K-nearest neighbor algorithm (KNN) were compared with the optimized deep RNN. The regular ML models and the optimized deep RNN have been applied the selected features. The results showed that the optimized deep RNN with the selected features by univariate has achieved the highest performance for CV and the testing results compared to the other models.Breast cancer is a dangerous disease with a high morbidity and mortality rate. One of the most important aspects in breast cancer treatment is getting an accurate diagnosis. Machine-learning (ML) and deep learning techniques can help doctors in making diagnosis decisions. This paper proposed the optimized deep recurrent neural network (RNN) model based on RNN and the Keras–Tuner optimization technique for breast cancer diagnosis. The optimized deep RNN consists of the input layer, five hidden layers, five dropout layers, and the output layer. In each hidden layer, we optimized the number of neurons and rate values of the dropout layer. Three feature-selection methods have been used to select the most important features from the database. Five regular ML models, namely decision tree (DT), support vector machine (SVM), random forest (RF), naive Bayes (NB), and  K-nearest neighbor (KNN) algorithm on the Breast Cancer Wisconsin (Diagnostic) Data set (BCWD) to predict BC. The result indicated that the SVM classifier was the best. Naji et al. [Breast cancer (BC) is one of the most frequent malignant tumors in the world, accounting for 10.4% of all cancer deaths in women aged between 20 and 50 , predicti et al.  applied i et al.  applied i et al.  have appi et al.  applied i et al.  proposedi et al.  proposedi et al.  designedi et al.  proposedi et al.  used thei et al.  applied i et al.  used twoi et al.  used GA The proposed system of predicting BC consists of two approaches: regular machine-learning (ML) approach and deep learning (DL) approach. In regular ML approach, five ML models are used, namely DT, SVM, RF, NB, and KNN to train and evaluate the BCWD data set. Grid search with cross-validation is used to optimize ML algorithms. In the DL approach, an optimized deep RNN model is proposed and optimized using Keras–Tuner optimization technique. The steps of the proposed system include feature-selection method, spitting database, optimization and training the models, and evaluating the models as shown in We used Breast Cancer Wisconsin (Diagnostic) Data set (BCWD) to train and evaluate the models . The datThe key advantages of employing feature-selection algorithms are that they allow us to identify the most essential features in a data set.Correlation methods: we studied the correlation between features using a correlation matrix . We remoUnivariate feature selection works by selecting the best features based on univariate statistical tests. It assigns scores for each feature and the best features that have the highest score .Recursive feature elimination (RFE) is a wrapper-type feature-selection algorithm. RFE assigned scores for each features, and features that have the highest scores will be extracted. Scikit-learn library  is used We used correlation to reduce the number of features in this study and then applied two types of feature-selection algorithms to the data that remained after correlation: univariate feature selection and recursive feature elimination (RFE).The BCWD data set is divided into two parts: a training set and a testing set. We employed stratified CV to train and optimize the models with the training set, and the results of CV were recorded for each model. Models are evaluated using a testing set, and the results of the testing set were recorded for each model.K-nearest neighbor algorithm (KNN) [k subsets in order to train ML algorithms on k−1 subsets (the training set). The remainder is used to test ML algorithms [In regular ML approach, five ML algorithms, such as decision tree (DT) , supporthm (KNN) , random hm (KNN) , and naihm (KNN)  were usegorithms .We proposed an optimized deep RNN model for breast cancer diagnosis based on recurrent neural networks (RNNs) and the Keras–Tuner optimization technique. F-measure (FM), where TP indicates true positive, TN indicates true negative, FP indicates false positive, and FN indicates false negative.As illustrated in equations  to 4), , 4), theThis paper's experiments were run on Python 3 and a GPU. The optimized deep RNN was implemented using the Keras package. The ML models were implemented using the scikit-learn package. The data set was divided into two parts: an 80% training set for optimizing the models and registering cross-validation (CV) results and a 20% testing data set (unseen data) for evaluating the models and registering the testing results. First, we studied the correlation between features and removed features that have high correlation above 90% with other features. After that we applied two feature-selection methods on the selected features by correlation to select eight features. Next, the regular ML models and the optimized deep RNN models were applied to the selected features by correlation, selected features by univariate, and selected features by RFE. We adapted some parameters of the optimized deep RNN for each experimental batch size = 10 and epochs = 100. All of the trials were repeated four times in total. The results of CV and the testing of each experiment will be discussed in detail.As seen in heat map The results of applying ML models and the proposed model to the selected features by correlation are shown in In ML approach, the highest performance is registered by RF , while the worst performance is registered by NB . The second-highest performance is recorded by SVM . In DL approach, the optimized deep RNN has enhanced AC by 0.91%, PR by 1.03%, RE by 1.04%, and FM by 1.1%.In ML approach, the highest performance is registered by LR , while the worst performance is registered by NB . The second-highest performance is recorded by SVM . In DL approach, the optimized deep RNN has enhanced AC by 1.14%, PR by 1.39%, RE by 1.14%, and FM by 1.18%.After selecting 17 features of applying correlation matrix, the univariate feature-selection method is applied to 17 features, and 11 features that have the highest scores will be selected. The scores of all features of applying univariate to 17 features are shown in The results of applying ML models and the proposed model to select features by univariate are shown in In ML approach, the highest performance is registered by RF , while the worst performance is registered by NB . The second-highest performance is recorded by DT RF . In DL approach, the optimized deep RNN has enhanced AC by 3.32%, PR by 3.37, RE by 3.45%, and FM by 3.48% rather than ML approach.For the testing result, the highest performance is registered by RF , while the worst performance is registered by NB . The second-highest performance is recorded by SVM . In DL approach, the optimized deep RNN has enhanced AC by 2.74%, PR by 2.39, RE by 2.74%, and FM by 2.8% rather than ML approach.RFE algorithm sets some of the rankings for each feature. We applied REF to 16 features after coloration and selected the 11 features which ranked the best. The ranking of features is shown in The results of applying ML models and the proposed model to the selected features by RFE are shown in In ML approach, the highest performance is registered by RF , while the worst performance is registered by NB . The second-highest performance is recorded by DT . In DL approach, the optimized deep RNN has enhanced AC by 1.35%, PR by 1.05, RE by 1.31%, and FM by 1.33%.In ML approach, the highest performance is registered by RF and SVM  and , respectively, while the worst performance is registered by NB . In DL approach, the optimized deep RNN has enhanced AC by 1.32%, PR by 1.58, RE by 1.32%, and FM by 1.35%.In our work, first, features have been selected from the BCWD data set using correlation matrix. After that, two feature-selection algorithms, namely Univariate and RFE have been applied to features after correlation, and 11 features have been selected. Regular ML and the optimized deep RNN have been applied to the selected features, and the result of CV and the testing have been registered. Overall, the optimized deep RNN models have achieved the best performance for each feature-selection methods. This paper used two approaches: the regular ML approach and the deep learning approach to predict breast cancer. In the DL approach, this paper proposes the optimized deep RNN model based on recurrent neural network (RNN) and the Keras–Tuner optimization technique. The optimized deep RNN consists of the input layer, six hidden layers, six dropout layers, and the output layer. In each hidden layer, we optimized the number of neurons and values of the dropout layer. In the regular ML approach, DT, RF, SVM, NB, and KNN were compared with the optimized deep RNN. Three feature-selection methods: correlation matrix, univariate, and REF were used to select the essential features from the database. The regular ML models and the optimized deep RNN are applied to selected features. The results show that the optimized deep RNN with selected features by univariate method has achieved the highest performance for cross-validation and testing results.


Diabetic kidney disease (DKD) is the most important cause of the end-stage renal disease (ESRD) and the main cause of renal replacement therapy. Excessive inflammatory response and renal fibrosis are the keys to the development of this disease, and the conventional Western medical treatment is difficult to achieve and obtain long-term stable clinical results in all patients with DKD. Many studies have shown that Chinese medicine as a complementary and alternative medicine may be another therapeutic option to mitigate the progression of DKD to ESRD. In recent years, many doctors have used the Bushen Huoxue therapy to assist Western medicine in the treatment of the disease and have achieved certain clinical effects. However, most of the current studies are small sample studies, and there is no evidence-based confirmation.  To systematically evaluate the efficacy and safety of the Bushen Huoxue therapy combined with conventional Western medicine in the treatment of DKD.  A comprehensive search of literature databases such as CNKI, Wanfang, Pubmed, and Cochrane Library was conducted. The screening condition was that the control group was treated with conventional Western medicine and the experimental group was treated with Bushen Huoxue therapy's RCT on top of the control group, and the RCTs were published from January 2011 to October 2021. The Cochrane risk bias assessment tool was used for literature quality evaluation, and RevMan 5.3 software was used for statistical analysis. P < 0.01), significantly reduce Crea , P < 0.01), 24 h UTP , P < 0.01), BUN , P < 0.01), UAER , P < 0.01), and blood sugar, and have certain medication safety , P=0.87).  A total of 23 RCTs were finally included, with a total of 2,105 patients. Meta-analysis results show that the experimental group can effectively improve the clinical efficacy ,  Chinese medicine based on the Bushen Huoxue therapy has a good clinical effect in the treatment of diabetic kidney disease and has certain safety. However, due to the limitation of the quality and quantity of the included literature, the above conclusion still needs more rational experiments to further verify. Diabetic kidney disease (DKD) is one of the most common microvascular complications of diabetes and a major cause of the end-stage renal disease (ESRD). Pooled data from 54 countries show that more than 80% of ESRD arises from diabetes, hypertension, or a combination of both and that ESRD is 10 times more prevalent in patients with diabetes than in those without diabetes , and in The current treatment strategy for DKD aims to control blood glucose, blood pressure, and lipid levels by aggressive control, and although there are many Western drugs available for clinical treatment of DKD, only blocking renin-angiotensin-aldosterone system (RAAS) is an effective treatment, and commonly used drugs include angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) –6, but tPatients who met the diagnosis of DKD and were staged using the Mogensen staging method.(1) Type of study: an RCT experiment, whether blinded or not, without language restriction; (2) interventions: the control group was treated with conventional Western medicine for DKD, including blood glucose control, blood pressure lowering, lipid regulation, and other conventional treatments (no restriction on drug dose and dosage form); the experimental group added oral Chinese medicine preparation with Bushenhoxue as the main effect  on the basis of the control group; (3) outcome indicators: at least one of the following should be included: total clinical efficiency, 24-h urine protein quantification (24h UTP), blood creatinine (Crea), urea nitrogen (BUN), urinary albumin excretion rate (UAER), fasting blood glucose (FBG), and glycated hemoglobin (HbA1c); adverse reactions; and good balance and comparability between groups are the inclusion criteria.Duplicate publications; literature with incomplete data or incomplete key information; included patients with other comorbidities affecting renal function; and interventions that included nonoral TCM treatments such as acupuncture, tui na, and proprietary Chinese medicine injections are the exclusion criteria.https://www.cnki.net/), Wanfang Data Service Platform (https://www.wanfangdata.com.cn/index.html), VIP database (http://www.cqvip.com/), China Biomedical Literature Network (http://www.sinomed.ac.cn/)) and English databases . The search terms included “diabetic nephropathy,” “diabetic nephropathy,” “herbal medicine,” “Busenhoxue,” and “random.” The search was performed using subject terms + free words, and the search strategy is shown in In this study, a comprehensive search was conducted for studies of biological therapeutic interventions for DKD in the last 10 years, with the search period specified as January 2011 to November 2021, and the databases searched included Chinese databases . When A total of 557 relevant studies were retrieved, and after screening, 23 RCTs with a total of 2,105 patients were finally included, with 1,053 patients in the experimental group and 1,052 patients in the control group, and all patients were matched at the baseline level. The sample size of an individual experiment ranged from 50 to 200 , and meta-analysis using a fixed-effects model showed that the clinical effective rate was higher in the experimental group than in the control group, with a statistically significant difference , P < 0.01), indicating that Bushen Huoxue therapy adjuvant treatment of DKD can significantly improve the clinical efficacy , and because of the different assays used in each study, the SMD was used to express the results, and meta-analysis was performed using a random-effects model, which showed that the level of Crea was lower in the experimental group than in the control group after treatment, and the difference was statistically significant , P < 0.01, P < 0.01), with a better reduction in Crea in the experimental group.A total of 11 studies  mentioned Crea, with 567 patients in the experimental group and 568 patients in the control group. The heterogeneity between studies was large , and meta-analysis using a random-effects model showed that 24 h UTP levels were lower in the experimental group than in the control group, with a statistically significant difference , P < 0.01, P < 0.01), which indicated that the experimental group was more effective in reducing 24 h UTP.A total of 12 studies  mentioned 24 h UTP, with 652 patients in the experimental group and 651 patients in the control group. There was statistical heterogeneity between studies , and meta-analysis using a random-effects model showed a statistically significant difference with SMD = −1.47, 95% CI , P < 0.01, and meta-analysis using a fixed-effects model showed that BUN levels were lower in the test group than in the control group, with a statistically significant difference , P < 0.01)  .In this study, two blood glucose-related indicators were analyzed, including FBG and HbA1c, 13 studies recorded FBG and 6 studies recorded HbA1c, and meta-analysis was performed for both indicators, both expressed as MD, and according to the results of meta-analysis, the overall blood glucose indicators in the experimental group were lower than those in the control group, and the differences were statistically significant (I2 = 0%. P=0.50), and the differences were not statistically significant when analyzed using a fixed-effects model , P=0.87)  , and theFunnel plots were plotted for studies with >10 literature on combined outcome indicators, and total effective rate, Crea, 24h UTP, BUN, and FBG after treatment showed significant asymmetry in the funnel plots Figures –18, indin = 200).This study completed a systematic evaluation in accordance with the Cochrane risk bias assessment tool version 5.1.0 and the PRISMA statement . The resDKD is part of systemic microvascular disease and glomerulosclerosis caused by diabetes mellitus, which is the leading cause of renal replacement therapy in Europe and the United States, accounting for about 1/2 of cases, and it is the second most common cause of ESRD after glomerular disease in China . In receThe key to Bushen Huoxue therapy of this disease is to grasp its fundamental pathogenesis. Diabetes mellitus over time consumes yin and injures qi and accumulates heat and injures fluid, the kidneys are involved, kidney qi is depleted, blood stasis is prolonged, and the peripheral veins and viscera are not allowed to flow, so the kidney function is completely lost in the advanced stage. The disease is characterized by a combination of deficiency and actuality. The disease is characterized by a mixture of deficiency and reality, and the deficiency evidence is more obvious. The flexible addition and reduction in medicine based on the principle of holistic view and evidence-based treatment are the outstanding advantages of traditional Chinese medicine.Despite our working group's best efforts to control for literature inclusion criteria, literature quality, and other details, there are still certain shortcomings in this study that deserve to be explored for future avoidance and improvement. First, it was affected by the quality of the literature. None of the literature included in this study mentioned blinding and allocation concealment, and therefore, the original literature outcomes are unknown for selective bias, implementation bias, and measurement bias. However, it is reassuring to note that all the literature is RCT, with no omission of endings, which ensures that the results of this study are more credible. Second, a total of 23 studies were included in this study, and the study period was limited to 10 years, which resulted in an inadequate amount of literature. Our reflection on this point is that Chinese clinical trials in China in the last decade have been relatively standardized, and we made a selection to ensure the quality of the study and strictly limited the time. In addition, our results showed no difference in safety between combined Chinese and Western medicine treatment and Western medicine treatment alone, which may be related to the lack of strict control of drug dose and duration in this study, and to the number of literature. Finally, the funnel plot showed publication bias in this study, which may be due to the fact that negative results are difficult to publish and positive results are more likely to be reported. To address the above issues, in future studies, we will continue to conduct large-sample, multicenter, rigorous clinical trials and high-quality evidence-based analyses to verify the accuracy of the findings of this study.


Background: Various classifications have been proposed to subtype Parkinson's disease (PD) based on their motor phenotypes. However, the stability of these subtypes has not been properly evaluated.Objective: The goal of this study was to understand the distribution of PD motor subtypes, their stability over time, and baseline factors that predicted subtype stability.Methods: Participants (n = 170) from two prospective cohorts were included: the Early PD Longitudinal Singapore (PALS) study and the National Neuroscience Institute Movement Disorders Database. Early PD patients were classified into tremor-dominant (TD), postural instability and gait difficulty (PIGD), and indeterminate subtypes according to the Movement Disorder Society's Unified PD Rating Scale (MDS-UPDRS) criteria and clinically evaluated for three consecutive years.Results: At baseline, 60.6% patients were TD, 12.4% patients were indeterminate, and 27.1% patients were PIGD subtypes (p < 0.05). After 3 years, only 62% of patients in TD and 50% of patients in PIGD subtypes remained stable. The mean levodopa equivalent daily dose (LEDD) was higher in the PIGD subtype . Lower LEDD  and higher TD/PIGD ratios  were independent predictors of stability of TD subtype with an area under the curve (AUC) of 0.787 (95%CI: 0.669–0.876), sensitivity = 57.8%, and specificity = 89.7%.Conclusion: Only 50–62% of PD motor subtypes as defined by MDS-UPDRS remained stable over 3 years. TD/PIGD ratio and baseline LEDD were independent predictors for TD subtype stability over 3 years. More than 6 million people suffer from Parkinson's disease (PD) worldwide, and these numbers will continue to rise due to increasing life expectancy and aging , 2. The de novo PD patients in TD/mixed/AR and TD/mixed/PIGD subtypes according to two methods proposed by Jankovic et al. and Kang et al. With the development of the Movement Disorder Society's Unified PD Rating Scale (MDS-UPDRS), Stebbins et al. further validated these subtypes with optimal specificity and sensitivity obtained for the TD/PIGD ratio to define TD, indeterminate, and PIGD subtypes  , 11. Witsubtypes .To date, only one previous study has investigated motor subtypes using the criteria set by Stebbins et al. However, one limitation of that study was that the study had a short follow-up duration of 12 months . AnotherThis is a retrospective study based on data collected prospectively from idiopathic PD patients from the Early PD Longitudinal Singapore (PALS) study and the National Neuroscience Institute Movement Disorders Database. The PALS study is a prospective cohort study undertaken to understand PD progression, while the Movement Disorders Database has prospectively collected clinical information from a clinic cohort and has been in existence since 2002. Details of both cohorts have been described previously , 22. TheAll the participants were examined by movement disorder specialists at the National Neuroscience Institute, a tertiary center in Singapore, and evaluated within 2 years from their diagnosis at the institute. MDS-UPDRS was performed annually for three consecutive years when on medications from their first clinical visit. Each patient was evaluated and followed by the same neurologist on each visit. The institute has adopted the MDS-UPDRS for clinical evaluation of PD patients since 2014 after all clinicians had completed and passed the training program.The MDS-UPDRS at baseline and subsequent visits was completed in the on-medication state. Levodopa equivalent daily dose  at baseline evaluation was calculated from the dosages of prescribed dopaminergic drugs based on the standard conversion table as previously reported . PatientParticipants were deemed to have a “stable” subtype if their subtype remains the same throughout all 3 years and an “unstable” subtype if their subtype classification shifts at any point during the follow-up .This study aims to understand the distribution of pre-defined motor subtypes of PD using the MDS-UPDRS criteria and to examine the stability of Parkinson's subtype during the follow-up of 3 years in patients with early PD. We also sought to identify the independent predictors of stability of the subtypes that included age, sex, LEDD, and TD/PIGD ratio.Post-hoc analyses were performed using Bonferroni and Dunn's test, respectively, for significant variables. Multivariable logistic regression analysis was used to investigate the association of the baseline variables in TD and PIGD subtypes and the stability of subtypes (as the binary outcome variable), and odds ratio (OR) along with 95% confidence interval (CI) were reported. Specificity and sensitivity of factors predicting the TD subtype were analyzed from the area under the curve (AUC) using receiver operating characteristics (ROC). Youden index (sensitivity + specificity−1) approach was used to calculate the optimal cut-off point in the ROC analysis. Significance level was set at a p < 0.05. The statistical analysis was performed in SPSS .Descriptive statistics including mean ± standard deviation and median (interquartile) and frequency (%) is reported for continuous variables and categorical variables, respectively. The baseline characteristics of the patients were compared among the subtypes using analysis of variance (ANOVA) or Kruskal-Wallis test for continuous variables  and chi-square test for categorical variables. ANOVA was performed for age, gender, disease duration, MDS-UPDRS III, and MMSE; Kruskal-Wallis was conducted for LEDD; and chi-square for gender and subtype stability, respectively. p = 0.01). It should be also noted that there is a slightly higher dispersion in LEDD in the PIGD compared to TD or indeterminate. The coefficient of variation of LEDD is 0.75, 0.69, and 0.84 in TD, indeterminate, and PIGD groups, respectively. When baseline MMSE was compared between stable (n = 88) and unstable (n = 82) groups, no significant differences were found between the two groups .A total of 170 idiopathic PD patients that comprised of 111 patients from the PALS cohort and 59 from the Database cohort were included in the study. There were 100 (58.8%) out of 170 patients who were male. Baseline demographic and clinical characteristics are summarized in Post-hoc analysis revealed the LEDD dose to be significantly higher in the PIGD subtype as compared to the TD subtype.Post-hoc analyses revealed that both the TD and PIGD subtypes to both be significantly stable as compared to the indeterminate subtype.The stability and fluctuations of PD subtypes over the 3 years is summarized in p = 0.04, OR 0.35, 95% CI: 0.12–0.98), lower LEDD , and higher TD/PIGD ratio  at baseline were the independent predictors of stability over 3 years for the TD subtype. There was no statistically significant predictor found for the PIGD subtype  revealed that higher TD/PIGD ratio scores with a cut-off of 4.2 could predict TD subtype stability over 3 years with an AUC of 0.78, 95% CI (0.69–0.87), sensitivity = 50.0%, and specificity = 99.9% . A combiIn this study from two prospective cohorts, we reported the stability of PD motor subtypes as defined by MDS-UPDRS scores over 3 years. Only 62% of TD and 50% of PIGD patients maintained their subtype stability in the early stages of the disease over 3 years. The indeterminate subtype group was the most unstable subtype of all, possibly due to its fluctuating nature. PIGD patients had higher LEDD. TD/PIGD ratio and LEDD were the independent predictors of the TD subtype stability over 3 years. A combination of both factors after optimization of their cut-offs improved the identification of TD patients who remained stable at 3 years, with a sensitivity and specificity of 58 and 90%, respectively.There is a scarcity of studies that have investigated the stability of PD motor subtypes. Even among these few studies, the study populations, the study durations, and criteria used to perform motor subtyping have been varied. Schiess et al.  modifiedThe PPMI cohort provided further insights into the motor classification of PD, using the MDS-UPDRS , 19. At We further explored clinical markers that predicted the stability of PD. The PIGD subtype had significantly higher mean LEDD compared to the other two subtypes. This can be explained by the presence of greater motor deficits in PIGD patients that required more dopaminergic medications , 23. AftWe believe that these motor subtypes are clinically and pathophysiologically distinct, and their clinical implications are also different. The TD subtype has a more benign course, comparatively slower rate of progression, and better response to levodopa therapy . The PIGDespite the traditional reliance on motor subtypes to classify PD, the results of this study and previous investigations demonstrate a lack of stability for these motor subtypes over time. This brings into question the reliability and usefulness of the various criteria that have been used to perform motor subtyping. In view of this, PD subtyping has evolved to include data-driven approaches such as cluster analysis (CA), which is a highly sensitive statistical method that has gained favor in recent times. The major advantage is that these subtypes are derived from data rather than from pre-defined criteria used in conventional classification systems and can include additional variables other than conventional motor ones. In a systematic review, seven studies were identified that used CA to identify subtypes in the broad clinical spectrum of PD , 32. TheOur study's strength is the 3-year longitudinal follow-up of patients to assess the stability of their motor subtypes. While we recognize that other factors such as physiotherapy could affect subtype classification and stability, our sample is an early PD cohort, and most of the patients at this stage have not received active physiotherapy in our clinic setting. We also only assessed the MMSE data at baseline and will be following the cohort to determine if their cognitive status is affected by longer-term subtype stability.In summary, we demonstrated that PD motor subtypes as defined by the MDS-UPDRS become unstable over time in the early course of the disease, with only 50–62% of patients remaining stable over 3 years. We have also shown that a higher TD/PIGD ratio and the inclusion of LEDD at baseline may improve the identification of TD patients who remain stable with a TD subtype at 3 years. These findings have implications for clinical studies of PD subtypes, the evaluation of biomarkers for subtypes, and the design of clinical trials. Further studies on larger populations to validate these findings are needed.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Singapore Health Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.AK and SYEN: data analysis and manuscript writing. AW, NC, XC, DH, WL, H-LN, S-TC, SXMN, ZX, K-YT, W-LA, and E-KT: data collection and patient referral. LT: conception, design, and manuscript writing. All authors involved have read, and approved the submitted version.This study was supported by the Singapore Ministry of Health's National Medical Research Council under its Open Fund Large Collaborative Grant (MOH-OFLCG18May-0002).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.


Adverse drug reactions (ADRs) are regarded as a major cause of death and a major contributor to public health costs. For the active surveillance of drug safety, the use of real-world data and real-world evidence as part of the overall pharmacovigilance process is important. In this regard, many studies apply the data-driven approaches to support pharmacovigilance. We developed a pharmacovigilance data-processing pipeline (PDP) that utilized electronic health records (EHR) and spontaneous reporting system (SRS) data to explore pharmacovigilance signals.To this end, we integrated two medical data sources: Konyang University Hospital (KYUH) EHR and the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). As part of the presented PDP, we converted EHR data on the Observation Medical Outcomes Partnership (OMOP) data model. To evaluate the ability of using the proposed PDP for pharmacovigilance purposes, we performed a statistical validation using drugs that induce ear disorders.To validate the presented PDP, we extracted six drugs from the EHR that were significantly involved in ADRs causing ear disorders: nortriptyline, ; metoclopramide ; doxycycline ; digoxin ; acetaminophen ; and sucralfate . In FAERS, the strongest associations were found for nortriptyline , sucralfate , doxycycline , and hydroxyzine . We confirmed the results in a meta-analysis using random and fixed models for doxycycline, hydroxyzine, metoclopramide, nortriptyline, and sucralfate.The proposed PDP could support active surveillance and the strengthening of potential ADR signals via real-world data sources. In addition, the PDP was able to generate real-world evidence for drug safety.The online version contains supplementary material available at 10.1186/s12911-021-01520-y. Adverse drug reactions (ADRs) are among the top 10 leading causes of death and result in annual costs of approximately $75 billion in the United States (US); hence, they represent a significant public health concern . CurrentPost-marketing surveillance typically engages a number of approaches to monitor drugs, using real-world data . Real-woWidely accepted standardized data structures are also referred to as common data models (CDM) and they are used to efficiently utilize data from hospitals. The use of a CDM is beneficial as it unifies the terms used in each medical institution into standard terminology. Different types of CDM are used according to the purpose of the study, such as the Sentinel CDM  and the In this study, we used two different real-world data sources: EHR and SRS data, and developed a pharmacovigilance data-processing pipeline (PDP) that converts the two data sources to OMOP CDM. The process includes standardizing terminology, transforming and loading each EHR and SRS data tables into OMOP CDM. We devised the objectives of PDP to further validate detected novel drug-ADR signals with different real-world data sources, and especially using laboratory and measurement results from EHR data. We used the laboratory and measurement results as supplementary data for statistical analysis and conducted meta-analysis on the signals, we could identify the consensus results from heterogeneous data.We extracted pure tone audiometry (PTA) reports from the EHR data for the detection of ADRs resulting in ear disorders which we chose as the target ADR to evaluate the PDP. Hearing loss is one of the most chronic disabilities and the World Health Organization (WHO) has estimated the annual cost of unaddressed hearing loss to be approximately $750 billion , 14. AltFor systematic pharmacovigilance, we developed the specialized data process pipeline for data cleansing  related to drugs and ADRs from different real-world data sources. Since it is difficult to detect and assess the drug-induced ADRs from only one data source, we converted EHR and FAERS data into OMOP CDM for integrating actual ADR reports and clinical data. Yu, Yue, et al. study  proposedThe representative unstructured data used in this study, PTA reports, results in a graph image. Therefore, we manually input numerical values into CDM table, and categorized the condition for normal or abnormal based on the values. Similar to PTA reports, various case report form (CRF) data are missed or could not be inserted to the OMOP CDM tables. Since there are different reports data that can be used for identifying disorders of patients, it is important to design study accordingly. Using the appropriate clinical test indicators, we can identify whether a drug induced ADRs based on evidence. The overview of PDP used for active surveillance of drug-ADRs is shown in Fig. We analyzed all EHR data for patients obtained from January 1, 2014 to December 31, 2018 of Konyang University Hospital (KYUH), comprising a total of 347,040 patients. Each EHR contains information on admissions, discharges, drug prescriptions, laboratory results, and nursing documents. As the EHR data includes a patient’s personal information, a new patient ID was assigned to prevent re-identification when the data were converted with the PDP. Diagnosis information, visit information, and prescription information corresponding to the newly assigned patient ID were mapped and could be visualized for each patient. The PTA reports of information contained in the EHR tests table was confirmed by connecting the patient ID with the primary key in the person table.FAERS contains seven tables, for patient demographic and administrative information (DEMO), drug/biologic information (DRUG), adverse events (REAC), patient outcomes (OUTC), report sources (RPSR), drug therapy start and end dates (THER), and indications for use/diagnosis (INDI) . The rawPTA reports were related to EHR data by patient ID, and the data were stored as an image file containing a results graph Fig. a. TherefWe selected drugs based on the activities–enabled pharmacovigilance MetaNurse algorithm , which iWe applied 1:1 propensity score matching (PSM) to each of the 13 tables and then performed Cox proportional hazard regression analyses to calculate the HR and 95% confidence interval. Propensity score matching and Cox proportional hazard regression analyses were computed. The independent variables were gender, age, number of visits (only those subject to outpatient care), and hospitalization period (only those subject to inpatient care), and the dependent variable was set as taking or not taking the target drug. We matched the date of the drug prescription for patients who were not taking the target drug to the date of prescription for patients who were taking the target drug. The above process is shown in Fig. In EHR, we created an analysis table based on drug and condition tables, each including prescription and diagnosis information. When the patient was prescribed a target drug, it was categorized as 1 for Medication in each table. When diagnosis of ear disorders and abnormal PTA test occurred within 365 days after the prescription of the target drugs, this was categorized as 1 for Outcome. Then, we processed the diagnosis and PTA information independently.A indicates the number of co-occurrences of interest. The number of co-occurrences with a drug of interest but without an ADR of interest, was defined as B, and the number of co-occurrences without a drug of interest but with an ADR of interest was defined as C. D indicates the number of co-occurrences without either drug or ADR of interest. We calculated the odds ratio between the two variables, and determined whether it was a significant outcome by considering the 95% confidence interval and the p-value. Finally, we performed a meta-analysis using Forest plot in R. This method was developed for use in medical research as graphical representation of a meta-analysis of the results of randomized controlled trials  cases) than in men (56 [16.3%] cases), with sex not specified in 16 (4.7%) cases  was calculated by taking into account the number of events in case/control for each of the 9 drugs identified in EHR and FAERS. For the 9 drugs, the RR (and 95% CI) values in both models  were acetaminophen , cimetidine , digoxin , doxycycline , epinephrine , hydroxyzine , metoclopramide , nortriptyline  and sucralfate . We generated a plot of the values, including both the random effects model and the fixed effects model in Fig. 7–0.93, 0In this study, we have used a combination of diagnostics for ear disorders and PTA reports contained in the EHR to perform pharmacovigilance. The drugs that were detected in both EHR and FAERS were doxycycline, nortriptyline and sucralfate. The HR for nortriptyline was 8.06 in the EHR and the ROR was 1.94 in FAERS, whereas the value for sucralfate was about 1.22 in both the EHR and FAERS. These results showed that nortriptyline and sucralfate were potent drugs that caused ADRs of ear disorders. When the meta-analysis was conducted with a random effects model, the drugs with a significant RR were doxycycline (1.42), nortriptyline (2.91), and sucralfate (1.15). When using the fixed effects model, doxycycline (1.30), hydroxyzine (1.15), metoclopramide (1.62), nortriptyline (1.94), and sucralfate (1.15) were the drugs with a significant RR.Through meta-analysis, we detected 5 drug-ADRs pairs for ear disorders, and classifications of each drugs are antibiotic, antidepressant, and etc. Of these, nortriptyline, which showed the highest signal in the meta-analysis, is an antidepressant. Previous studies have shown that antidepressants are effective in ameliorating tinnitus –35, but To validate the performance of the presented data processing pipeline also for other diseases beyond ear conditions, we analyzed 2 additional System Organ Classes (SOCs) and conducted a meta-analysis. We considered commonly used measurements for analysis, then found the target blood and liver functions tests. The drugs were filtered using the drug selection algorithm described in the methods section. The blood tests used to detect neutropenia and thrombocytopenia were absolute neutrophil count (ANC) and platelet levels, respectively. In the case of neutropenia, the RR using two models  for metoclopramide was 1.58 (1.42–1.77) and 3.28 (0.54–20.00), and that of palonosetron was 4.76 (3.95–5.74) and 6.64 (2.52–17.46)  we analyzed EHR data of only one institution; 2) the EHR data contains fewer patients. First, in general, the use of only one hospital for analysis may make it difficult to demonstrate the validity of a signal. Therefore, we developed a PDP to combine EHR data and SRS data, and used additional information such as the PTA reports of EHR data for analysis. The problem of the small number of patients in EHRs may be overcome through meta-analysis with the FAERS result. Owing to the relatively small number, it was statistically analyzed with the results of sufficiently large numbers of data.As the SRS data contains valuable and extensive information about the relationship between drugs and ADRs compared with other medical data sources, we will use Korean SRS data in future studies. We intend to expand the PDP with Korea Adverse Event Reporting System (KAERS) data, similar to FAERS. As KAERS also uses other types of terminology, the information should first be converted to a CDM and then the appropriate tables should be analyzed.EHR has well-structured time-dependent information and covariate measurements, but there are complexities in the identification and definition of ADRs, whereas FAERS contains clear definitions of ADRs, but does not include time-based information and inspection records . We propAdditional file 1. Figure S1. Risk ratio for Blood and Lymphatic system disorders from KYUH-EHR and FAERS (Neutropenia). Figure S2. Risk ratio for Blood and Lymphatic system disorders from KYUH-EHR and FAERS (Thrombocytopenia). Figure S3. Risk ratio for Hepatobiliary disorders from KYUH-EHR and FAERS (Acute hepatitis).


All patients received serum tumor markers detection, so as to compare the CT- and ultrasound-guided percutaneous transthoracic needle biopsy results and pathology results, levels of serum tumor markers among all patients and the patients with different lung cancer types, and diagnostic efficacy of tumor markers, as well as complication rate (CR) in patients. The sensitivity and specificity of ultrasound-guided percutaneous transthoracic needle biopsy were 0.880 and 0.800, respectively, while those of CT-guided percutaneous transthoracic needle biopsy were 0.909 and 0.625, respectively; the CA125 and CEA levels in the lung cancer group were higher than those in the benign group (P < 0.001); the CA125 and CEA levels of the patients with adenocarcinoma were higher than those with squamous carcinoma, and the CEA levels of the patients with small-cell carcinoma were lower than those with adenocarcinoma (P < 0.05); the sensitivity, specificity, and Youden indexes of CA125 were 0.638, 0.833, and 0.471, respectively, while those of CEA were 0.766, 0.778, and 0.544, respectively; there were no significant differences in CR between the two groups (P > 0.05). CT- and ultrasound-guided percutaneous transthoracic needle biopsy is a safe and feasible diagnostic modality for lung cancer, and its combination with serum CA125 and CEA can significantly improve the accuracy of the detection results, which is worthy of promotion and application in clinical practice.The number of patients with lung cancer is difficultly diagnosed in the early stage. The purpose of the study was to investigate the effects of CT- and ultrasound-guided percutaneous transthoracic needle biopsy combined with serum CA125 and CEA on the diagnosis of lung cancer. 120 patients with suspected lung cancer admitted to our hospital from January 2019 to January 2020 were selected and divided into an ultrasound group ( The number of patients with lung cancer has soared across the world in recent years, and when diagnosed, the patients have entered the advanced stage of the disease, severely hindering treatment progress –3 and ren = 60) and CT group (n = 60), according to different modalities of percutaneous transthoracic needle biopsy. There were no significant differences in the general information between the two groups (P > 0.05), and the patients and their family members signed the informed consent, as shown in 120 patients with suspected lung cancer admitted to our hospital from January 2019 to January 2020 were selected and divided into an ultrasound group ((1) Patients were diagnosed with space-occupying lesions in their lungs by imageological examination. (2) Patients underwent surgical treatment and obtained pathological results. (3) This study was approved by the hospital ethics committee.(1) Patients had mental disorders and could not communicate with others. (2) Patients had other organic diseases. (3) Patients had coronary heart disease, arrhythmia, and coagulation disorders.All patients received serum tumor marker detection. In the ultrasound group, the patients underwent ultrasound-guided percutaneous transthoracic needle biopsy, while the CT group patients were given CT-guided percutaneous transthoracic needle biopsy, and the specific methods were as follows.Patients' fasting venous blood samples were collected in the morning, and the serum was isolated after self-coagulation and stored in a freezer at −25°C for detection within 3 days. The CA125 and CEA levels were measured by the electrochemiluminescence immunoassay  20113402843).After the location of lung lesions was clarified by chest CT in patients, an ultrasound probe  was adopted to examine the affected tissues and their structure to determine the needle entry position. Then, the puncture sites were sterilized and given local anesthesia, and the puncture angle, depth, etc., were all checked before an ultrasound-guided percutaneous transthoracic needle biopsy. After that, the biopsy tissues were fixed with 10% formaldehyde solution  for detection.The location of the lesions in patients' lungs was clarified according to the chest CT, and the patients were asked to take appropriate positions. The lesions were scanned with 3 mm in each layer by using a CT scanner  20093300931), and metal bar localizers were placed in the corresponding body surface sites. After that, the scanning continued, to determine the appropriate puncture sites, and the puncture angle, depth, etc., were calculated by measuring before the puncture sites were disinfected and given local anesthesia. Then, a biopsy gun  was used after the puncture needles were confirmed inside the mass by scanning, and the biopsy tissues were fixed with 10% formaldehyde solution before detection.CT- and ultrasound-guided percutaneous transthoracic needle biopsy results and pathology results were compared to calculate the sensitivity and specificity of the two diagnostic methodsSerum tumor markers levels: the patients were divided into the lung cancer group and the benign group, according to their pathological findings, and the serum CA 125 and CEA levels were compared between the two groupsSerum tumor markers levels in patients with different lung cancer types: the serum CA125 and CEA levels of the patients with adenocarcinoma, squamous carcinoma, and small-cell carcinoma were comparedDiagnostic efficacy of tumor markers: the sensitivity, specificity, and Youden indexes of serum CA125 and CEA were compared, and the value of Youden indexes close to 1 indicated higher authenticity and better diagnosis –22CR: the cases of complications including pneumothorax, hemorrhage, and hemoptysis were recordedt-test, and enumeration data were tested by the X2 test and normality test. The differences had statistical significance when P < 0.05.The selected data processing software for this study was SPSS20.0, and the software selected to draw the pictures of the data was GraphPad Prism 7 . Measurement data were tested by the The sensitivity and specificity of CT- and ultrasound-guided percutaneous transthoracic needle biopsy are shown in P < 0.001), as shown in Figures The CA125 and CEA levels in the lung cancer group were higher than those in the benign group (P < 0.05), as shown in The CA125 and CEA levels of the patients with adenocarcinoma were higher than those with squamous carcinoma, and the CEA levels of the patients with small-cell carcinoma were lower than those with adenocarcinoma (The diagnostic efficacy of CA125 and CEA is shown in P > 0.05), as shown in There were no significant differences in CR between the two groups , and the CA125 and CEA levels of the patients with adenocarcinoma were higher than those with squamous carcinoma, and the CEA levels of the patients with small-cell carcinoma were lower than those with adenocarcinoma (P < 0.05), suggesting that tumor markers can effectively diagnose lung cancer, among which CEA has a high sensitivity for adenocarcinoma. CA125 is also a major marker of adenocarcinoma, and the reason why CA125 levels increase in lung cancer patients is that the CA125 antigen inside patients' bodies is stimulated and then constantly released and finally enters the blood through autonomous absorption, elevating CA125 levels.In addition to a percutaneous transthoracic needle biopsy, serum tumor markers detection is also a routine diagnostic modality for lung cancer. Generally, the accuracy of imageological examination in judging lung cancer is limited, while serum tumor markers can enhance physicians' knowledge, such as lung cancer cell differentiation, and are of great importance in judging patients' lung cancer conditions and classification –19. In tIn this study, the sensitivity, specificity, and Youden indexes of CA125 were 0.638, 0.833, and 0.471, respectively, while those of CEA were 0.766, 0.778, and 0.544, confirming that CEA and CA with high clinical application value can combine with percutaneous transthoracic needle biopsy to further improve the diagnosis rate of lung cancer. The scholar Wanda Lawrence has pointed out in his study that the Youden indexes of CA125 and CEA are 0.475 and 0.544, respectively , and theP > 0.05), confirming that ultrasound- and CT-guided percutaneous transthoracic needle biopsy have high safety and feasibility, which can be applied widely in clinical treatment.Moreover, our study results also found that CR in both groups was low, and there were no significant differences between groups (In conclusion, CT- and ultrasound-guided percutaneous transthoracic needle biopsy combined with serum CA125 and CEA, with high application value, can further improve the diagnosis rate of lung cancer in patients, which is worthy of application and promotion in clinical practice.


A factor analysis of MRB yielded 4 dimensions: prosocial behaviors, interpersonal transgressions, antisocial behaviors and secret transgressions. Prosocial behaviors were predicted by self-transcendence–self-enhancement (SET) value contrast only while the three transgression categories were associated with both SET and openness to change–conservation (hedonism–conformity) contrast. Norm-breaking guilt was more strongly associated with behaviors than were empathic guilt and shame. However, shame was (positively) associated with secret transgressions in three countries, after controlling for values. The associations were strongest in Bulgaria and Estonia while fewer associations were found in Finland and Portugal. The implications of the findings for the cross-cultural psychology of morality are discussed.University students ( The circular continuum reflects motivational compatibility and conflict among values so that the more compatible any two values are, the closer they are on the circle. Values located on the opposite sides of the circle are in conflict. This motivational continuity is manifested in the sinusoid form of the magnitudes of correlations both among the values and between the values and other variables as one moves along the circle.In Schwartz’s model, the goals and interests that values serve can be either compatible or conflicting with each other. The values form a two-dimensional continuum, organized along a circular structure consisting of two main dimensions, self-transcendence vs. self-enhancement and openness to change vs. conservation. Self-transcendence refers to motivation to transcend selfish concerns and promote the welfare of others . Self-enhancement comprises values, which motivate people to further their own personal interests even at the expense of others . Openness to change values refer to motivation to follow one’s own intellectual and emotional interests , whereas conservation values refer to preferring the From the point of view of morality, values can be categorized into two broad categories: conservation values inhibit antisocial behavior or justify resistance to temptation to deviate from moral norms and self-transcendence values promote or justify prosocial, altruistic actions . For insStudies of value-behavior relations see .It has been a common assumption that when normative pressures are strong, values do not predict behavior or attitudes. Normative pressure could be due to value importance or behavior frequency  so that The second paradigm starts from a certain behavior and examines the values that predict it. For instance, political activism or engaging in risky sexual behavior  are best predicted by universalism and hedonism, respectively. Typically, the pattern of value-behavior correlations follows the sinusoid form implied by the notion of motivational continuity. Political activism is positively predicted by values that are adjacent to universalism, viz., self-direction and stimulation, and negatively by values that are opposite to universalism. Given the motivational continuity of the Schwartz Value Model, the highest positive and highest negative correlations of a certain behavioral or attitudinal variable are not necessarily with the exact opposite values, e.g., universalism and power, respectively, but might also be with an adjacent value, e.g., universalism and achievement. However, most of the patterns for the 30 value–behavior/attitude relations reviewed by While most of the value-behavior patterns reported in the literature have been bipolar, i.e., to the highest positive correlation of a value with a behavior corresponds the highest negative correlation of the opposite value, a unipolar pattern was found for artistic occupations by As mentioned at the outset, In the study of guilt and shame, there is a lot of confusion and controversy  from the samples, which do not necessarily reflect the national average differences.To summarize our research questions, we wanted, first, to explore the nature of the value-behavior relations from the viewpoint of moral values, by looking at behaviors that in the reports and minds of our respondents group together. Moral values are exemplified by their two functions, promotion of other people’s welfare (Self-Transcendence) and inhibition of doing bad things, in the sense of following norms . To what extent do we find correlational patterns that follow the main axes, Self-Enhancement–Self-Transcendence and Conservation-Openness to Change, as has usually been the case in previous studies, to what extent patterns in which the main motivational contrasts are mixed, as in risky sexual behaviors ?Second, we examine the question, raised by The third focus are the associations of the moral behavior categories with tendencies to feel empathic or norm-breaking guilt and shame and the role of values and moral emotions in explaining the reported frequencies of different categories of MRB. More specifically, we examine the question whether taking emotional variables into account adds any explanatory power beyond values.A fourth focus is cultural variation in the strength of value-behavior-emotion links. While the four target countries, Bulgaria, Estonia, Finland, and Portugal are all members of the EU, they have differing historical backgrounds and recent histories, which are reflected in the contradictory scores on such cross-cultural value dimensions as individualism or cultural tightness–looseness. Our data provide an opportunity to compare the variation in the light of cross-cultural typologies.The research procedure followed the principles for research with human participants and the study did not involve elements requiring ethical review (Finnish Advisory Board on Research Integrity 2019). The respondents provided an oral informed consent to participate the study and they were informed that they could withdraw their participation any time without any reason.1 consisted of 758 university students in the fields of psychology and social sciences. They were recruited from Sofia , Tallinn , Helsinki , and Coimbra . The percentage of female respondents was 82% , and the samples differed in terms of gender (χ2(3) = 36.80, p < 0.001). The mean age for the whole sample was 23.5 years (sd = 5.7). Mean ages for the subsamples were: Sofia 21.3 (sd = 1.5), Tallinn 27 (sd = 6.9), Helsinki 25 (sd = 5.8), and Coimbra 20.0 (sd = 2.3). Because the variances of age were not homogeneous, we conducted a non-parametric Kruskal–Wallis test to examine whether age differed between the samples. The test revealed that age varied between the countries (χ2(3) = 389.24, p < 0.001). The multiple comparisons using a Mann–Whitney Test with Bonferroni adjustment showed that Finnish respondents were older than respondents in Bulgaria and Portugal (both ps < 0.001) and younger than in Estonia (p < 0.05). The age of Bulgarian respondents differed significantly from the age of Portuguese and Estonian respondents (both ps < 0.001). Thus, further analyses are controlled for gender and age.The sampleThe respondents filled out in class a questionnaire consisting of demographic questions, the A panel of Finnish graduate and post-graduate students and post-doctoral researchers in psychology and social psychology generated, in a “brainstorming” session, a list of MRB. The instruction was to forget moral psychological theories and just try to find a set of everyday behaviors that were meaningful and more or less likely to occur in college students’ life. The definition of each item took into account the likelihood of each behavior so that for some behaviors  the wording was “ever” whereas for behaviors that were supposed to occur more often, it was “within the past year” or “6 months” or “2 months.” The response alternatives were “not possible” (0), “no” (1), “yes” (2). The list of behaviors was translated from English/Finnish into Bulgarian, Estonian, and Portuguese. A principal component analysis with Varimax rotation yielded seven factors with eigenvalues greater than 1 accounted for 52.51% of the total variance. Based on the Scree plot we ended up to limit the number of factors to four with a cutoff 0.40 for inclusion of a variable in a factor. The four factors, accounted for 35.14% of the variance. In all, as many as 13 of the original 30 items were discarded, either because of the high frequency of “not possible” responses or because they failed to load on the factors. The final list of behaviors is shown in The Portrait Value Questionnaire (PVQ-40)  was usedThe version of Tangney’s TOSCA (adults)  we used All measures for which there was no previous translation were translated from English into Finnish, Bulgarian and Portuguese and back translated to English by native bilinguals.2(3) = 111.072, p < 0.001; stimulation χ2 (3) = 33.723, p < 0.001; hedonism χ2 (3) 27.805, p < 0.001, achievement χ2(3) = 72.936, p < 0.001; power χ2(3) = 77.088, p < 0.001; conformity χ2 (3) = 27.747, p < 0.001; tradition χ2 (3) = 48.968, p < 0.001; and benevolence χ2(3) = 59.052, p < 0.001. The multiple comparisons using a Mann–Whitney Test with Bonferroni adjustment showed that compared to Estonian sample, Bulgarian students had lower scores in universalism, conformity and benevolence and higher scores in hedonism and achievement . Comparing to Finnish sample, Bulgarians had higher scores in stimulation, achievement and power and lower scores in universalism and benevolence . They also showed higher scores in stimulation, achievement and power and lower scores in universalism, tradition and benevolence than Portuguese students . Estonian and Finnish samples differed in stimulation, power, conformity  as well as in universalism and benevolence . Estonians also showed higher scores in stimulation, power, conformity and lower scores in hedonism and tradition than Portugese sample . Samples from Finland and Portugal differed in universalism, benevolence and tradition, the former two being higher in Finland and tradition in Portugal (ps < 0.001).The means and standard deviations of the main variables are shown in ps < 0.01). Age was positively related to universalism, security and conformity and negatively to hedonism, and achievement and norm-breaking guilt .Across the samples, gender  was positively related to achievement, power, and negatively to benevolence, universalism, empathic guilt, norm-breaking guilt, and shame  and with antisocial behavior stronger in Portugal than in Finland . Hedonism showed significantly higher correlation with interpersonal transgression in the Bulgarian sample than in the Finnish sample , and the correlation of power with interpersonal transgressions was higher in Bulgarian, Estonian and Portugal samples than in Finnish . For benevolence, the correlation with interpersonal transgressions was lowest in Bulgaria, differing from Finland . The norm-breaking guilt showed strongest negative correlation with interpersonal transgression in Bulgaria, which differed from zero correlation in Portugal . With secret transgressions, the norm-breaking guilt correlated lowest in Estonia compared to Finnish sample .The correlations of the number of self-reported MRB with values, guilt and shame in four countries, controlled for gender and age, are shown in Interpersonal transgressions were predicted by the self-enhancement–self-transcendence contrast in three countries, except Finland, and by the openness to change–conservation contrast in Bulgaria and Estonia, where they were also associated with guilt over norm transgressions. Thus, Portugal was the only country to show approximative motivational continuity whereas a marked mixed pattern of correlations was evident in Bulgaria and Estonia. For prosocial behaviors no clear pattern emerged. The guilt and shame measures were not related to prosocial behaviors either, with the exception of empathic guilt in Portugal. Antisocial behavior was linked to the openness to change–conservation contrast in Bulgaria and Portugal, and showed an additional power–universalism contrast in Bulgaria. Hedonism was associated with antisocial behavior in Finland. Low norm-breaking guilt predicted antisocial behavior in three countries, not in Finland. Secret transgressions were predicted by power in Portugal and by hedonism in the three other countries. In Bulgaria we found both self-enhancement–self-transcendence and openness to change–conservation contrasts, in Finland only a weak openness–conservation contrast. An intriguing finding was the positive association of shame-proneness with secret transgressions in three countries.p < 0.01), but not as well as did the homogeneous pattern in Portugal (rho = 0.98).In all, r = 0.22, and benevolence, the inhibiting value, r = −0.14. The mean difference in the magnitudes of 11 pairs of coefficients is 0.03. Moreover, all three unipolar patterns involve a propelling value.With regard to the strength of the associations of propelling and inhibiting values with behavior, the data in We further examined the predictors of MRB by means of hierarchical regression analyses. Gender  and country  were entered as dummy variables on the first step with age; values were entered on the second step and guilt and shame variables on the third step. To avoid the problem of multicollinearity, i.e., having opposite values that correlate highly negatively with each other simultaneously in a regression model, two models were calculated for every dependent variable. In the first model self-transcendence and conservation values were used and in the second model self-enhancement and openness-to-change values were entered because these value sets are located on different sides of the circumplex. Thus, altogether we ran eight regression analyses: two models for each of the dependent variables.Summaries of the hierarchical regression analyses are reported in For prosocial behaviors, moral emotions did not increase explained variance, but age (positively), country  as well as values were significant predictors. Self-transcendence and openness to change values predicted positively and conservation negatively prosocial behavior. In the first model, the predictors explained 14% and in the second model 13% of the total variance.s = 0.20), and altogether the predictors explained 11 and 12% of total variance in the first and second model, respectively.Antisocial behaviors were strongly predicted by male gender, country  and norm-breaking guilt (negatively). Of the values, only self-enhancement was weakly related to it. The predictors explained 17% of the total variance in both models. Secret transgressions were significantly predicted by female gender, country (Estonia positively), and of the values self-transcendence and conservation negatively and self-enhancement positively. Norm-breaking guilt and shame were significant predictors in the first model and shame in the second model. Shame was the most powerful predictor in both models  were more strongly related to behavior than the values thwarting it. This was our second research question, and we largely corroborated the previous findings by With regard to the moral emotional variables, our third research focus, the introduction of the guilt-over-norm-breaking measure to the TOSCA, to complement the empathy-based guilt measure, appeared useful, as this measure was more frequently (6 vs. 2 times out of 12) and more strongly (mean/r/’s = 0.15 vs. 0.08) associated with the three transgression categories than was empathic guilt. This finding highlights the important role that norms play in MRB. While empathic guilt did not add explanatory power beyond values in the hierarchical regression analyses, norm-breaking guilt did so in most of the analyses. Shame, on the other hand, was not associated with other types of MRB than secret transgressions, but it played an important role in explaining these transgressions.That secret transgressions formed a category of their own was an unexpected finding. While secret transgressions were associated with hedonism in Finland, in the three other countries they were positively related to power. In Bulgaria and Estonia, a mixed pattern of correlations similar to the other two morally negative categories was found.What do the present exploratory findings tell us generally about moral behavior? The relatively high proportion of motivationally mixed correlation patterns in our data was striking, against the background of previous research focused on finding motivationally pure behavior. Instead of being simply an issue of egoism vs. altruism or breaking norms vs. following them (hedonism–conformity), moral behavior often seems to involve both those aspects, if our findings lend themselves to be replicated.What do our findings tell us about moral values? A look at values in terms of the number of their correlations with the behavioral categories  indicateWe replicated the Secret transgressions were consistently correlated with power, which suggests that domination of others is associated with admitting that one has penetrated into their privacy. An intriguing finding was the association of shame-proneness with secret transgressions. Research suggests that people who value power are not likely to feel shame , so thisIn the social psychology and sociology of morality, interest in secrets has been next to non-existent, as one looks in vain for the term in the handbooks. In fact, the only reference to it we found in psychological literature on moral judgments was 50 years old. Lady with lapdog, muse: “The whole private personal life is kept a secret, and perhaps that is partly the reason why civilized individuals are so anxious that their personal secrets should be respected.” Writing about medical secrecy, Raymond privacy to the 1995 version of his value survey. While this item turned out to be neither motivationally pure nor having culturally invariant meaning, in the Finnish national value measurements its importance has been fairly high (16-19/57), higher than wisdom, for instance  secrets is a pervasive phenomenon in social life  from theinstance . In 1999instance . Thus, nThe fourth question addressed in this study were cross-cultural differences. The value priorities in three of the four target countries, Estonia, Finland, and Portugal, were close to the pan-cultural consensus , with beHowever, a comparison of the value hierarchies of the samples shows that the Bulgarian sample was the most individualistic one, with self-direction and achievement as its top values, and also loosest in terms of value dispersion. This could explain the strong associations. But the associations were almost as strong in Estonia, which on the sample level was quite similar to Finland and Portugal in terms of value hierarchy and close to Finland on tightness-looseness. To understand why behavior links were stronger in Estonia and Bulgaria than in Finland and Portugal, we could speculatively appeal to the communist past of those two countries. In ex-communist countries, individualism may to a great extent be associated with breaking social norms while in older democracies it would be easier to combine individualistic values with following norms. The fact that the respondents were  university students is naturally a serious limitation of the present study. In further studies, more gender-balanced samples should be used. Also the fact that of the 30 items in the original MRB scale as many as 13 were discarded in the process of analysis suggests that our attempt to sample actions that would be representative of the morally relevant actions in the life of students was not entirely successful. Moreover, it would have been preferable to arrange a four-country brainstorming session to construct the MRB questionnaire instead of using the version that was produced in Finland. However, as this study was exploratory and aimed at producing new ideas, from an inductive starting point, the findings that were consistent across most of the four countries would suggest that they are worth pursuing further, with more diverse and representative samples and new questionnaires. One promising direction is the examination of the significance of secrets in the social psychology of morality. The right to have secrets is one of the bases of freedom, democracy and rule of law and deserves more attention. Is the finding that shame-prone individuals who have high regard for power are more likely than others to report breaches of privacy replicable in other contexts? As power and the proclivity to feel shame have been found to correlate negatively, it would be interesting to delve deeper into this issue. Another issue that seems to deserve further scrutiny is the finding that our inductively derived morally relevant behavior categories were largely motivationally mixed in relation to the Schwartz value model, in contrast to majority of previous findings on value-behavior associations.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The patients/participants provided their oral informed consent to participate in this study.LM, KH, and MS-K: conceptualization, study design, and funding acquisition. LM, MS-K, JV, KP, and KL: data collection and analysis and providing critical revision. LM and KH: writing – original draft. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


I2: 76.56%; P = 0.014; CI 1.27 to − 0.28) and Greater wing angle  between AS and control subjects. Cleft palate, anterior open bite, crowding in the upper jaw, and hypodontia occurred more frequently among AS patients. Significant shortening of the mandibular width, height and length is the most reported feature in AS patients. CT scans can help patients with AS decide whether to pursue orthodontic treatment alone or to have their mouth surgically expanded. The role of well-informed orthodontic and maxillofacial practitioners is critical in preventing and rehabilitating oral health issues.This meta-analysis aims to compare Apert syndrome (AS) patients with non-AS populations  on craniofacial cephalometric characteristics (CCC) to combine publicly available scientific information while also improving the validity of primary study findings. A comprehensive search was performed in the following databases: PubMed, Google Scholar, Scopus, Medline, and Web of Science, an article published between 1st January 2000 to October 17th, 2021. PRISMA  guidelines were followed to carry out this systematic review. We used the PECO system to classify people with AS based on whether or not they had distinctive CCC compared to the non-AS population. Following are some examples of how PECO has been used: People with AS are labeled P; clinical or genetic diagnosis of AS is labeled E; individuals without AS are labeled C; CCC of AS are labeled O. Using the Newcastle–Ottawa Quality-Assessment-Scale, independent reviewers assessed the articles' methodological quality and extracted data. 13 studies were included in the systematic review. 8 out of 13 studies were score 7–8 in NOS scale, which indicated that most of the studies were medium to high qualities. Six case–control studies were analyzed for meta-analysis. Due to the wide range of variability in CCC, we were only able to include data from at least three previous studies. There was a statistically significant difference in N-S-PP ( Baumgartner and Wheaton were the first to describe AS clinically in 1842, and Eugene Apert, a French pediatrician, published a series of cases in 1906, in which he reviewed the condition extensively2. The syndrome affects anywhere from 1/65,000 to 1/200,000 newborns, regardless of gender4. In nearly all cases, missense mutations in the FGFR2 gene (on chromosome 10q25–10q26) are to blame, and these are only found in men7. People with AS are 50% more likely to have a child with AS, according to the research that has been done on the subject of passing the syndrome on to future generations9. In AS, fibroblasts are unable to produce the essential fibrous material found in several craniofacial tissues, such as bone sutures and cartilage, as well as during tooth formation and regeneration due to the FGFR family of mitogenic signaling molecules (FGFRs)10. The mutated FGFR2 gene may therefore have an impact on the dental abnormalities seen in AS11.It's estimated that only 4.5% of people with craniosynostosis have Apert syndrome (AS), which is also known as acrocephalosyndactyly12. AS is associated with several other health problems, including a lack of intellectual development, obstructive sleep apnea, and frequent ear infections13. Craniosynostosis, hypoplasia of the midface, and syndactyly of the hands and feet are other phenotypic features of AS14. In addition, AS is associated with a wide range of significant central nervous system abnormalities, which may be due to the prevalence of mental deficiency in patients with this syndrome15. Patients with concave facial profiles may have a reduced volume of nasopharyngeal and oropharyngeal spaces due to hypoplasia of the middle third of the face. Chronic mouth breathing, breathing difficulties, or even sudden death can result from the combination of this and possible posterior nasal stenoses17. Dental crowding, skeletal anterior open bite, unilateral crossbite, Angle Class III malocclusion, lip with inadequate posture, cleft palate, uvula Bifida in 30% of the palates, upper and lower palate, macroglossia, retained teeth, and thick gums are all symptoms of AS in the mouths of those diagnosed with the condition19.Most patients with AS have long, lean heads with high foreheads and sunken eyes, as well as abnormalities in the way their eyelids close. This is due to the disordered growth of the skull and faceHowever, until now, no systematic review of the existing literature has been conducted on the CCC of AS patients. This meta-analysis aims to compare AS patients with non-AS populations on CCC to combine publicly available scientific information while also improving the validity of primary study findings. When it came to CCC obtained from lateral teleradiographs or computed tomography (CT) scans of the head, there was no difference between people with AS and the general / non-AS population, according to the review.20  guidelines and registered at the University of York's (U.K.) PROSPERO database (Registration No. CRD42021282637).The following databases were searched thoroughly: PubMed, Google Scholar, Scopus, Medline, and Web of Science, with restrictions on the publication date from 1st January 2000 to October 17th, 2021. The keyword combinations were used mixed with the Boolean operator “AND”  are labeled C; CCC of AS are labeled O and are examined using lateral cephalometric measurements or a CT scan. There were case–control, cross-sectional, and cohort studies that compared the Cephalometric and CT scan measurements of people with AS to non-AS participants that met the inclusion criteria. Two researchers (MKA & KCS) worked independently on the selection process, and any discrepancies over the results were resolved by consensus. There was a third assessor called in when the first two couldn't agree (DS). There was also a manual search of the papers' bibliographic references that were discovered during the initial search.We used the PECO22: two working collaboratively (MKA and KCS) and a third working independently (DS).Two researchers (MKA and KCS) retrieved the following information from each article: authors with year, country, sample size, gender, and final remarks from the study. Given the wide range of CCC used in the papers, it was decided that only those measurements that were replicated in at least two articles would be included in the meta-analysis, those were: SNA°, SNB°, PPR-S-PPL, N-S-PP and greater wing angle Table . For eac2 index with Galbraith plot. A statistically significant Q statistic result (p 0.05) revealed heterogeneity. Furthermore, indices of heterogeneity I2 of approximately 25%, 50%, and 75% were found to indicate low, moderate, and significant heterogeneity, according to the results. All statistical analyses were carried out using MedCalc (version: 19.3) and R studio (metafor package).Each finding was the subject of a meta-analysis of its own. There could only be a meta-analysis when a mean datum was presented in at least three articles because the CCC taken by different publications differed. As expected, there was some evidence of heterogeneity among the individual studies, so a random-effects model was used. Each outcome was assigned a pooled effect size (mean difference) and a 95 percent confidence interval. Heterogeneity in effect size was examined with the Q statistic, IOur initial search strategy yielded 4140 papers from databases such as PubMed, Web of Science, Google Scholar, Scopus, and ScienceDirect. After eliminating 3124 papers in the detection phase, the remaining 1016 papers were further screened . A total of 38 studies were considered worthy, but 25 were excluded due to unusable data formats. Thus, based on the research objectives and inclusion and exclusion criteria, 13 studies were eventually included in this study , while Lu24 reported the most cases33. Cleft of the soft palate, anterior open bite, severe crowding in the maxillary dental arch, and congenitally missing teeth occurred more frequently among AS patients34. Significant shortening of the mandibular width and length, and, subsequently, reduced height is the most reported feature in AS patients32.Table 2 index provides a more accurate way of assessing effect size heterogeneity. Table I2: 44.49%; P = 0.165; CI 1.26 to − 2.84)      with a significant difference to the non-AS patients.As shown in Table .2019). Four of the thirteen items received a maximum score of eight, with the remaining four receiving a score of seven. A funnel plot was generated to visualize publication bias among the studies  in the gene for FGFR2 are responsible30. Children with AS had smaller arch dimensions than other children. From primary to mixed dentition, the dimensions of the dental arch hardly changed31. Increased mandibular asymmetry, increased lower facial height ratios, decreased transverse dimensions, an increased inclination of the palatal plane, and a more protruding mandible were observed in the AS patients compared to non-AS. Patients with AS had a more severe abnormal craniofacial growth pattern, morphology, and mandibular asymmetry compared to patients with another craniosynostosis37.Compared to non-AS patients, AS patients' dental development was delayed29. CCC of the mandible and maxilla can be misinterpreted both anteroposteriorly and vertically if a person has an abnormal cranial base. As a result, many researchers advise taking CCC with the Frankfort plane as a Ref.38. A reduced anterior cranial base, despite AS's smaller maxilla, can make the SNA similar to that of controls because the N point would be located further posteriorly35.SNA and SNB angles were found to be smaller in AS patients, but the anteroposterior position of the maxilla was found to be the same in both AS and non-AS39. The sphenoid growth center is a responsible and explanatory variable for the deformity of both the maxilla and the sphenoid. The maxilla was held up or pulled back in space by the sphenoid when the pterygoid plates were rotated posteriorly, pointing to the sphenoid as the primary culprit. As the right and left greater wings diverge more sharply, the orbital contents are pushed forward and the orbital cavity is reduced in size41.Midface retrusion is influenced by the pterygoid plates' posterior/counterclockwise rotation and their articulation with the maxilla. The pterygoid plate is rotated posteriorly, resulting in the retrusion of the maxilla and the entire midface42. Syndromes may immobilize their midline cranial base due to the advanced closure of the Sphenooccipital and Ethmosphenoid synchondroses23. The development of the midface in a transverse direction is likely to be disproportionately compounded. Maxillary width is affected by AS, with an increase in the greater wing angle and the separation of the bilateral lateral pterygoid plates. Maxillary growth does not always follow the regulation of the cranial base, and it may be influenced by the regulatory and masticatory functions of the maxillary bone itself. Rather than relying solely on the skull base, a 'double adjustment' mechanism may also influence the zygoma's growth pattern25.In AS, synchondrosis of the upper and lower jaw occurs in the same time, between the ages of 2 and 643. With so few studies reporting on each outcome metric, it is critical to proceed with extreme caution when interpreting the results. A meta-analysis may yield a different result if more studies are included because of the small number of research studies included.It was possible to abandon the idea that there were no significant differences in CCC between people with AS and the general population, even though this study had several flaws, although the significant difference was discovered. These CCC must be combined, and reference planes used to determine the different positions of the maxilla and mandible to arrive at conclusive findingsThe cranial base lengths of AS patients were reduced in proportion to the severity of the disease. In early infancy, the zygoma is the most severely deformed anatomical facial structure, in positional relationships and geometrical shape. In AS person's midface is protruding and, the mandible points down, the orbital volume is smaller, hypoplasia, a delay in dental development, open bites with dental crowding, and cleft palates. CT scans can help patients with AS decide whether to pursue orthodontic treatment alone or to have their mouth surgically expanded. The role of well-informed orthodontic and maxillofacial practitioners is critical in preventing and rehabilitating oral health issues.


To investigate bone mineral density (BMD) differences between assisted reproductive technology (ART)-conceived children and naturally conceived (NC) children.This retrospective cohort study included ART-conceived children and controls aged 1 to 12 years assessed with a follow-up protocol. Maternal and paternal background, birth condition, and growth and development indicators were analyzed.in vitro fertilization (IVF) (p=0.026) or intracytoplasmic sperm injection (ICSI) (p=0.008) had a positive impact on the BMD Z score. Male infertility only (p=0.010) or male infertility combined with polycystic ovary syndrome (PCOS) (p=0.026) may affect the BMD Z score. In the embryo transfer cycle subgroup analysis, compared with natural conception, both stimulation cycle fresh embryo transfer (p=0.019) and natural cycle frozen embryo transfer (p=0.006) had a positive effect on the BMD Z score.The ART and NC groups exhibited differences in maternal and paternal childbearing age; maternal weight; maternal body mass index (BMI); maternal alcohol consumption; paternal smoking; delivery method; and serum zinc, iron, and lead levels. Multifactor analysis adjusted for relevant factors showed that paternal childbearing age and group significantly affected the BMD Z score. In the subgroup analysis, The BMD levels of the ART and control groups were generally in the normal range. Paternal childbearing age and the use of ART independently affected the BMD Z score of the offspring. Infertility has become an increasingly common health problem, affecting approximately 48.5 million couples worldwide . Due to via in vitro fertilization (IVF) and fresh embryo transfer and those born via natural conception (A study in 2015 showed that the speed of sound (SOS) level measured within 96 hours in ART preterm infants was lower than that measured in the naturally conceived (NC) group . Howevernception .BMD is defined as the mass of bone mineral per unit volume. BMD is an indicator not only of the status of bone salt deposition but also of the status of bone development in children and adolescents . ChildhoBMD is affected by many factors, including genetic factors, birth state –17, age Additionally, the health of offspring born after ART has been a focus of public attention. Whether ART itself or parental infertility affects the BMD of the offspring has not yet been reported.Therefore, the purpose of this study was to determine whether the BMD of ART offspring is affected by infertility or ART itself and to explore the possible mechanism by which parental fertility and ART influence BMD to promote the bone health of ART-conceived children.via ART in our center (ART group) or were NC (NC group) and came to our hospital for a physical examination in the Child Health Department from 2012 to 2015. The ART-conceived offspring included live-born infants from 2001 to 2014 in the Clinic Center of Reproductive Medicine of Jiangsu Province Hospital. The two groups were matched according to their age in months. Local institutional  ethical approval (2012-SR-048) was obtained prior to data collection.The children who were recruited were conceived in vitro fertilization and embryo transfer (IVF-ET) or ICSI as the ART method, infertility factors that included polycystic ovary syndrome (PCOS) and/or male factors , and embryo transfer cycle that was carried out via a fresh embryo being transferred in a stimulated cycle or a frozen embryo being transferred in a natural cycle.The inclusion criteria for the ART group were as follows: willingness to participate voluntarily and cooperatively, prepubertal status, singleton birth, full-term birth, The inclusion criteria for the NC group were as follows: willingness to participate voluntarily and cooperatively, prepubertal status, singleton birth, full-term birth, and natural conception.The exclusion criteria for the ART group were as follows: illness or use of drugs, trauma or fracture, high-intensity sports training, family history of metabolic diseases, use of glucocorticoids by the mother during pregnancy, and donated sperm or eggs.The exclusion criteria for the NC group were as follows: illness or use of drugs, trauma or fracture, high-intensity sports training, family history of metabolic diseases, and use of glucocorticoids by the mother during pregnancy.In total, 84 individuals were included in the ART group, and 123 individuals were included in the NC group. Informed consent was obtained from a guardian of each participant included in this study.Two weeks before follow-up, the subjects were notified by telephone of the time, place and contact person for the follow-up assessment.The day before the follow-up assessment, the participants were called to confirm whether they were free to participate. The pregnancy information of the ART group was retrieved and printed from the Center of Clinical Reproductive Medicine system.On the day of the follow-up, the specific follow-up procedure was explained, and an informed consent form was signed by the patient. The Pediatrics department conducted general physical examinations (height and weight), trace element analyses, and bone density tests. Parents filled out the questionnaire. After all the items were completed, the information was checked, and it was confirmed that there were no omissions; then, the data were entered into the computer.Using an Omnisense 7000P ultrasonic bone densitometer , after calibration by professional operators each day, the ultrasonic propagation velocity value (SOS) in the middle of the left tibia was measured by a standard method. The Z score of the SOS value of Asian children of the same age and sex was used as the standard.2.Height and weight were measured at the Department of Children’s Health Care by skilled personnel. The accuracy was within 0.1 cm and 0.1 kg, respectively. Body mass index (BMI)=weight (kg)/height (m)Peripheral blood was taken from the child’s ring finger. The levels of zinc (Zn), copper (Cu), iron (Fe), calcium (Ca), magnesium (Mg) and lead (Pb) in peripheral blood were analyzed by an AA7000M atomic absorption spectrometer . The following normal ranges for different elements were applied: Zn (mg/L): 5–11.94; Cu (mg/L): 0.76–2.5; Fe (mg/L): 418.48–660.8; Ca (mg/L): 84–62.86; Mg (mg/L): 28.3–50.4; and Pb (μg/L): 0–100.Data were analyzed using IBM SPSS 17.0 for Windows . In the single factor analysis, normally distributed continuous data are presented as the mean ± standard deviation (SD), and nonnormally distributed continuous data are presented as the median (interquartile range). Categorical data are presented as the frequency (%). Normally distributed continuous data were compared using an independent t test, and nonnormally distributed continuous data were compared using the Mann-Whitney U test. Unordered categorical data were compared using the chi-squared test, and ordered categorical data were compared using the rank-sum test. In the multifactor analysis, multiple linear regression analysis was used. Statistical significance was defined as p < 0.05.We evaluated whether there was a difference in indicators between the two groups Table 1 The medians of the Z scores of the two groups were within the normal range, indicating that the total bone density level was not significantly abnormal in the ART or NC children.After adjustments were made for the above confounding factors, paternal childbearing age (p=0.012) was still found to negatively affect the BMD Z score independently, which means that the higher the paternal age was, the lower the Z score would be. Grouping (p=0.004) positively affected the Z score of BMD, and the effect was greater than that of the father’s age. In other words, the Z score of the ART group was higher than that of the control group Table 2.Next, we divided the ART group into different subgroups according to the ART method, infertility factors and embryo transfer cycles to find the source of the difference in BMD between the two groups.In the ART method subgroup analysis Table 3 In the infertility factor subgroup analysis Table 4,In the embryo transfer cycle subgroup analysis Table 5,ART has been used to treat infertility for more than 40 years. It has been confirmed that ART is associated with adverse perinatal outcomes, including premature birth, low birth weight, and increased risk of birth defects. A poor ART intrauterine environment and ART gamete manipulation, among other factors, are considered to be possible causes of poor ART pregnancy outcomes , 36. Thevia ART.Bone density characterizes bone development. Childhood is a critical period for bone development. Prevention and treatment of childhood bone mineral deficiency is important for reducing childhood rickets and osteoporosis in adulthood. Therefore, it is particularly important to assess the bone density of offspring conceived Previous studies focused mostly on the BMD of ART-conceived offspring at birth or within a short period of time after birth. There is no long-term follow-up study on the bone development of ART-conceived offspring at preschool age. Therefore, this study focuses on the BMD of preschool-aged ART-conceived offspring. Whether there is a difference between the ART-conceived children and the NC offspring at the same age and the possible influencing factors were examined.via IVF fresh embryo transfer at 4-10 years old and the NC offspring , socioeconomic background, nutritional status, and puberty. In our previous research, we collected data on the height of parents and found that the difference in height between the two groups was not statistically significant. Therefore, when we recruited participants, we chose families located in Nanjing, Jiangsu Province, to reduce the gap between family socioeconomic backgrounds and increase follow-up compliance. This study failed to accurately collect data on the eating habits of each participant. When we collected the study data, we collected information regarding the family’s dietary preferences in the questionnaire: vegetarian, meat-eaters, balanced diet or special eating habits. The vast majority of families consumed a balanced diet, and the offspring’s nutritional status was evaluated during the physical examination. It can be roughly considered that there was no significant difference in nutritional status between the two groups. Both groups of offspring were prepubertal children, thus eliminating the influence of pubertal sex hormones on bone development. We used inclusion and exclusion criteria to reduce selection bias, but there may still be potential uncontrolled confounding factors.Paternal childbearing age can independently affect the BMD Z score, and the higher the father’s age is, the lower the bone mineral density Z score will be. After adjustments were made for related confounding factors, the BMD Z scores of the ART group and the control group were still significantly different, that is, the bone density Z score in the ART group was significantly higher than that in the control group. The method of conception, ART indications and embryo transfer cycle all had a positive effect on the Z score of BMD.via ART.The sample size of the subgroups still needs to be expanded to verify the results. However, additional longer-term, prospective follow-up multicenter studies are required to understand the increased risks among children conceived The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethic Committee in First Affiliated Hospital of Nanjing Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.XX wrote the draft of the manuscript and performed the data analyses. LC, JW, and XY conducted the health tracking survey and acquired the data. LG and YZ recruited the participants. FD and YC reviewed and edited the manuscript. JL and YM designed the study. All authors contributed to the article and approved the submitted version.This work was funded by the National Key Research and Development Program of China , the National Nature Science Foundation of China (81730041), and The National Key Research and Clinical Centre of Reproductive Medicine in Jiangsu Province of China (YXZXB2016001).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.