p = 0.1) or the combination of MH, US, and UC (94.9%) . The reported sensitivity results were similarly comparable between FC (94.2%) and the previous combinations . Among MH, UC, US, and FC, the latter had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of MH and US (93.8%) (difference = 0.04, Generally, the surveillance test depends upon the target population to be studied. If a marker is planned to be used for bladder cancer screening in the general population, the primary target is to have a high positive predictive value to reduce anxiety and further expensive investigations in false-positive cases. Conversely, if a marker is to be used for monitoring a high-risk population, the marker must have a high negative predictive value to detect each case of the targeted pathology . Our stuDespite all technological advances, Koo et al. recently reported that two-thirds of patients under surveillance for NMIBC experienced a variable degree of procedural discomfort or worry; hence, attempts to alleviate the process-related stress are ongoing . Therefode novo infection-related to FC. Although 18% of our patients showed evidence of newly acquired UTIs following FC, the clinical significance of this bacterial infection was limited, and none of them was hospitalized for urosepsis. Herr reported that only 2% developed febrile UTIs following this invasive outpatient procedure [We elected to include infection-free patients and those with persistent UTIs were excluded from our protocol. The aim is to accurately determine the incidence of rocedure . We beliCurrently, the calculation of the cost-effectiveness of any diagnostic and interventional procedure constitutes a pivotal role in sound medical practice. In fact, surveillance cost explains why NMIBC is considered one of the most expensive cancers to manage . MossaneWe have included patients with T1-LG disease and excluded high-grade diseases to attempt to improve the sensitivity and NPV of the diagnostic combination tests. According to the EAU guidelines, most of the tumors infiltrating the lamina propria would require lifelong surveillance . NeverthUrine analysis for MH was included for being readily available, non-invasive, and as MH is closely pertinent to urothelial cancers . AccordiMore than three decades ago, the transabdominal US was suggested as a non-invasive, cost-effective diagnostic for surveillance of NMIBC ,27. NeveAlthough the addition of MH to US has reduced the number of falsely negative lesions by only one, it is important to highlight the merits of adding MH to US. First, urine analysis is routinely performed in everyday practice, so it would not add a significant extra-cost for the diagnosis. In addition, MH has improved the results, and consequently, its importance might emerge in large cohorts of patients.We introduce a non-invasive, readily available, and cheap combination for the surveillance of NMIBC that would be considered the first station. If both modalities yielded negative results, in this case scenario, FC could be precluded. On the other hand, if any had positive results, FC should be recommended. In this study, this combination could exempt approximately one-third of patients from doing FC without potentially compromising cancer detection. Further studies with a combination of urinary biomarkers might heighten the accuracy of the proposed combinations.Nevertheless, the study is not devoid of its weakness. We did not account for approved urinary biomarkers, which have shown clinical significance in the surveillance of NMIBC . We acknThe combination of negative transabdominal US, the absence of MH in urine analysis, and optionally negative cytology could be safely considered as the first station for NMIBC surveillance in patients with T1-LG disease. This approach might mitigate the need for FC in this selected group of patients without compromising cancer detection. Further studies are needed to validate these findings.


The intra-reader reliability was excellent [ICC (95% CI) of 0.91 (0.88–0.95)] and the inter-reader reliability was good (0.80 (0.71–0.86). The assessment of EF was feasible, with a mean time of 2 min. No correlations were found with disease activity indices in PsA patients. Conclusion: The assessment of EF is a feasible and reproducible test and may be explored as a potential imaging biomarker.The aims of this study were as follows: (1) To evaluate the entheseal fibrocartilage (EF) during Achilles tendon insertion in patients with Psoriatic Arthritis (PsA) by using power Doppler ultrasound (PDUS), (2) to assess the intra and inter-reader reliability of the evaluation of EF thickness, (3) to compare the EF thickness of PsA patients, athletes and healthy controls (HCs), and (4) to evaluate the correlations between EF abnormalities, disease activity and functional indices in PsA. Methods: Consecutive PsA patients attending our unit were asked to participate. HCs and agonist athletes were enrolled as a control group. A bilateral PDUS evaluation of Achilles tendons was performed in order to evaluate the EF in all patients and controls. Results: In total, 30 PsA patients, 40 athletes and 20 HCs were enrolled. The median (IQR) EF thickness among the PsA patients, athletes and HCs was 0.035 cm (0.028–0.04) cm, 0.036 (0.025–0.043) cm and 0.030 (0.020–0.038) cm, respectively ( Psoriatic Arthritis (PsA) is a chronic inflammatory disease that is characterized by the presence of arthritis, enthesitis, dactylitis and axial involvement in patients with a personal or family history of psoriasis, and is a disease in which different clinical manifestations run together ,2. Of thRecently, OMERACT published a scoring system for enthesitis that assesses the presence/absence of hypoechogenicity, thickening, calcifications/enthesophytes, and erosions, as well as color Doppler activity semi-quantitatively expressed from 0 to 3. This tool allows the assessment of enthesitis in the whole group of SpA to be better evaluated and standardized .On the other hand, from a pathogenetic point of view, improvements in PDUS imaging techniques may further enhance our capacity to evaluate the inflamed target tissue in SpA and PsA ,13,14. IEntheseal fibrocartilage (EF) can be assessed using different imaging tools, including magnetic resonance imaging (MRI) and PDUS. However, the disadvantages of MRI include patient discomfort, the lack of availability, and time and cost; meanwhile, the availability of high-resolution PDUS can ensure a good visualization of this important tissue, which can be visualized as an anechoic layer at the enthesis, immediately adjacent to the bone ,18.The validity of using PDUS to visualize EF in terms of face and content was demonstrated in one study , but theFurthermore, few studies have been published on the modifications made to fibrocartilage during growth, aging processes or in biomechanical stress conditions ,20; therIn this light, the aims of this study were as follows: (1) to evaluate the EF during Achilles tendon insertion by using PDUS in PsA patients, (2) to assess the intra and inter-reader reliability of the evaluation of EF thickness, (3) to compare the EF thickness of PsA patients, athletes and healthy controls (HCs), and (4) to evaluate the correlation of EF thickness with disease activity and functional indices in PsA.A cross-sectional study that included consecutive PsA patients who attended our Unit , fulfilled the inclusion criteria and were asked to participate was conducted. Furthermore, soccer and basketball players attending the Sport Medicine clinic of our department for routine controls that fulfilled the inclusion criteria, and a group of HCs, were asked to participate and were enrolled as control groups. All patients and controls were enrolled from March 2022 to October 2022.(1)Age < 50 years-old.(2)Satisfying CASPAR criteria for PsA .The inclusion criteria for the PsA patients were as follows:(3)At least 5 years of competitive activity and at least 10 h of weekly training.(4)Absence of any musculoskeletal complaints in recent years.The inclusion criteria for the athletes were as follows:The exclusion criteria included participants of the age < 18 years old.Demographic and clinical data, including age, sex, height, weight, body mass index (BMI), smoking habits and hours of weekly training (for the athletes group), were collected for each patient and the controls. Finally, it was ensured that PsA patients had not been athletes in the past.A detailed medical history and physical examination data were collected for all patients. Demographics and disease characteristics, including disease duration, level of education and pattern of articular manifestations, were evaluated. The laboratory parameters included the C-reactive protein test (performed within two weeks of enrollment) as a part of the routine monitoring of our patients. The clinical assessment was performed by the same expert rheumatologist (EL) and encompassed an evaluation of 68 tender and 66 swollen joints, experiencing enthesitis and dactylitis. The pattern of articular involvement was also collected, as well as comorbidities and related diseases. Enthesitis was assessed by using the Leeds Enthesitis Index (LEI) , and dacPatients, athletes and HCs underwent a PDUS evaluation during bilateral Achilles tendon insertions. PDUS assessments, using the grey scale and power Doppler modes, were performed in a darkened room by two rheumatologists (FMP and SS) using the same equipment, who were blinded to the study groups and to each other’s findings. Patients were asked to take a prone position with their feet hanging over the examination table in a neutral position for the assessment of the Achilles tendon insertion. Bilateral ultrasound examination was carried out using a multiplanar scanning technique. Particular attention was paid to minimizing the transducer pressure on the anatomical structures by using a large amount of gel. Care was also taken to alter the angle of the probe in order to prevent anisotropy. High-resolution US assessment was performed using a Samsung HM70A plus device with linear 6–18 MHz probes. For PD examinations, the pulse repetition frequency was set to 800 Hz. Images were electronically stored and blinded in order to determine the time point of acquisition and a given subject. To assess the intra-reader reliability, images were re-assessed after two weeks.Findings consistent with entheseal pathology were graded both on a binary scale in the grey scale mode and semi-quantitatively from 0 to 3 in the power Doppler mode, as previously described . FurtherThe thickness of the anechoic layer was measured at its thickest point in the longitudinal scan a, as preEF abnormalities, such as focal disappearing and erosions of the cortical bone, were also evaluated.The study was approved by the institutional review board of the University of Molise (protocol n. 0001-017-2021) and performed according to the Helsinki declaration. Written informed consent was obtained for all patients and controls regarding their participation in the study and the use of clinical data.Statistical analysis was performed using IBM SPSS Statistics for Macintosh, Version 28.0.Numerical variables were summarized by using the median and Inter-Quartile Range (IQR), or the minimum and maximum value (min/max).Intra and inter-reader reliability were assessed by using the intraclass correlation coefficient-ICC .t test for unpaired data for variables normally distributed, and the Mann–Whitney test was used for unpaired non-normally distributed variables. We used the Shapiro–Wilk test to evaluate the distribution of the variables.For continuous variables, the significance of the differences was determined using the Student’s p ≤ 0.05 value was deemed statistically significant.Correlation between the EF thickness (mean between the two sites) and clinical features was evaluated using Spearman’s Rho. Kruskal–Wallis analysis was carried out to evaluate the differences in EF among the three groups. Dunn’s post hoc tests were carried out on each pair of groups. Categorical variables were compared using the χ-square test or Fisher’s exact test. A We enrolled 30 PsA patients, 40 athletes and 20 HCs. A total of 178 enthesis sites were evaluated (one athlete had missing data).Of the 30 PsA patients, 4 (13.3%) reported previous Achillodynia. The others did not report entheseal symptoms in their clinical histories.During PDUS examination, no statistically significant differences were found between the two sides (right and left within each group).The intra-reader reliability was excellent [ICC (95%CI) of 0.91 (0.88–0.95)] and the inter-reader reliability was good [ICC (95% CI) of 0.80 (0.71–0.86)]. p = 0.05 between PsA and HCs; p = 0.008 between athletes and HCs). PsA patients and athletes had a statistically significant higher EF thickness with respect to HCs. Moreover, no differences were found between the sexes in terms of the EF thickness.Interestingly, no statistically significant correlations were found between the EF thickness and BMI, age, disease duration, LEI, DAPSA, and PsAID in PsA, and no correlations were found between clinical characteristics and the hours of training per week in athletes .Of note, during the PDUS examination of the enthesis, erosions and power doppler positivity within 2 mm from the cortical bone were present in four of the PsA patients. Erosions were not found in athletes and HCs. In the four PsA patients with cortical bone erosions, EFIwas not visible within the erosion. One HC showed power doppler positivity at the entheseal site. Enthesophytes were generally more present in athletes. Enthesitis is the hallmark of SpA, including PsA. Inflammation at entheseal sites also affects the bone and other structures, such as bursae, and supports the concept of a synovial–entheseal complex that has been proposed by McGonagle et al. in recent years ,30. The Our results partially agree with those previously published. In particular, some differences and similarities have been found: (1) the median EF thickness values reported in our study are slightly lower than those reported by Aydin et al. This could be related to the different US equipment used; (2) the measure of EF was feasible and reliable and could be easily performed in clinical practice; and (3) our study confirms the EF interruption when erosive changes are present but, interestingly, also demonstrates a slight but statistically significant increase in the EF thickness in PsA patients and athletes compared to HCs.This result is of particular interest, since, in patients without clinically evident enthesitis, changes in EF could be observed, resembling those seen in agonist athletes; however, the clinical significance of this result must be further evaluated.Furthermore, no patients had clinically active enthesitis and most of the patients were in good control of the disease. This, in turn, may be the reason for the lack of correlation between EF thickness and the composite measure of disease activity. It could be speculated that EF thickness represents a marker of damage in athletes due to repeated trauma while that of long-term damage in PsA patients.We also confirm the reproducibility of the EF assessment using PDUS examination with good values of ICC found regarding the intra and inter-reader reliability.Moreover, the assessment of EF was feasible and quick, and required no more than 2 min.In this light, PDUS of EF could be integrated into the evaluation of the enthesis organ and may provide further information regarding both PsA and SpA, in which clinical and PDUS findings do not always overlap ,35.This study has some limitations: the cross-sectional design does not permit the assessment of sensitivity to change, and thus further studies are needed. Moreover, we did not enroll patients with degenerative diseases such as osteoarthritis, which may produce abnormalities in the EF. Finally, the median age and sex were not balanced between the three groups; however, no correlation was found between EF thickness and age.In conclusion, this study has demonstrated the reliability of the evaluation of EF thickness and significant differences in respect to HCs. However, we fail to demonstrate a correlation with the disease activity indices, probably due to the factors mentioned above.Our pilot study potentially suggests the use of EF assessment in the evaluation of PDUS abnormalities in PsA patients and may pave the way for further large studies on this particular aspect.


The length of treatment was six months. The follow-up after treatment was six months. Patients were evaluated before, during, and after treatment through clinical visits, laboratory tests, and the application of four questionnaires . Results: No statistically significant difference was observed for the depression and sleepiness questionnaires. However, in the Lanns scale for pain, all groups decreased the mean and median values in time (p = 0.001), without differentiation among the groups (p = 0.188). The recurrence rates of genital herpes within 60 days after treatment were 15.8%, 33.3%, and 36.4% in the melatonin, acyclovir, and association of melatonin with acyclovir groups, respectively. Conclusion: Our data suggest that melatonin may be an option for the suppressive treatment of recurrent genital herpes.Suppressive therapy of recurrent genital herpes is a challenge, and melatonin may be an alternative. Objective: To evaluate the action of melatonin, acyclovir, or the association of melatonin with acyclovir as a suppressive treatment in women with recurrent genital herpes. Design: The study was prospective, double-blind, and randomized, including 56 patients as follows: (a) The melatonin group received 180 placebo capsules in the ‘day’ container and 180 melatonin 3 mg capsules in the ‘night’ container ( Genital herpes is an infectious disease caused by the herpes simplex virus (HSV), especially type II, with a recurrent character and increasing worldwide prevalence . HSV remMelatonin, produced by the pineal gland, influences several physiological processes  acting tAspergillus sp., given once a day for seven days, was compared with acyclovir 200 mg, five times a day, for five days. The study found a significant benefit with the combination containing melatonin [Recently, a combination of melatonin, magnesium, phosphorus, and acids extracted from elatonin . It was elatonin . As the https://clinicaltrials.gov/ (accessed on 5 February 2019), under number NCT03831165, in February 2019. The study was approved by the Ethics Committee of HCFMUSP . The study followed the statement of ethical principles for medical research involving human subjects from the Declaration of Helsinki.A prospective, double-blind, randomized study was conducted at the Lower Genital Tract Pathology (PTGI) Outpatient Clinic of the Gynecology Division of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). The study protocol was registered in Initially, volunteers from the PTGI Outpatient Clinic, Collaborator Specialties Center, Basic Health Units, and women invited by the media  were referred for screening and selection. All participants were informed about the nature of the study and signed an informed consent form. Of these women, 90 were eligible and randomized. Because there were follow-up losses and dropouts, fifty-six women completed the study. Nineteen (33.9%) were randomized in the melatonin group; 15 (26.8%) were randomized in the acyclovir group, and 22 (39.3%) were randomized in the acyclovir with melatonin group .Recruitment began on August 2018, and follow-up finished on August 2019. No interim analysis was performed, and the trial ended when all patients completed the follow-up period. Only women between 15 and 49 years with a clinical diagnosis of recurrent genital herpes were included. Pregnant or postpartum women (up to 3 months), use of oral acyclovir in the last 60 days, autoimmune diseases, immunosuppression , active liver disease, undiagnosed vulvar ulcers, severe depression (Beck inventory ≥ 30), use of antiviral drugs, immunosuppressants, antidepressants, imiquimod, allergy to melatonin or acyclovir, and women with gynecological cancer were excluded. Other eligibility criteria were the ability and willingness to provide written informed consent for the study.n = 30), melatonin (n = 30), or acyclovir with melatonin (n = 30). The drug of each group was not known either by the patient or by the researcher until the end of the study. The allocation number of each participant was placed in a well-sealed, opaque envelope. A nurse outside the research team was responsible for distributing the medication to the participants. Names of patients and hospital were recorded in the envelopes. The envelopes were stored in an appropriate place within the institution.Simple randomization was performed through the Randomizer iOS application. Eligible women were randomized to receive acyclovir , in which acyclovir and melatonin were previously analyzed and approved according to their pharmaceutical specifications. The drugs were inserted into capsules that were not different in odor, shape, color, and size. Capsules were stored in bottles that were delivered to the participants by nurses of the Gynecology Outpatient Clinic. All women received two containers, labeled ‘day’ and ‘night’, and were instructed to take one capsule, orally, from the ‘day’ container at 10 AM and one capsule, orally, from the ‘night’ container at 10 PM for six months. The acyclovir group received 360 capsules of 400 mg acyclovir twice a day , adverse effects , and other possible occurrences, such as feelings of happiness or sadness, better or worse physical and psychological disposition, improvement or worsening of sexual performance, and mood change. In addition, the patients were submitted to general and gynecological physical examinations. On the sixth visit, 180 days after the beginning of the medication, possible side effects were verified and cured, and permanence or appearance of vulvar lesions were evaluated through physical examinations. Post-treatment follow-up was performed on the seventh and eighth visits, scheduled for 30 and 60 days, respectively, after the end of the medication. At this time, the results of laboratory tests, possible side effects, and disclosure of the medication used for each participant were revealed.Blood samples were collected to perform complete blood count , blood glucose (hexokinase method), HIV serology (electrochemiluminescence method), VDRL (flocculation method), and HSV . Immunophenotyping of T lymphocytes (CD4/CD8 ratio) was performed using flow cytometry  in the Flow Cytometry Laboratory, Instituto do Câncer do Estado de São Paulo (ICESP).The investigators used patients’ responses to fill out the following questionnaires: (a) Beck’s Depression Inventory, composed of 21 categories of symptoms and attitudes that reveal cognitive and affective behaviors related to depression ,14; (b) Participants who missed the outpatient scheduled visits were called by telephone or message through the WhatsApp application for new scheduling. When women did not attend the rescheduled appointment, or in the event of a change of address or telephone number without notification to the researcher or institution, she was considered as follow-up failure. Patients who became pregnant during the study, who used less than 80% of the capsules, or lost their medication, were also considered follow-up failures .Shapiro–Wilk and Kolmogorov–Smirnov tests were used to access data distribution previously to the statistical analysis. For variables with parametric distribution, data were expressed as mean, standard deviation, median, and interquartile range (IQR) for data with nonparametric distribution. Categorical data were expressed as total numbers and proportions.To test the hypothesis of nonmodification in the measurements among the different group interventions in time, ANOVA model was used, and the Tukey post hoc test, when applicable . Wilcoxot-test was applied to compare the recurrence of herpes between 30 and 60 days in the same group. All tests considered a bidirectional alpha of 0.05 and were performed using the R software (https://www.r-project.org (accessed on 22 September 2021), LD package for nonparametric analysis, IBM SPSS 25 , and Excel 2016 ® (Microsoft Office).The Relative Treatment Effects (RTEs) were calculated by ∆ treatment\∆ time. The paired The data on the prevalence of herpes in the the Brazilian population of women were accessed to calculate the apropriate sample number of patients to be included in this study. Based on two studies ,22, and p = 0.010).The median and IQR (interquartile range) age was similar among the melatonin, acyclovir, and acyclovir plus melatonin groups: 41; 32–42 years, 42; 33–48 years, and 42; 30–50 years, respectively. No significant differences were observed for age of menarche, age of first sexual intercourse, number of sexual partners, number of pregnancies, parity, abortion, or body mass index . The socp = 0.228) and at 60 days (p = 0.369), a lower percentage of recurrence after 60 days was observed in the melatonin group compared to the others, although not statistically different.p = 0.451). Although the melatonin group recorded a higher mean evolution (2.16 ± 0.69 to 2.46 ± 0.47), no significant difference was observed among the groups.p = 0.001), without differentiation among the groups (p = 0.188). The VAS also presents variability in time (p < 0.001) and among groups (p = 0.002); however, none of the findings displayed any significant interaction among the groups and times  estimates that there are 572,000 new genital herpes infections in the United States in a single year. Recurrences can occur even in those who were treated during their initial infection because treatment does not eradicate the latent virus, which can subsequently reactivate. Over time, the first recurrence may affect less than 20% of patients, but the number of subjects with a chronic recurrent form (>10 recurrences) is low . Those patients need chronic suppressive therapy with acyclovir for a long time, and the asymptotic period is short. Therefore, new treatments, such as melatonin, may be an option for those women . ConsideIn previous studies, a combination of melatonin with magnesium, phosphorus, and fatty acids extracted from Aspergillus sp for seven days has shown to improve HSV symptoms in more than 95% of patients , suggestRegardless of the type of treatment used in this study, there was an increase in the total number of leukocytes and lymphocytes at the end of the study. These cells are responsible for combating the virus . CD4 T lRegarding the questionnaires applied, the VAS and Lanns scales were used to evaluate the variable pain differences demonstrated among the groups. Because this scale may have a few limitations and be biased by depressive symptoms, the Beck scale was also applied ,14. In tIt should be considered that the recurrences themselves can cause high levels of emotional stress, emphasizing that one third of patients have more than six recurrences per year that impact on the quality of life . AnotherThe SF-36 questionnaire , a multidimensional instrument , was usen = 5). HSV disease causes significant harm to the patient‘s quality of life, while a full cure does not occur due to the viral persistence inside of the organism. Our manuscript evaluated the use of melatonin versus acyclovir both in monotherapy and in combination. It should be noted, however, that the strength of this study is that the effect of melatonin alone on genital HSV was evaluated, while another study evaluated a compound [The present study has some limitations: (a) loss of patients during the study; 16 participants did not attend the scheduled visits; 2 gave up because they were pregnant; 1 presented excessive sleepiness; 3 lost medications; 10 did not take the control tests in the correct period, and 2 did not deliver the final questionnaires. Given that all types of treatment employed are in the long term, this naturally decreases the patient’s adherence ; (b) somcompound . AdditioIn short, melatonin may be considered a therapeutic option in the treatment of recurrent genital herpes, especially in women with resistance to antiviral drugs, such as acyclovir. However, the study demonstrated that its association with acyclovir would not add any advantage. On the contrary, it could increase recurrence. Some of the factors that may have influenced the results of the present study include the inhibitory action of melatonin on thymidine kinase, which is an important enzyme for the activity of acyclovir on herpetic infection.Finally, melatonin contributes to protecting the oral cavity from tissue damage due to the action of its receptors. The experimental evidence suggests that melatonin can be useful in treating several common diseases of the oral cavity, such as HSV disease . In our Our data suggest that melatonin may be used as an option for suppressive treatment of recurrent genital herpes.


We aimed to determine the association between red blood cell transfusions (RBCT) and bronchopulmonary dysplasia (BPD) in neonates.A systematic review and meta-analysis were conducted using data obtained from literature search of PubMed, Embase, and Web of Science from their inception till May 1, 2022. Two reviewers independently selected potentially relevant studies, and after data extraction, they assessed the methodological quality of the included studies using the Newcastle–Ottawa scale. Data were pooled using random-effects models in Review Manager 5.3. Subgroup-analysis was performed based on the number of transfusions and adjusted results.Of the 1,011 identified records, 21 total case-control, cross-sectional, and cohort studies were selected, which included a total of 6,567 healthy controls and 1,476 patients with BPD. The pooled unadjusted odds ratio  and adjusted OR  showed significant association between RBCT and BPD. A substantial heterogeneity was noted, which could be due to different variables controlled for in each study. The subgroup analysis showed that heterogeneity may be partially explained by the extent of transfusion.The association between BPD and RBCT remains unclear based on the current data due to the substantial heterogeneity among the results. Well-designed studies are still needed in the future. Bronchopulmonary dysplasia (BPD) is a common complication in preterm infants. This complication can lead to asthma, wheezing, limitation of activity tolerance, and recurrent low respiratory tract infections , 2. InfaRed blood cell transfusions (RBCT) are commonly used in neonatal intensive care units. A previous survey reported that the vast majority of extremely low BW infants and 58% of preterm infants (<32 weeks of GA) received RBCT in the neonatal period –11. HoweWe performed this systematic review and meta-analysis in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines , 22. We Studies were selected by screening titles, abstracts and full texts. Studies were included if they had a control group, and reported mean and standard deviation [(SD) or the data can be converted to mean and SD] of the number and total volume of RBCT between BPD patients and controls, as well as the odds ratio (OR) of RBCT for BPD. Case reports, letters to the editors, articles with incomplete data, and studies with less than 10 samples were excluded from analysis.One reviewer (J.Z.) extracted data from the selected studies into a predetermined form. The first author, published year, study design, country, group size, sample size, BPD diagnosis and transfusion data were recorded. Another reviewer (L.T.) checked the data to ensure the accuracy. Any disagreements were settled with a third reviewer (T.T.Z.).Two authors (J.Z. and L.T.) independently evaluated the quality of each included study using the Newcastle–Ottawa scale (NOS) for case-control or cohort studies . This scp < 0.05 was considered statistically significant. Heterogeneity across studies was assessed using the chi-square test and I2. An I2 value > 75% indicated high heterogeneity. Publication bias was assessed visually based on the symmetry of funnel plots. Sensitivity analyses were performed by excluding one study at a time, to test the stability of the results. We calculated the mean and SD of the number or volume of RBCT scans using sample size, median and interquartile range (IQR) according to Hozo et al.  of total number of administered RBCT and total RBCT volume in patients with BPD and those without BPD, and the OR of RBCT for BPD, using a random effect model. A two-tailed o et al. , when neA total of 1,011 articles were retrieved from the databases using systematic and manual searches. After removing the duplicates, and performing screening of abstracts and full-text articles, 21 studies , 26–41 wn = 10), cohort (n = 9), and case–control (n = 2).All included participants had a GA of less than 32 weeks at birth or BW of less than 1,500 g. Studies included populations from different countries, with being China and the USA being the most common. Although all studies reported the association between BPD and RBCT, their objectives varied. In half of the included studies the primary objective was to investigate risk factors of BPD including RBCT. Two studies collected data based on medical records , 26, andThe NOS scores of the included studies ranged from 4 to 8, and detailed information is provided in the supplemental files. In all included studies, exposed and non-exposed controls were drawn from the same community. However, common weaknesses were lack of adequate confounder adjustments such as neonatal sepsis, maternal diseases during pregnancy, and outcome assessment based on medical records without a description of blind.I2 = 56%)  and adjusted analysis . There was a substantial heterogeneity between studies (2 = 56%) . In addi2 = 56%) .I2 = 89%, p < 0.01).A pooled analysis of RBCT including 227 cases and 465 controls  found thI2 = 95%, p < 0.01) between patients with BPD and controls. . These estimate association between RBCT and BPD for different numbers of transfusions did not differ between groups. Our study provides data on the total volume of transfusions, and the number of transfusions between BPD and non-BPD groups.via an acute inflammatory response (The relationship between RBCT and BPD may be explained by several mechanisms. When immature lungs are exposed to a hyperoxic environment, this could lead to a disruption of the alveolar-capillary barrier, overexpression of inflammatory mediators, vascular leakage, and cell death . RBCT inresponse . Some neresponse . The hypresponse .Investigations exploring the association between RBCT and BPD should consider several other factors based on our study. First, the number or the volume of transfusions showed substantial heterogeneity across studies, ranging from one to more than seven. We grouped the studies according to the number of transfusions performed. Although the ORs of BPD did not differ within the groups, heterogeneity was significantly reduced in each subgroup. As hypothesized, a higher number of transfusions may increase the risk of BPD. This might be explained by the small number of studies and variables that were adjusted differently between studies. The second factor that could have influenced the results on the association between RBCT and BPD may be the timing of transfusion. Duan et al.  investigRBCT in neonates could be a lifesaving intervention in certain emergencies, but it is also known to cause adverse events, such as dissemination of infectious disease and inappropriate immune responses . Our finThis is the most comprehensive review and analysis of the evidence on the relationship between RBCT and BPD. However, substantial heterogeneity across the body of studies was clearly identified. Many aspects, such as lack of or inadequate confounder adjustments, severity of BPD, and the number of transfusions significantly varied. The association between RBCT and BPD needs more studies to confirmit in the future. This review provides empirical evidence that demonstrating the importance of accounting for potential confounders when interpreting data in this area.


The combined effects of prolonged drought with the COVID-19 pandemic have led to challenges in goat production, affecting the sustainability of farming families and goat welfare. This study aimed to investigate the impacts of these factors at the farm level and on farmers’ well-being in the Coquimbo region of Chile. This study also assessed the relationship between farmers’ perceptions of their goats’ welfare and mental health indicators. Small-scale goat farmers were interviewed using a telephone survey. They were asked about information regarding their farm and the challenges resulting from exposure to drought and the COVID-19 pandemic. The survey also included Likert scales and a questionnaire aimed at comprehending farmers’ perceptions of these events and assessing their impacts. Nearly all farmers perceived disruptions in the food supply chain, a lack of water for their animals, and economic constraints. These factors had negative effects on goat productivity, animal health, and farmers’ mental health. We found that farmers who perceived their animals to be in a good state of welfare showed better mental health indicators and were more motivated to work with them. A close link between farmers’ well-being and animal welfare was identified. Mentally healthy farmers are more likely to be attentive and proactive toward their animals, contributing to better overall welfare and farm sustainability.p = 0.025). Additionally, farmers who perceived better welfare of their animals showed lower levels of depression , anxiety , and stress . These findings emphasize the importance of addressing farmers’ mental health and veterinary support as crucial aspects to ensure both goat welfare and farm productivity.Considering the interconnections between human well-being, animal welfare, and the environment, this study aimed to investigate the impacts of drought and the COVID-19 pandemic on small-scale goat farmers’ well-being and their perception of goats’ welfare following the One Welfare framework. Using a telephone survey, close-ended questions, and Likert scales, we assessed the impacts of drought and the COVID-19 pandemic on human well-being and animal welfare in the Coquimbo region of Chile. The DASS-21 questionnaire was used to evaluate farmers’ mental health. Goat farmers perceived the scarcity of water and food for animals as factors that negatively affected animal productivity and welfare and caused an increase in farmers’ stress levels. Farmers who had not been visited by a veterinarian showed higher levels of stress than those who received one visit during the year (M = 10 vs. 2,  Droughts are a natural phenomena characterized by a prolonged dry period that can significantly jeopardize the sustainability of production systems ,2. In ChAlthough the welfare of animals is clearly compromised under drought conditions, it is important to recognize that the mental and physical health of livestock farmers can also be affected, compromising their overall quality of life and perceptions of well-being . In 2020Clinical depression is a complex and variable mental disorder that affects approximately 280 million people in the world . This diThe concept of mental health is considered broad and complex, with multifactorial aspects. Its balance is influenced by the interaction of social, affective, economic, health, biological, psychological, and cultural elements . MoreoveSince there are important interconnections between human well-being, animal welfare, and the environment, the consequences of these extreme and prolonged events should be assessed using a more holistic approach. Using the framework of One Welfare, this study investigated the effects of drought and the COVID-19 pandemic on the well-being of small-scale goat farmers. This study also assessed the relationship between farmers’ perceptions of their goats’ welfare and indicators of depression, anxiety, and stress.The study was conducted from May to December 2021 and was approved by the Scientific Ethical Committee of the Universidad de Las Américas, Chile (CEC_FP_2023003). Two steps were involved in this cross-sectional study: (1) a pilot study to test the survey instrument and (2) a validated survey targeting goat farmers from the Coquimbo region. The Coquimbo region is located in Central Chile (between 29°20′ and 32°15′ south latitude) and its climate varies from semi-desert to Mediterranean temperate [The pilot study involved telephone surveys targeting small-scale goat farmers in the Metropolitana and Valparaíso regions of Chile. This pilot study aimed to test and validate the survey instrument. Twelve goat farmers completed the pilot survey. From these preliminary results, the survey was refined. Overall, two questions were removed and three questions were reworded to improve clarity.Following the completion of the pilot study, a comprehensive database of 267 goat farmers was obtained through a collaboration with government institutions associated with the Ministry of Agriculture of Chile. These farmers were previously enrolled in the Agricultural and Livestock Program for the Integral Development of Small Dryland Farmers in the Coquimbo region (PADIS). The final version of the survey was applied via telephone and a total of 130 goat farmers were contacted, agreed to participate, and completed the survey.® platform. The study was voluntary and ensured anonymity and confidentiality. If respondents declined to participate at the beginning or during the survey, they were thanked for their time and the call was concluded.The survey was designed following a One Welfare approach, meaning that a combination of questions addressing the impacts of drought and the COVID-19 pandemic on human well-being and animal welfare were included. The survey questions were administered via telephone interviews , and datThe survey comprised two sections and a total of 49 questions. The estimated duration of the survey was 20 min. The first section focused on demographic and general aspects of the production system, including questions related to the participant’s gender, age (in years), the type of ruminants present on their farms, the specific purpose of their production , the management approach employed in their production system , and the total number of animals. Additionally, farmers were asked whether their farms had received visits from a veterinarian during the current year, and if so, the frequency of those visits was recorded .The second section of the survey focused on gathering information about farmers’ perceptions and challenges resulting from drought and the COVID-19 pandemic. Using closed-ended questions with a binary response format (Yes/No), farmers were asked about the impact of these events on animal husbandry, particularly on animal health, feed and water access, feed costs, and mortality rates, as well as the need to sell/relocate or euthanize animals. Participants were also directly asked whether they believed that COVID-19 could impact their livestock, whether they had to undergo quarantine during this period, and whether the situation had a detrimental effect on their work with their animals.Likert-scale questions were also employed to evaluate farmers’ perceptions regarding the impact of drought and the pandemic on various factors throughout 2021. These factors included the productivity of their animals, economic resources, animal welfare, and whether they had experienced a sense of discouragement in working with their animals.Lastly, the DASS-21 questionnaire was used , which hp < 0.05) were used to assess the impact of drought and the COVID-19 pandemic on farmers’ well-being and goats’ welfare, using scores obtained from the DASS-21 subscales  as dependent variables and demographic and perception questions as independent variables. Likert-scale questions were also used as covariables in these regression models.The demographic data, perceptions of animal welfare, individual well-being, and scores obtained from the DASS-21 questionnaire were summarized using descriptive statistics. Generalized Poisson regression models (p < 0.05) to assess the relationship between levels of depression, anxiety, and stress, as well as farmers’ perceptions of the impact of drought and COVID-19 on their well-being and goat welfare. Statistical analyses for this study were performed using the SPSS version 26 software .The internal consistency of the DASS-21 questionnaire and its subscales was calculated using the Cronbach’s alpha statistic. In addition, Spearman correlations were utilized  and the rest were women , with a median age of 55.5 years (IQR: 46–64). Twenty-three farmers (29.9%) had other ruminants (sheep and/or cattle) in addition to goats on the farm. The median number of goats in each system was 44 animals (IQR: 30–65), mostly managed under semi-intensive systems , followed by intensive  and extensive  management. Most survey respondents (49%) managed dual-purpose goats (meat and milk), followed by dairy goats (46%) and meat-focused goats (5%).The final response rate of the telephone survey was 48.69% (130 farmers out of 267 were successfully contacted and agreed to participate in the study). Most of the respondents were men  reported not having received any veterinary care. Meanwhile, 22.31% of farmers indicated that they had been visited by a veterinarian at least once during the year, with 16.15% reporting visits every three months and 14.62% reporting monthly visits.Farmers’ perceptions of animal welfare resulted in a mode and median score of 5, with the scoring scale ranging from 0 (very bad) to 7 (very good). Similarly, when asked about feelings of discouragement towards working with their animals , the mossr = 0.60, p < 0.05), depression and stress , and anxiety and stress . In addition, the depression, anxiety, and stress subscales exhibited α coefficients of 0.83, 0.82, and 0.80, respectively.The DASS-21 questionnaire presented good levels of internal consistency based on an α coefficient of 0.87. Significant positive correlations were observed among the scores obtained in each DASS-21 subscale. Specifically, there were positive correlations between levels of depression and anxiety (p = 0.019 ( = 0.019 .2(3) = 8.676, p = 0.034) (2(3) = 1187.500, p = 0.025). The stress scores ranged from 0 (low) to 28 (high).Significant relationships were observed between the frequency of veterinary visits and the DASS-21 stress scores (χ= 0.034) . Farmersp < 0.001), their perception of an increase in the cost of animal feed (p = 0.005), the possibility that the lack of water and/or feed affected the health of their animals (p < 0.001), the need to sell animals due to a lack of water and/or feed (p = 0.001), and other factors, as shown in There were several factors that significantly affected farmers’ stress levels, such as economic problems for buying food for their animals (p = 0.038) and anxiety .The need to relocate or sell animals due to a lack of feed and/or water were variables that significantly predicted the levels of anxiety and stress . Additiop < 0.001; sr = 0.24, p = 0.005) and stress  among farmers. Negative correlations were observed between perceived levels of animal welfare and the DASS-21 subscales: depression , anxiety , and stress . This indicates that farmers who perceived higher levels of welfare in their animals exhibited fewer signs of depression, anxiety, and stress.Farmers’ feeling of discouragement about working with their animals and their perception of their goats’ welfare were factors that significantly affected the three DASS-21 subscales  and their perception of their animals’ welfare. Farmers who perceived good animal welfare were less likely to experience depression, anxiety, or stress. The effect and relationship observed in this study between farmers’ mental health and their goats’ welfare could indicate that farmers are likely to project their own well-being onto their animals, highlighting the importance of addressing mental health to promote better animal welfare outcomes ,56. In aRecent health challenges have emphasized the need for a comprehensive approach that considers the connections between human, animal, and environmental health. The One Health approach has been pivotal in fostering interdisciplinary collaboration, but it must be complemented by the One Welfare concept to address the complex interactions across species. The results from this study indicate that animal health is linked to the mental health of farmers, highlighting the need to increase awareness and support. Furthermore, veterinarians seem to play an important role, helping farmers to feel less stressed and anxious during uncertain periods. Farmers’ mental health can be highly vulnerable due to economic, cultural, and environmental factors and limited access to mental health support in rural areas. Environmental concerns such as drought have been one of the main stressors for agricultural stakeholders, along with the COVID-19 pandemic, providing an additional stress factor that has generated new obstacles for farmers and increased uncertainty regarding farm performance and family income. These situations trigger depression, stress, and/or anxiety among farmers, particularly among females. Motivation to work with animals is also associated with the mental state of farmers. As we look toward the future, feeding the growing global population will require sustainable agriculture and livestock practices, and a focus on both animal welfare and farmers’ well-being will be vital in achieving this goal. Therefore, by applying the One Welfare approach in animal welfare and production studies, we can increase the awareness and opportunities for proper care of the mental health of livestock stakeholders and preserve animal welfare.


The search for new drugs is an extremely time-consuming and expensive endeavour. Much of that time and money go into generating predictive human pharmacokinetic profiles from preclinical efficacy and safety animal data. These pharmacokinetic profiles are used to prioritize or minimize the attrition at later stages of the drug discovery process. In the area of antiviral drug research, these pharmacokinetic profiles are equally important for the optimization, estimation of half-life, determination of effective dose, and dosing regimen, in humans. In this article we have highlighted three important aspects of these profiles. First, the impact of plasma protein binding on two primary pharmacokinetic parameters—volume of distribution and clearance. Second, interdependence of primary parameters on unbound fraction of the drug. Third, the ability to extrapolate human pharmacokinetic parameters and concentration time profiles from animal profiles. Now more than ever, the emergence of deadly viruses and viral pandemics in the last several decades has necessitated the demand for antiviral drug discovery. The discovery and development of new antiviral drugs is one of the most complicated and time-consuming processes which requires a considerable amount of energy and resources. The initial, essential qualification of new chemical entities is in vitro potency. However, the clinical translation with effective efficacy is always challenging due to unfavourable pharmacokinetic (PK) properties and pharmacokinetic-pharmacodynamic (PK-PD) correlation at the pharmacological dose. The process of antiviral drug discovery is summarized graphically in The emergence of drug resistance development has outpaced the discovery of new molecules, thus generating a major cause for concern. One significant reason for suboptimal antiviral response could be the result of inadequate exposure and/or poor PK-PD properties of the investigational drug. Maintenance of sufficient plasma exposure within the therapeutic window is one of the most critical requirements to stop viral replication and the emergence of resistance . It has d,ssV), and clearance (Cl) of many antiviral drugs, may impact local efficacy [dV), plasma and tissue binding are given by:uf: unbound fraction in plasma; PV: plasma volume; TV: tissue volume; and u,Tf: unbound fraction in tissues.The role of membrane transporters expressed in various tissues in the human body may play an important role in pharmacokinetics, distribution, and toxicity of drugs. Generally, efficacy of a drug has a direct relationship with distribution into tissues of interest. Plasma protein bindings (PPB) have been demonstrated to significantly influence the rate of diffusion of drugs between plasma and tissues. Therefore, PPB influence partitioning between plasma and tissue or volume of distribution at steady state  either have a higher propensity to bind to plasma proteins or are too polar to distribute into tissue. Similarly, high dV drugs are largely lipophilic and are distributed more into tissues. This implies that a higher dose is required to achieve a necessary concentration in plasma.From Equation (1), it clearly shows uV) can be shown by rearrangement of Equation (1)Volume of distribution of unbound drugs , after attaining steady state equilibrium, the free drug concentration in plasma is equal to free drug concentration in intracellular spaces of the tissues ,10. This1/2).H: hepatic blood flow rate; uf: unbound fraction in plasma; Clint: intrinsic clearance.Clearance of a drug can be influenced by plasma protein binding. The unbound fraction of the drug is subject to hepatic or renal clearance. Drugs with high plasma protein binding are generally cleared slowly from the body and thereby influence terminal half-life , BCRP (breast cancer receptor proteins), and OATP (organic-anion-transporting polypeptides). These efflux transporters limit absorption from the intestines and drug release to systemic circulation. Alteration of intestinal and/or hepatic transporters by the substrates is one important criterion to be considered in understanding drug-drug interactions (DDIs). Furthermore, the modulation of metabolizing enzymes by genetic polymorphism and diseased condition often causes a change in plasma and/or tissue exposure, leading to change in efficacy and/or toxicological effects ,12.The variability in intestinal absorption and the PK profile in animals and humans is better explained through cytochrome (CYP) P450 mediated metabolism. CYP metabolising enzymes present mainly in the intestine and liver and are important components of drug metabolism and the mechanism that converts drug molecules into a more polar substance—a very complex process. The major substrates and inhibitors of metabolizing enzymes of antiviral drugs are listed in There are several aspects of drug development that must be understood before a drug can be tested in humans. In vitro and in vivo animal studies are conducted to understand the efficacy and safety of drug candidates and to provide critical pharmacokinetic information, including ADME properties of the drug. Previously “go/no go” decisions were made on review of nonclinical data, but presently actionable decisions are drawn by critically reviewing the predicted human outcomes along with nonclinical data. This saves time, money, and potential harm to human subject’s reaction to change in efficacy and/or toxicological effects ,12.dV), are scaled by the exponential function of body weight (BW). Based on the similarities of mammals, a generalized allometric equation can be written as:Y is the pharmacokinetic parameter to be calculated, mainly Cl; W is the physiological parameter, mainly average body weight of a species; a and b are allometric coefficient and exponent, respectively. This exponential equation can be made linear after logarithmic transformation and a and b can be estimated using linear regression. The logarithmic transformation of Equation (7) can be written as:Once the decision has been made to advance the potential drug molecule into human studies—or make decisions on lead molecules—nonclinical data are used to predict human outcomes. One common method for predicting human doses is simple allometric scaling ,27. Usinplasma) is converted to blood parameter (Clblood) using RB (blood to plasma partition coefficient ratio) value by the following equation:Plasma clearance of each species is computed via intravenous pharmacokinetic study. The plasma parameter (ClY) versus log(W) scale to compute a and b. Human primary pharmacokinetic parameters are then calculated by using computed a and b values and average adult human weight. However, for drugs metabolized by the liver, that also have low extraction rate, the error associated in computing these pharmacokinetic parameters using simple allometry is high [b is between 0.55 and 0.71; MLP should be incorporated into the scaling equation when b is between 0.71 and 1.00; BrW should be incorporated when b is greater than 1.00. Predicted clearance is underestimated or overestimated if b is greater than 1.30 or less than 0.55, respectively [These intravenous blood pharmacokinetic parameters, from at least three species, are graphically plotted on log using the Adolph Dedrick method .(10)loguf is the fraction unbound in plasma. Vdss,blood,iv is volume of distribution at steady state in blood following intravenous administration. The a and b values computed from at least three species and the average adult human weight is estimated. Human Vdss,blood,iv is calculated by multiplying with human (uf/RB). Human predicted elimination half-life is estimated using Equation (6) by incorporating predicted human clearance (Cl) and volume of distribution at steady state (Vdss).Here In addition to predicting human pharmacokinetic parameters, prediction of the human plasma concentration-time profile of a drug candidate using modelling and simulation is equally important for predicting PK-PD correlation, estimation of efficacious dose, and dosing frequency in humans.0.25, respectively. In the Dedrick plot using kallynochrons, apolysichrons, and dienetichrons, as time units b and c are the allometric scaling exponents of Cl, Vdss, and Cl × MLP, respectively [dssV, and t1/2. The derived complex Dedrick equations are as follows:The general idea behind the physiological species-invariant time method originates from the allometric approach, with the prediction accuracy dependent on the allometric relationships of the pharmacokinetic parameters across species. Short-lived, small animals generally clear drugs from their body at a faster rate  per unit of body weight (rate/body weight) compared to long-lived, larger animals. However, if clearing of drugs from the body is measured according to the biological clock of each species, all animals irrespective of different species tend to clear drugs at a similar rate. The species-invariant time method is based on this assumption: by normalizing the concentrations by body weight, and transforming the chronological time to the physiological time, the plasma concentration-time curves should be superimposable in all species . Dedrickectively ,37. The b and c are the exponents of clearance and volume of distribution, respectively, in simple allometric equation; D is the dose in mg.B and C are coefficients, and Concentration scale in y-axis = max). The PK parameters indicate the time course of antibiotics but not the antibacterial potency. Therefore, the PK-PD indices, which are indicators of efficacy, are derived by combining both PK parameters and MIC—AUC0–24h/MIC, Cmax/MIC, and T>MIC (time above MIC). AUC0–24h/MIC is defined as the ratio of area under the concentration-time curve to the MIC; Cmax/MIC is defined as the maximum concentration divided by the MIC; and T>MIC represents the percentage of dosing interval in which drug concentration stays above the MIC. These indices are always calculated as total or free drug concentration based on serum protein binding of the drug [The understanding of pharmacokinetic and pharmacodynamic (PK-PD) parameters of any drug is key for successful therapy. The concept of PK-PD was initiated in the 1940s by Dr. Harry Eagle ,39, and the drug ,46,47,4850 or EC90 is an indicator of the antiviral potency of drugs and can be used synonymously as MIC50 or MIC90, respectively, of antibacterial. EC50 or EC90 is defined as the 50% or 90% effective concentration. By integrating the drug exposure to EC50 or EC90 of the virus , the clinical antiviral effect can be predicted as the desired pharmacodynamic index [50 value of oseltamivir carboxylate against influenza A and B strains were reported to be 0.17–44 μg/L in cell culture [0–24h to IC50 ratio was predicted as the pharmacodynamic parameter of efficacy in the hollow fibre model [50 was found to be the PK-PD parameter of peramivir in the mouse model of influenza [50, but T>EC50 [>EC50 of zanamivir, oseltamivir exhibited AUC0–24h/EC50 as the best predictor of efficacy linked to half-life. Though these studies provide excellent understanding into PK-PD indices of antiviral drugs, more clinical data are needed to make more robust PK-PD modelling of antiviral drugs.Though the concept of PK-PD of antivirals is equivalent to that of antibacterials, the PK-PD of antivirals is not well studied. Antiviral ECic index ,50. The ic index . These dic index ,53. Howe culture . The pha culture . Five-da culture . The PK/re model . Similarnfluenza . Howevert T>EC50 . The terfree/EC50/90  mentioned in this article are simplified, reliable, and a relatively less time-consuming method for extrapolation of preclinical data to humans.In summary, during the preclinical phase of the drug discovery process, prior information on human pharmacokinetic parameters such as Cl, V2 values . Over th2 values . Hence,


Aging is associated with many personal, social, and environmental challenges that increase the risk of loneliness. Loneliness is a painful emotional experience associated with a perceived lack of connection and intimacy. Loneliness accelerates health deterioration, but the presence of chronic health conditions (comorbidities) in older individuals may potentiate the feeling of loneliness. The relationships between health status and loneliness in older individuals have not been assessed in an integrated manner, although it is necessary for planning efficient interventions. The aim of this study was to fill in this knowledge gap, by attempting to create an integrated model of loneliness in older individuals.The sample consisted of 189 (58% F) older individuals (> 60 years) , attendees in Primary Health Care. Different factors associated with loneliness in the older population were assessed, and classified as demographic, environmental, physical , and psychological, in addition to functional abilities. A set of standard questionnaires was used to assess psychological factors and functional abilities. The hierarchical regression model assessed the effect of particular blocks of factors on status loneliness. The second aim was to analyze how psychological factors mediate associations between health status (comorbidity level) and loneliness.Indicated that increasing comorbidity, anxiety, lack of positive moods, not having hobbies/activities, low perception of social support, impaired cognitive function, and suppression of emotion expression, are significant predictors of loneliness. Mediation analysis informed us of how to help patients with comorbidities feel less lonely. Interventions that were suggested were those that can reduce anxiety and depression, improve cognitive abilities and emotional regulation control, and enhance social support.Results can help understand the pathophysiology loops linking poor health status (comorbidity level) of older individuals and loneliness, and have significant potentials from the translational perspectives, as a decision-support tool.The online version contains supplementary material available at 10.1186/s12877-023-04436-6. Aging is associated with many personal, social, and environmental challenges that may increase the feeling of loneliness . LonelinSo far, a number of factors have been identified as associated with loneliness in older individuals. They can be grouped into several categories, including: 1. demographic  2. environmental , 4. physical or health-related , and 5. psychological factors , in addition to 5. decreased functional abilities (daily functioning) , 7. To lA recent systematic review of longitudinal studies of risk factors for loneliness in older individuals has revealed a total of 120 risk factors examined, but only a few hold stability across the studies . Those wLoneliness is increasingly viewed as a mediator in associations between different predisposing factors and poor health of older individuals . The patIt is not only that loneliness accelerates health deterioration, but also poor health may potentiate the feeling of loneliness. Having chronic diseases diminish one`s functional capabilities and opportunities to achieve desired levels of social activities, which can potentiate the feeling of loneliness , 15. AdaSuch course of aging can lead to the development of the “loneliness trait” – a profile of older individuals who suffer from loneliness, outlined by the set of specific psychosocial characteristics and comorbidity patterns, and relatively stable over time Fig.  3, 16]., 16.3, 1Knowing characteristics which individuals suffering from loneliness have, and how to improve their psychosocial resources and/or to alleviate detrimental effects on health of negative emotions that usually accompany loneliness, such as hostility, distress, pessimism, anxiety, and low self-esteem, can slow down development of comorbidities, while enabling promotion of active aging , 17.The aim of this study was to fill in some of these knowledge gaps, by attempting to create an integrated model of loneliness in older individuals burdened with comorbidities, considering different type of factors and their relative contributions to the trait loneliness, including: 1. demographic, 2. environmental, 3. physical  and 4. psychological, in addition to 5. functional abilities. In particular, we wanted to identify chronic health conditions with the highest impact on loneliness, and to assess the role of social and emotional perceptions and appraisals, as well as functional abilities, in mediating the link between poor health (the presence of comorbidities) and loneliness. We proposed that such integrated research approach can provide a theoretical framework for intervention optimization, which could alleviate the feeling of loneliness in older individuals, despite the presence of comorbidities and poor health.The data collection procedure was conducted during a period of 1.5 year, in a primary care (PC) setting, in the town of Osijek (approximately 60. 000 citizens) – a capital of the largest county in eastern Croatia. It lasted from August 2018 to January 2020, with variable intensity, being abruptly cut off by the outbreak of the COVID-19 pandemic in Europe, which in Croatia was announced in February 2020. Thus, the COVID-19 pandemic did not affect the data. The project was funded by the University of Osijek and approved by the Ethics Committee of the Faculty of Medicine, of the Josip Juraj Strossmayer University of Osijek (No. 641–01/18–01/01).N = 189, F = 110)  were recruited by two general practice (GP) teams, members of the teaching basis of the Faculty of Medicine Osijek, upon their agreement. These GP teams work in the urban area of the town of Osijek and provide care for about 4.000 patients in a total. PC patients in Croatia reflect well the structure of the adult general population of the local area, since citizens in Croatia have a free access to PC, and almost all have regulated compulsory health insurance status. The GP team leaders were provided with detailed information about the planned project and the data collection methods.Participants . Excluded were also patients with acute illnesses, with severe mental illnesses to whom communication is difficult, as well as those with some severe chronic conditions, like terminal or palliative patients and those on the permanent dialysis programme. Informed consent was obtained from all eligible individuals who agreed to participate. Before signing the informed consent form, they were informed of the purpose of the questionnaires.https://goo.gl/forms/uZlZ1NefjpQEGq9j2. A respondent was placed in the silent room, the door next to the GP, and had time as much as he/she needed for the survey. An educated administrator monitored the procedure and helped respondents fill out the questionnaires. The GP was easily available for any query.All requested items and questionnaires were placed on the google platform, as the uniform survey, that was accessible through the link A large set of data was collected to provide a comprehensive review of factors known to associate with loneliness in older individuals. The data was divided into categories, like: 1. demographic, 2. environmental, 3. physical  and 4. psychological factors, in addition to 5. functional abilities . This scale contains 20 items describing different emotions associated with loneliness, with ten items worded in a negative direction, and 10 items worded in a positive direction. The items are scored on a 4-point scale, as: never, rarely, sometimes, and often. The coefficient of test reliability varies between 0.89 and 0.94 and the test-re-test reliability over a one-year period was r = 0.73.The UCLA Loneliness Scale, version 3, that we used to measure the feeling of loneliness, is simply for use and thus appropriate for the elderly population . Since tThe GAS and GDS tests, used for screening participants on anxiety and depression, are suitable for use among older population, as based on the ability to discriminate well between symptoms of mental, cognitive, and physical disorders , 20. ForThe MSPSP consists of 12 items, and the translation and adaptation into Croatian has been performed before . The resThe 6-item cognitive impairment test (CA) is brief and simple, and practical for use in PC, for screening older individuals on mild dementia . CompareThe ERQ measures respondents’ tendency to regulate emotions in two ways: cognitive reappraisal, and expressive suppression . The capBelieves in self-efficacy is a necessary pre-requisite for lifestyle changes, and is therefore an important target in health improvement programs. The GSE is a 10-item psychometric scale, designed to assess self-beliefs to cope with a variety of difficult demands in life . The GSETwo related scales, ADL and IADL, measure physical self-maintenance, by items describing the one`s level of functioning in daily living . Both teAll analyses were conducted in R v.4.0.3. . Categorp < 0.05, and effect size values were estimated with Cohen’s d index . Th. Th71]. Associated with this hypothesis, and also supported by the results of this study, is another hypothesis. It states that the presence of chronic diseases and functional deficits in older individuals may be a more important source of chronic stress and a reason of emotional dysregulation associated with the feeling of loneliness, than living alone. It is suggested by a discrepancy between the number of participants who reported to live alone (a quarter) and a number of those who reported loneliness (three quartiers), and also by the results of the regression model, where variable “living alone “ has drastically lost its impact on loneliness (the outcome variable) when variables indicating health status (comorbidity level) and psychological disorders, were added to the initial model. Recent evidence from the lock-down period of the COVID-19 pandemic, supports this assumption, indicating that social isolation has higher effect on the prevalence of loneliness and mental health deterioration in younger adult groups, than in the elderly population , 73, 74.Taken together, this study revealed an old true that psychological adaptation of older individuals to living with chronic diseases is challenging Fig.  75]. Sp. Sp75]. The key message of this study is yet that caring for mental health of older individuals should be in the centre of strategies aimed at both, alleviating loneliness, and protecting health and functional abilites of older individuals from accelerated deterioration Fig. . For thiOf particular interventions, our results suggest activities such as crafting, that encourage motor skills, creativity, attention, and planning. Similarly, literature review provides evidence on the effectiveness of the mindfulness-based therapy for alleviating loneliness and improving everyday functioning of older individuals . BecauseThis study represents an integrated model of loneliness in older individuals burdened with comorbidities, but who are still functioning well. Results are supposed to improve understanding of the pathophysiology loops linking comorbidities and loneliness and can be used to inform interventions. The study has several limitations. One is the bias in data collection, since only older individuals who came to their GPs for consultations were included in analysis. In addition, there could have been a bias in passing tests, as there was a large batery of tests, which could have been tiresome for older people. Also, there was a little control of variables in the methods. Future research should focus on optimization of the pool of variables that would be appropriate to enter the predictive model and on searching for comprehensive analytical methods that can be used to get replicative results.Additional file 1: Table S1. Differences in demographic variables  by status loneliness.Additional file 2: Table S2. Differences in demographic variables  by status loneliness.Additional file 3: Table S3. Differences in environmental factors  by status loneliness.Additional file 4: Table S4. Differences in physical factors (diagnoses of chronic diseases and geriatric conditions) by status loneliness.Additional file 5: Table S5. Intercorrelations between loneliness, physical factors (comorbidity level), psychological factors  and functional abilities (IADL).Additional file 6: Table S6. Results of hierarchical multivariable regression for predicting loneliness.Additional file 7: Table S7. Standard tests indicating participant psychological characteristics and functional abilities (IADL) as mediators in the relation between health status (comorbidity level) and loneliness.