Physical education classes often fail to include sufficient exercise intensity to induce changes in body tissue composition and physical fitness. Short-term high-intensity interval training protocols incorporated into physical education lessons are one possible solution to this problem. Existing studies have not examined how individuals differing in body mass index  respond to high-intensity interval training exercises. Therefore, this study aimed to evaluate the effects of a Tabata protocol on body composition measurements, aerobic capacity, and motor performance in underweight and overweight adolescents  vs normal-weight adolescents (here regarded as the control group). The sample included 58 adolescents  who completed the high-intensity interval training and the following set of measurements pre- and post- intervention: height, weight, body fat percentage and waist-to-hip ratio, physical efficiency index (based on the Harvard Step Test), agility (in 4 × 10 shuttle run test), and lower-limb muscle power in vertical jump. The results showed that high-intensity interval training was effective in reducing body weight, waist-to-hip ratio, and body fat percentage only in overweight individuals. Improvement in aerobic capacity was found only in underweight and overweight boys. Further research should focus on the development of customized exercise protocols and their adaptation to girls and assess the sustainability of the changes induced. Malnutrition in all its forms, including overweight, obesity, and underweight forms, is the primary cause of global health deterioration. Currently, over-nutrition and undernutrition  are widespread across the globe and affect individuals in every country and region of the world . Both maOverweight, obesity, and underweight forms in childhood and adolescence may bring about numerous consequences and lead to health problems in adulthood. Being underweight increases the risk of infectious diseases. In girls, it often causes menstrual cycle disorders and increases the risk of miscarriage, preterm birth, and faster involution of the reproductive system in adulthood ,5,6. BeiBody weight is linearly related to body mass index (BMI). For this reason, BMI is an essential biological measure of a population’s biological condition and related social phenomena . Due to Many researchers have focused on finding optimal methods to combat obesity and overweight. Results have shown that one of the most important and effective methods to address obesity and overweight is physical activity ,14. ActiHowever, studies on the benefits of such programs are inconclusive. Different degrees of effectiveness have been shown depending on the type of exercise, the form of the classes, and the range of parameters analyzed. The most common effects are those related to the reduction of BMI and body fat and, sometimes, improvement in physical fitness in obese and overweight individuals . HoweverIt also remains unclear what type of program, type of exercise, duration, and volume constitute optimal training for inducing the desired changes in adolescents. The results of a few studies have indicated that high-intensity interval training (HIIT) may be appropriate. The training is based on a short intervention time  of very intensive effort (from 75% HRmax). Such intensity in this training improves the maximum oxygen uptake in adolescents . The effParticipants comprised boys and girls aged 16 years (see details below) from a Polish general secondary school. The students who attended the school were of the same sociocultural level and lived in the same geographical area . In addition, they were recruited on the basis of two inclusion criteria. The first criterion required being in the first year of general secondary school (10th grade), during which the HIIT program was introduced. The second criterion was that parental consent had to be obtained to participate in this research. Exclusion criterions were metabolic diseases or asthma. It was implicated of medical contraindications.High-intensity interval training (HIIT) is generally a form of interval training alternating short periods of intense anaerobic exercise with less intense recovery periods, until the participant is too exhausted to continue. The students followed a 14-min HIIT exercise regimen based on the Tabata training method, presented in the form of a video during one of three PE lessons per week. Tabata training takes its name from Izumi Tabata, who examined changes in the aerobic and anaerobic systems after high intensive interval training (HIIT) utilizing his own protocol.The Tabata protocol was followed for a period of one school semester (10 weeks). The remaining PE lessons were conducted in accordance with the PE curriculum adopted by the school for first-year students. The diets of the participants were not analyzed, but students were instructed to maintain their diet and normal level of activities of daily living and not to engage in any other organized physical activity outside of the PE classes . 2), normal-weight (BMI = 18.5–24.99 kg/m2), and overweight (BMI ≥ 25 kg/m2). Underweight and overweight adolescents were regarded as experimental groups and were compared with normal-weight adolescents, who were regarded as the control group.Participants comprised 39 boys and 45 girls who attended the Tabata program. The analysis was based on data from 28 boys  and 30 girls  who completed the HIIT program as well as a set of measurements before and after the intervention and who were not excluded on the basis of the aforementioned inclusion criteria. Data were excluded from participants involved in organized physical exercise  or additional recreational activities during the previous six months , those who had medical contraindications for motor activity and/or cardiovascular and respiratory diseases , those who discontinued participation in PE classes , and those who failed to complete all tests . No participants withdrew from the program due to fatigue or lack of interest. The included participants were divided into three groups: underweight . The study was also conducted in accordance with the ethical principles for medical research involving human subjects contained in the Declaration of Helsinki by the World Medical Association. Additionally, the study met the “ethical standards in sport and exercise science research” . All parMorphological and motor measurements were performed before and after the 10-week intervention. The tests were conducted on one day, from 8:00 a.m. to 1:00 p.m., in sports halls in standard conditions for each group. Each participant was wearing a T-shirt, shorts, and shoes. Only anthropometric measurements were conducted without shoes. The measurements were performed in the following order: anthropometric measurements, vertical jump, 4 × 10 m shuttle run agility, and the Harvard Step Test. The protocol used for each measurement was based on recommendations for the assessment of health- and skill-related physical fitness . Morphological measurements included body height, with an accuracy of 0.1 cm, using anthropometers  and body weight and body fat percentage (BF%) using an InBody230 body composition analyzer  with the bioelectrical impedance method. The tool has very high reliability. InBody230 was reliable in men and women as indicated by high intraclass correlation coefficients for BF% (≥0.98), FM (≥0.98), and FFM (≥0.99) and low standard error of measurement . Before Aerobic capacity was assessed using the Harvard Step Test. Physical efficiency index (PEI) was next calculated. Reliability of this test is acceptable at the intraclass correlations coefficient (ICC) = 0.63 . The HarThe PEI was calculated using the following formula : PEI =  was performed according to a previous description . Two par2/8, where g = 9.81 m/s2). The best attempt was used in our data analysis.The power of the lower limbs was assessed using the static vertical jump procedure in the vertical jump test, in which a static position with a knee flexion angle of 90° was maintained for 2 s before a jump attempt without any preparatory movement. All jumps were executed with the hands on the hips. Three jump attempts were performed, separated by 15-s intervals. The jumps were performed on a g-force tracker  with the obtained flight time (t) being used to estimate the height of the rise of the body’s center of gravity (h) during the vertical jump  conception and constitute morphological, muscular fitness and endurance, cardio-vascular endurance, and motor abilities (speed and agility) health-related fitness components. The scientific rationale for the selection of all of these tests, as well as their reliability in young people, have previously been published ,27,28.During one PE lesson per week, participants followed the HIIT exercise regimen based on the Tabata training protocol . A PE lemax) of the participants was determined according to the formula proposed by Tanaka, et al. [max = 208 − 0.7 × “age” (age = 16 years in this study). A calculated HRmax of 197 bpm was used to calculate the high-intensity exercise range of 75%–80% (145–157 heartbeats/min). During the PE lesson with Tabata training, the effects of the program were monitored using HR measured by a Polar H1 heart rate monitor . The HR was displayed on the Polar H1 watch screen to motivate the students to maintain adequate exercise intensity. On average, the participants achieved an HR of 156.2 bpm : 123.0–184.0) To verify the exercise intensity during the Tabata training, the maximum heart rate , detailed comparisons of post-hoc tests (Tukey’s HSD test) were used to determine pairwise differences. The significance level was set at α= 0.05. Cohen’s d values were calculated as a measure of effect size for mean differences with the following interpretation: above 0.8 were considered as large, between 0.79 and 0.5 (medium), between 0.49 and 0.2  and lower than 0.2  [The Shapiro–Wilk test was used to evaluate the normality of the distribution of data, and all variables showed a normal distribution. Descriptive data were presented as means and standard deviations. A two-way analysis of variance (ANOVA) was used to evaluate pre-training differences between groups . Next three-way analysis of variance (ANOVA) with repeated measures was performed (pre/post × BMI status × gender) to determine if there were any between-group changes as a result of the training. When significant differences were observed  . We usedDescriptive statistics of the parameters for boys and girls from the different BMI groups are presented in F = 2.53, df effect= 22, p = 0.0013, ηp2 = 0.3981). Statistically significant were also main effects—variation between gender  and BMI groups .Analysis of variance showed statistically significant interaction between factors , BMI , WHR , and BF% . Furthermore, BMI groups differed in vertical jump results . No other significant differences between the groups were observed for other variables. The two-way ANOVA found significant differences before training according to BMI status and gender, but the two factors did not interact with each other. BMI groups differed in body weight  and body weight . The gender differences in body fat were similar in terms of WHR  and BF% . Gender differences were also found in agility  and the vertical jump . Detailed comparisons showed the gender dimorphism of basic morphological features, as boys and girls differed in body height , BMI , WHR , and BF% . The intervention also demonstrated significant changes in aerobic capacity  and agility . The results of detailed comparisons using Tukey’s HSD test before and after the intervention are presented in Using ANOVA with repeated measures, the comparison of the results before and after the intervention revealed highly significant effects of HIIT on body weight , which almost exclusively concerned overweight boys and girls . The impComparisons between the groups following the intervention revealed the persisting direction of differences observed before training. Overweight boys and girls continued to differ from other groups; however, the differences were smaller than prior to the intervention. The HIIT program based on the Tabata protocol produced partial effects that can be considered from two standpoints. First, the changes concerned mainly overweight groups, both boys and girls. Second, the changes involved morphological rather than functional features. The effects included significant reductions in body weight, BMI, WHR, and body fat in overweight adolescents. However, additional improvements in aerobic performance were observed in both underweight and overweight boys. Our results are partially consistent with the findings of other researchers ,22,23 whAll analyzed morphological parameters constitute a morphological health-related fitness component. In this sense, the HIIT regimen can be considered to support the health of young people. In this study, its efficacy and usefulness in natural conditions  were verified. The implementation of such training programs and scientific verification of their effects in the school environment are not easy, with difficulties including the organization of school work, organization of lessons, attitudes of young people, diversity of the sports facilities, and curriculum requirements, which may explain the small number of studies that have addressed this topic. Furthermore, not all studies have documented positive effects of programs integrated into school PE curricula .There is still scarce information about the impact of various physical activity programs, especially regarding the effects of interval training with high or medium intensity on aerobic and anaerobic performance, and few studies have examined the effects on individuals with different BMIs. Such studies currently constitute one of the most important fields of research because of the growing percentage of overweight and obese people in Polish, European, and global populations, but they also concern underweight youth ,40,41,42In general, correlations between BMI and the level of physical fitness of young people with different BMI statuses have been documented . HoweverWe also found no improvements in anaerobic performance based on the results of the vertical jump test (power of lower limbs) and shuttle run test (agility). In our opinion, this can be explained by the fact that the interval training was focused on aerobic changes. However, our results differ from those published in previous work ,20, whicOur research has certain limitations. First, the number of participants was small. Second, there was no dietary control for the participants. It remains unclear whether the participants maintained their dietary preferences and what the energy supply was during the implementation of the 10-week HIIT (Tabata) training program. Third—there was a lack of a control group. One of the inclusion criteria was performing no other structured exercise during participants’ leisure time. However, it cannot be guaranteed that participants did not undertake any additional physical activity during the study period. In the future, participants should use accelerometers to monitor their daily physical activity. Moreover, research on the effectiveness of interval protocols included in PE classes should also consider nutritional aspects. The division of participants into underweight, normal-weight, and overweight (obese) groups allows researchers to capture the actual directions of changes and effects of the programs used. Our study documented a significant reduction in body weight and BMI as well as redistribution and reduction of body fat, but only in groups of overweight boys and girls. Furthermore, underweight and overweight boys improved their aerobic performance. If the improvement in overweight boys can be attributed to weight loss, this improvement in underweight boys (with no weight loss) can be viewed as a net effect of the Tabata program. Moreover, training had no effect on anaerobic performance. In conclusion, the Tabata program represents a useful tool for combating the problem of being overweight while avoiding adverse effects (in terms of weight and body fat reduction) among underweight and normal-weight individuals, for whom weight reduction is not desirable. However, further research should be oriented toward the definition of rules for HIIT protocols addressed to genders and groups with different BMI to induce a general improvement in aerobic performance.


Since this phenomenon is still unclear in melon, a half diallel experiment based on eight genetically distant breeding lines was conducted in six environments of Central Italy, assessing commercially important traits: yield, total soluble solids (TSS), and days to ripening (DTR). To estimate the additive  and the non-additive gene effects , yield was analyzed by Griffing’s methods two and four, and the results were compared to the GGE (Genotype plus Genotype by Environment interaction) biplot methodology; TSS and earliness were evaluated only by Griffing’s method four. Overall, GCAs were significantly more relevant than SCAs for all examined traits. Least square means (LsM), mid-parent heterosis (MPH), best-parent heterosis (BPH), as well as Euclidean and Mahalanobis’ distances were calculated and compared with the genetic distance (GD). As a few correlations were found statistically significant (only for TSS), it was difficult to predict the value of a hybrid combination only by knowing the genetic distance of its parents. Despite this, heterosis was observed, indicating either the presence of epistatic effects (additive × additive interactions) and/or an underestimate of SCAs embedded within Griffing’s method. The significant Env × Entries source of variation suggests development of hybrids in specific environments. The results are discussed with a breeding perspective.Heterosis is the superiority of an F Cucumis melo L.) is a diploid species (2n = 2x = 24) belonging to the Cucurbitaceae family; it is divided into ssp. melo, which includes Western melon cultivars  and ssp. agrestis, including wild types from India and Japan [Melon (nd Japan . Melon iaa) interactions, while the SCA is due to dominance effects and additive × dominant (ad) and dominant × dominant (dd) interactions [Melon breeding programs pursue three main goals: (i) increase yield and earliness, (ii) improve fruit quality, and (iii) progress with disease and pest resistances. Yield and fruit quality are key traits, while earliness is crucial for early greenhouse productions. The improvement of fruit quality is a complex trait, as it includes external  and internal fruit appearance (color and taste). Fruit flavor depends on a number of factors including aromatic profile, flesh consistency, and total soluble solids content . The latter is based on sugar concentration, and it is a reliable indicator of internal quality . A cruciractions .Beside Griffing’s analysis, Yan and Hunt  proposed1 hybrids over their parents, and it is used for traits such as growth rate, biomass production, and fertility. The superiority of hybrids in terms of yield, fertility, and resistance to biotic and abiotic stresses is being exploited in several crop species [One of the most powerful tools at breeder’s disposal is the assessment of the heterotic effect of hybrid combinations. Heterosis, or hybrid vigor, measures the phenotypic superiority of F species . Althoug species ,13, many species . Heteros species  found no1 hybrids, only for branch number, a significant correlation between genetic distance and heterotic effect was evident.The genetic distances inferred from molecular markers were suggested by Melchinger  as a pro1 performances, GCA and SCA effects, and heterosis for yield per plant, TSS, and earliness in melon, traits considered to be of the highest commercial value for melon breeding programs in order to generate superior inbred lines to be used as parents. Variance components and broad- and narrow-sense heritabilities were estimated as well as the correlation of genetic distance (GD) with least square means (LsM), SCA, mid-parent heterosis (MPH), best-parent heterosis (BPH), and Euclidean and Mahalanobis’ distances in order to predict F1 performance.Therefore, the present study was designed to assess the variation of FIn the present study, eight inbred lines of melon  and the p < 0.001) indicated ample differences amongst the six environments and amongst entries. Significant G × E interaction recommended looking at the variation in each environment separately.The ANOVA results for yield per plant according to Griffing’s methods two and four (with genotypes as fixed and replicates as random effects) are reported in -1, respectively. In fact, the highest ranking hybrids (LsM) were those having them as parents in combination with Ita1, Ogen, and Magyar Kincs and between themselves , clearly indicating that additive gene actions are more important than non-additive ones. Moreover, the ANOVA for yield per plant carried out in each environment always showed significant differences at the entries and the GCA sources , while Semselves . On the emselves  gave risOrthogonal comparisons between hybrids and parents for yield per plant were highly significant in all environments  and, accApart from the value 0.18 found in Latina 2015 (not reliable because the GCA variance was not significant), the narrow sense heritability estimates for yield per plant  ranged fThese values are in agreement with those reported by Feyzan , Zalapa GGE biplot was used to validate the results of Griffing’s method four, as it is able to display graphically and simultaneously the GCA values of all parents and their best combinations . The method is similar to the GGE biplot used in multi-environment trials data analysis. In Latina 2015 c, the GCThe polygon view  was obtaThe entries at the vertex with the largest distances from the origin are more responsive than others to the change of testers . Indeed,Concerning Perugia 2015 d, testerp < 0.001), requiring a separate analysis for each environment. Similarly, yield per plant entries and GCA sources were always significant, whereas SCA was never significant, indicating for this trait only additive gene actions  of hybrids over parents  and BPH  but, as reported above, the behavior of the entries in this environment was unusual and should not be considered reliable. However, GD showed significant correlations with LsM in Latina 2015 , Perugia 2015 , and Latina 2016 , thus the genetic relationship between parents could be useful to be known in advance although insufficient to predict the TSS of a given cross.Since SCA was not significant, it was not possible to correlate GD with SCA effects. However, in Perugia 2014, genetic distance showed a significant correlation with MPH  considering only the first five fruits per plot . Low DTR values of GCA, SCA, MPH, and BPH indicate earliness of parents and hybrids.p < 0.001, Except for Env × SCA, the combined ANOVA sources for earliness were all highly significant  in Perugia in all years and significant in Latina (p < 0.05) only in 2016 .Narrow sense heritability for earliness  ranged fSimilar to yield per plant, for earliness, no significant correlations were found between GD on one side and LsM, SCA effects, BPH, and MPH values on the other. Even using all traits together in a multivariate dimension , it was not possible to find a correlation with GD.The main goals of the present paper were to assess melon hybrids performances for a number of important commercial traits, to estimate gene effects and heterosis, and to detect any correlation between them and the genetic distance of their parents.aa epistatic effects included in GCA [ad and dd epistatic gene effects are likely not to influence heterosis. The lack of correlations between heterosis and GD confirms that the latter is not able to predict the former, since GD is unable to take epistatic interactions into account.Additive gene effects showed themselves to be the most important genetic component for all traits examined ; as a result, the narrow sense heritabilities were found rather high, indicating the possibility of achieving good selection gains. Moreover, our data indicated a central role of epistasis. In fact, a significant heterosis was recorded for yield and TSS, and this can be explained entirely by d in GCA . AdditioSeveral authors ,29,30,31aa epistatic effects, as for yield per plant. Only for TSS did we find significant correlations of GD with LsM in three out of five environments , thus an a priori knowledge of the genetic background of the possible parents could be useful to create pools to maximize the sugar content of the hybrids.When SCA source is not significant, as is the case of TSS, Baker  suggestsFeyzian et al.  suggesteMoreover, Kalb and Davis  hypothesIn the present study, the significant Env × Entries source of variation clearly indicates that hybrids are expected to be more successful when developed for a specific environment than across environments; lines will be best adapted to specific conditions, as reported for important traits such as yield per plant, TSS, and earliness. Moreover, since the additive effects included in GCA were more consistent than the non-additive ones (SCA), breeding for all of these traits needs to be addressed to increase line performances per se. In fact, mid-parent heterosis is expected to decrease proportionally due to accumulation of favorable dominant alleles at individual quantitative trait loci (QTL), but heterosis can be maintained by exploiting the additive × additive effects present in the parent combinations . As a coCucumis melo L.) were analyzed. According to the classification of Renner and Schaefer [C. melo spp. melo  and two to C. melo spp. agrestis  (1 hybrids) without reciprocals.In the present study, eight inbred lines of melon  . The eigThe genetic distance matrix among parental lines  was obta1 hybrids were carried out in the summers of 2014, 2015, and 2016 in two different locations: Bayer Crop Science R&D Site in Latina, Italy  and Papiano, the experimental farm of the University of Perugia, Italy . The two locations were representative of the melon production areas in Italy; during the growing season (May–August), Latina was characterized by average minimum, mean, and maximum temperatures of 17.1, 25.2, and 28.6 °C, respectively, vs. 17.2, 21.9, and 25.7 °C of Perugia. The mean total rainfalls during the same period were 126.6 and 218.2 mm in Latina and Perugia, respectively. The commercial hybrid  was used as a control. Four young plants per entry, previously grown in jiffy pots, were transplanted in the fields in plots of 0.8 m long and 2.5 m wide, arranged in a randomized complete block design with three replicates.The morphological evaluation and the comparison of the productivity of the eight parental lines and their 28 FThe cultivation protocol ensured optimal growing conditions throughout the season, applying the recommended rates of fertilizer and irrigation. Particular attention was given to the control of pests and diseases, as the level of genetic resistance among the entries was variable. Data were collected daily on a single-fruit basis for the following traits: (1) earliness ; (2) fruit weight ; (3) fruit length ; (4) maximum fruit diameter ; (5) fruit shape ; and (6) total soluble solids .F1 is the mean of the hybrid with parents P1 and P2, and Ph is the mean of the better parent between them. Standard errors for testing the significance of MPH and BPH were calculated as follows:Me is the error mean square from the ANOVA table, and r is the number of replications [Prior to any statistical analysis, data were tested for skewness, kurtosis, and subjected to a Q-Q (quantile-quantile) plot for normality by R statistical software Ver. 3.5.3 . Combineications .The diallel data of yield per plant were also analyzed by GGE biplot by averaging each cross over replications and including selfed parents. The statistical significance of “Environments” and of “G × E” source of variation in the combined ANOVA suggested to carry out the GGE biplot for each of the six environments. Each genotype was considered both an entry and a tester. Means of each tester were calculated, and an adjusted matrix was obtained by subtracting the tester mean from each cell. Details of the model are described in Yan and Hunt . GGE ana2 of Mahalanobis [Camussi et al.  and Lefealanobis . The Eucalanobis , was thealanobis  using thalanobis  with 10,


The key problem of non-grain energy plants’ scale development is how to estimate the potential of GHG emission reduction accurately and scientifically. This study presents a method coupled DSSAT (the Decision Support System for Agrotechnology Transfer) and the life cycle assessment (LCA) method to simulate the spatial distribution of sweet sorghum-based ethanol production potential on saline–alkali land. The GHG (greenhouse gas) emission mitigation and net energy gains of the whole life of sweet sorghum-based ethanol production were then analyzed.2 eq, equivalent to the carbon emission of 43.4 Kt gasoline. The LC-NEG potential was predicted at 5.02 PJ, equivalent to the caloric value of 109 Kt gasoline. On average, LC-GHG emission mitigation and LC-NEG were predicted at 55.09 kg CO2 eq/t ethanol and 4.33 MJ/kg ethanol, respectively.The results of the case study in Dongying, Shandong Province, China showed that developing sweet sorghum-based ethanol on saline–alkali land had GHG emission mitigation and energy potentials. The LC-GHG emission mitigation potential of saline–alkali land in Dongying was estimated at 63.9 thousand t COThe question of how to evaluate the potential of sweet sorghum-based ethanol development scientifically was solved primarily in this paper. The results will provide an important theoretical support for planning the bioenergy crops on saline–alkali land and develop the fuel ethanol industry. Biofuels have received much attention in recent years because of their energy and environmental efficiencies, with hopes to alleviate the energy crisis and prevent further climate change. Biomass has garnered tremendous interests as a potential feedstock for clean energy production at the same time , 2. The Sweet sorghum is selected as the study object for two reasons. First, studies showed that planting sweet sorghum on saline–alkali land could be helpful to maintain the sustainable development of the land . It can In recent years, literature on the sweet sorghum-based ethanol has increased, with most of the studies integrating LCA and DSSAT methods, and the related works have being widely carried out in China. Hao et al.  used DSSDongying, Shandong Province, China, was selected as the study area  in Dongying City accounts for 52% of the land area in Dongying City, accounting for 418,700 hm2 ; the soi2 . In summ2 .2  and GHG (Greenhouse Gases) emission mitigation potentials of developing sweet sorghum-based ethanol on saline–alkali land. The system was composed of five units: sweet sorghum cultivation unit, bio-ethanol production unit, bio-ethanol combustion unit, and two transport units. The input to the system consisted of energy and materials, and the output from the system included products/by-products, energy, and emission wastes  into the environment. A schematic of system boundary is shown in Fig. In this study, the DSSAT model was expanded to a spatial scale , as showThe life cycle of the sweet sorghum-based ethanol was divided into five stages shown as blue boxes in Fig. For life cycle inventory analysis, different stages relate to diverse data items. Data items relating to NEG and GHG emission mitigation assessment are listed in Fig. NEG (Net Energy Gain) refers to an energy economics concept which is defined as calculating the difference between the energy output of an energy source and the total energy input to produce the energy source. In the life cycle assessment of sweet sorghum-based ethanol, LC-NEG assessment is defined as calculating the difference between the energy output of sweet sorghum-based ethanol combustion and the energy input of fossil fuels over the life cycle of sweet sorghum-based ethanol production.i  are energy inputs of sweet sorghum planting and harvesting stage, sweet sorghum transport stage, bio-ethanol production stage, and bio-ethanol transport and distribution stage, accordingly; and FEby is the energy saved using by-products.According to Fig. i  and FEby are as follows [ethanol is the high calorific value of bio-ethanol, which is 29.66 MJ/kg:i is the energy intensity of the input materials i, Xi is the input quantity of material i, Ysw is the yield of sweet sorghum biomass, and β is the conversion ratio of sweet sorghum to ethanol:1 is the quantity of fossil fuel input at sweet sorghum transport stage, d1 is the average distance of transporting sweet sorghum to factories, and H1 is the energy intensity of the fossil fuel:Ei is the quantity of energy input  of bio-ethanol production in factories, and EEIi is the corresponding energy intensity of Ei:2 is the quantity of fossil fuel input at bio-ethanol transport and distribution stage, d2 is the average distance of transporting bio-ethanol to gasoline stations, and H2 is the energy intensity of the fossil fuel:i is the energy intensity of by-products and Mi is the yield of by-product.Formulas of BE, FE follows , 31:\docBefore conducting LC-GHG emission mitigation assessment, the carbon balance analysis of sweet sorghum-based ethanol should be clearly presented, because carbon dioxide comes from the atmosphere at sweet sorghum planting stage, and goes back to the atmosphere through bio-ethanol combustion stage . As showCfossil is the GHG emission over the life cycle of sweet sorghum-based ethanol by the unit kg CO2 eq/t ethanol; Ci  are GHG emissions of sweet sorghum at planting and harvesting stage, sweet sorghum transport stage, bio-ethanol production stage, and bio-ethanol transport and distribution stage by the unit kg CO2 eq/t ethanol, accordingly; Cavoided is the carbon release avoided by recycling and usage of the by-products by the unit kg CO2 eq/t ethanol.However, to guarantee the life cycle from sweet sorghum to ethanol combustion, the system requires extra carbon in forms of chemical fertilizers, fossil fuels, and so on, which are the main sources of bio-ethanol GHG emissions. The inventories of LC-GHG emission mitigation are listed in Fig. gasoline is conversion ratio of calorific value to GHG emission of gasoline with the value of 0.0189 kg CO2 eq·MJ−1.The formula of LC-GHG emission mitigation is:Field experiments were conducted in an energy crop cultivation base in Xianhe Town, Hekou District, Dongying, in 2014. PALO ALTO Biomass Sorghum was selected for the experiments, which is a hybrid sweet sorghum variety bred by NexSteppe Company in Scottsdale, the USA. PALO ALTO Biomass Sorghum has some primary superior qualities. The growing period of this high-yielding biomass sorghum ranges from 120 to 140 days, and its water content is low. After harvest, it can be directly burned in the boiler, and its calorific value and chemical composition are consistent with the current biomass source. And the sorghum stalks provide extra straw for fertilizing the next crop. Moreover, farmers obtain excellent profitability .According to the planting instructions of NexSteppe, five steps were implemented during the growth of PALO ALTO Biomass Sorghum, which included seed dressing, sowing, fertilizing, weeding, and fertilizing for a second time, as shown in Additional file Step 1: First, saline–alkali soil types were ascertained through relevant literature, because saline–alkali soil is not a basic classification unit in the soil classification system.http://www.soil.csdb.cn/map/).Step 2: Second, spatial distributions of the soil types confirmed in the first step were extracted from the China Soil Database , which was harmonized and processed based on the Soil Map of the World and various regional and national soil databases following an improved protocol of the Harmonized World Soil Database (HWSD) , 34. GSDStep 4: Finally, dataset of saline–alkali land was carefully organized and imported to the DSSAT model.Saline–alkali land is a poor-quality land type. Typically, a clay soil with pH > 8.5 or soil with high salt content is considered saline–alkali soil. In this study, four steps were used to extract the spatial distribution of saline–alkali land.http://data.cma.cn/).DSSAT model requires daily weather data available for the duration of the growing season, from the day of planting to the day of crop maturity. Ideally, to help the simulation and provide an estimation of soil conditions at planting time, beginning before planting day, and continuing to the end after crop maturity are preferred for the duration. Nine general variables and eight daily variables of weather conditions were examined, as shown in Additional file The cultivar coefficients were localized based on the field experiment data using the GLUE  method, which is a Bayesian estimation method that uses Monte Carlo sampling from prior distributions of the coefficients and a Gaussian likelihood function to determine the best coefficients based on experimental data , 39. TheInventories of LC-NEG assessment are sorted out from literatures and field experimental data . At sweeAt the stages of transport of sweet sorghum and bio-ethanol, the energy inputs of road transport and railway transport were calculated, see Table At the stage of bio-ethanol production, the energy input of electricity, steam, coal, and so on were calculated; see Table Fossil fuel-based substances were converted to GHG emissions using conversion coefficients and carbon emission conversion coefficients from the literature , 40–42. According to details of the field experiment in the section “Two stages of transport occur: one stage is sweet sorghum transported to factories, and the other is ethanol transported to stations. Two types of transport were road and railway transport, and in this study, sweet sorghum was transported by road for 88 km, whereas ethanol was transported by the combination of road transport for 100 km and railway transport for 500 km. In China, there are 38% trains with an internal-combustion engine and 62% trains with electricity. The carbon emission analysis is shown in Tables At the ethanol production stage, the consumption of electricity and coal was the basis for analysis of GHG emissions. The GHG emission analysis of ethanol production is shown in Table 2 eq/t ethanol.After ethanol being transported to stations, electricity is the primary power source, and in this study, the energy consumption was 0.0007 kWh/L, equivalent to 0.32 kg COAdditional file 1: Appendix A. Appendices Study area. Appendix B. Data for the histogram in Fig. Appendix C. Data for the histogram in Fig. Appendix D. Crop management of field experiments on PALO ALTO Biomass Sorghum. Appendix E. Status of crop growth during field experiment. Appendix F. Spatial soil profile properties prepared for DSSAT model. Appendix G. Variables of daily weather data.


Surgery is an important treatment option for desmoid tumor (DT) patients, but how to decrease and predict the high recurrence rate remains a major challenge.Desmoid tumor patients diagnosed and treated at Tianjin Cancer Institute & Hospital were included, and a web-based nomogram was constructed by screening the recurrence-related risk factors using Cox regression analysis. External validation was conducted with data from the Fudan University Shanghai Cancer Center.A total of 385 patients were identified. Finally, after excluding patients without surgery, patients who were lost to follow-up, and patients without complete resection, a total of 267 patients were included in the nomogram construction. Among these patients, 53 experienced recurrence, with a recurrence rate of 19.85%. The 3-year and 5-year recurrence-free survival (RFS) rates were 82.5% and 78%, respectively. Age, tumor diameter, admission status, location, and tumor number were correlated with recurrence in univariate Cox analysis. In multivariate Cox analysis, only age, tumor diameter and tumor number were independent risk factors for recurrence and were then used to construct a web-based nomogram to predict recurrence. The concordance index (C-index) of the nomogram was 0.718, and the areas under the curves (AUCs) of the 3-year and 5-year receiver operating characteristic (ROC) curves were 0.751 and 0.761, respectively. In the external validation set, the C-index was 0.706, and the AUCs of the 3-year and 5-year ROC curves are 0.788 and 0.794, respectively.https://stepforward.shinyapps.io/Desmoidtumor/).Age, tumor diameter, and tumor number were independent predictors of recurrence for DTs, and a web-based nomogram containing these three predictors could accurately predict RFS ( Desmoid tumors (DTs), also known as aggressive fibromatosis and desmoid-type fibromatosis, have an incidence of approximately 5 per 1 million persons and are characterized by no metastasis, but local progression and recurrence can occur . In geneDTs can occur at any age; the typical age of onset is 15–60 years, with a peak of onset at approximately 30 years . It was With an improved understanding of the natural course of DTs, changes in the treatment of DTs have also emerged. According to the latest treatment guidelines, the preferred treatment for DTs is no longer surgery or other treatments but close conservative observation , 13. TheAfter obtaining permission from the Tianjin Medical University Cancer Institute & Hospital ethics committee, the medical records of 385 patients diagnosed with DT pathologically were consecutively reviewed from January 2007 to June 2019. The information of these patients is identified from the medical record database. The following clinical and demographic variables were recorded: age, sex, location, pathological diagnosis, treatment methods, tumor diameter, tumor number, and resection margin status.Patients were followed up every three months during the first year after surgery. Patients were followed up every 6 months during the second year after surgery. Follow-up once a year occurred thereafter. After five years of follow-up, patients were admitted to the hospital only if they had clinical symptoms. Follow-up was performed mainly by ultrasound or MRI. The dates of surgery and recurrence were recorded. Finally, eighty patients were lost to follow-up, 21 patients did not undergo surgery, 3 patients died of other diseases (unknown specific time of death), 1 patient underwent surgery + chemotherapy, and none were diagnosed with FAP. These patients were excluded from the final analysis. The remaining 280 patients were treated surgically because of symptoms of pain or compression, and it was the purpose of this study to analyze the prognosis of these patients who received surgery. Of these, 13 patients received incomplete resection and 267 patients received complete resection , and tumor diameter was obtained from the pathology reports and classified into three groups .The chi-square test and the Fisher exact test were used to analyze categorical data. The Kruskal-Wallis test was used to analyze continuous data with nonnormal distributions. The Kaplan-Meier (KM) method was used to calculate RFS curves. The log-rank test was performed to assess the significance of differences between RFS curves. Univariate Cox and multivariate Cox analysis were used to screen risk factors related to recurrence. Cox analysis results were presented as the hazard ratio (HR) and 95% confidence interval (CI). Among them, the variables with p<0.05 in the univariate Cox analysis were included in the multivariate Cox regression for further analysis. In KM analysis and Cox analysis, all p values reported are two-sided, and p<0.05 was considered statistically significant. IBM SPSS 22 was used for data analysis.The discrimination of this web-based nomogram was evaluated by the concordance index (C-index) and the receiver operating characteristic (ROC) curve. The calibration was evaluated by the calibration plot.The patient demographics and tumor characteristics are shown in Among the 267 patients, 53 patients (19.85%) experienced recurrence, among which 31 patients experienced their first recurrence (31/207) and 22 patients experienced a second recurrence (22/60). The 3-year and 5-year RFS rates were 82.5% and 78%, respectively, with a median recurrence time of 15 months .In the Kaplan-Meier analysis, younger age, larger tumor diameter, multiple tumors, extremity tumors and recurrent tumors were significantly associated with lower RFS  of the 3-year and 5-year ROC curves were 0.751 and 0.761, respectively  Table 3.https://stepforward.shinyapps.io/Desmoidtumor/). The RFS curve and probability of the patient can be displayed by selecting the corresponding clinical features and follow-up time on the left side of the web interface  and European Organization for Research and Treatment of Cancer (EORTC)/Soft Tissue and Bone Sarcoma Group (STBSG) recommend active surveillance as the preferred initial treatment for DTs . When paIn contrast to the nomogram created by Crago et al. in 2013, which includes age, diameter, and location, our results show that although location was associated with recurrence in the univariate Cox analysis, the recurrence rate of tumors located in the extremity was higher than that of body tumors (p = 0.033), but location was not an independent predictor of recurrence in the multivariate Cox analysis p = 0.423) . Several . SeveraIn addition, compared with the nomogram created by Crago et al. in 2013, we believe our web-based nomogram has two innovations as follows. First, we added the tumor number as a predictor for the first time, and indicated that the recurrence rate of patients with multiple tumors was higher than that of patients with single tumors (p = 0.001). Actually, multiple DTs usually occur in FAP-related patients but are rare in sporadic DTs . Marco eIn this study, adjuvant radiotherapy did not reduce the postoperative recurrence rate. In fact, the role of postoperative adjuvant radiotherapy has been controversial in the past few decades. Different studies have come to different conclusions –31. A meIn terms of clinical application, we believe that the main application value of this web-based nomogram lies in the decision-making before surgery and enhancement of postoperative surveillance. First, for patients with a relatively high recurrence rate, such as patients aged <=30 years with a tumor diameter >10 cm and multiple tumors, the web-based nomogram indicated that the 5-year RFS rate was only 16%, suggesting that such patients are extremely prone to postoperative recurrence. In this case, surgery is not the preferred treatment, and doctors or patients can choose other treatments such as radiotherapy alone or systemic drug treatment. For patients with a low recurrence rate, such as those aged >30 years old with a tumor diameter <=5 cm and a single tumor, the web-based nomogram indicated that the 5-year RFS rate was 92%, which indicates that the probability of postoperative recurrence is low, and surgical treatment has shown its superiority compared with other treatments. Intensive follow-up is all that is needed after surgery. It is important to point out that this is a nomogram that has only been tested on patients undergoing surgery, and factors related to recurrence existed before surgery. Through this nomogram, the effectiveness and success rate of the operation can be predicted. For patients with a high recurrence rate after surgery, other treatments can be chosen. Therefore, the greater clinical significance of this nomogram lies in predicting the efficacy of surgery and the choice of treatment methods. Second, this web-based nomogram will also help enhance postoperative surveillance. For patients who have received surgical treatment, this web-based nomogram can accurately predict the recurrence probability at each time point after surgery so that doctors and patients can have a clearer understanding of the prognosis and strengthen postoperative surveillance. According to the latest Desmoid Tumor Management Guidelines published by “The Desmoid Tumor Working Group” and NCCN  guidelines, DT can be followed by MRI or CT, especially MR I . PostopeThe limitations of this study cannot be ignored. First, the type of CTNNB1 gene mutation was not included in our study, and several previous studies have confirmed that the type of CTNNB1 gene mutation is also associated with the recurrence of desmoid fibromatosis. There are three types of mutations in the CTNNB1 gene, namely, T41A, S45F, and S45P, among which patients with the S45F mutation have the highest recurrence rate , 38. We In summary, we developed, validated, and visualized a web-based nomogram including age, tumor diameter, and tumor number based on independent risk factors associated with recurrence to predict RFS in patients with DTs. In the future, the use of multiple technologies to further search for biological or clinical markers that predict the recurrence of DTs is a development direction of surgery, such as the combination of radiomics and artificial intelligence to find the imaging characteristics of DT recurrence. The preoperative evaluation of these characteristics can further predict the risk of recurrence to determine the optimal treatment plan.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 Tianjin Medical University Cancer Institute & Hospital ethics committee and performed according to the Helsinki declaration. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.HL drafted the manuscript. KH and YC provided part of data and revised the manuscript. TL, TY, ZL, CZ, LX, YC, and JY revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Key Nature Science Foundation of Tianjin [18YFZCSY00550 to JY].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.


The combined therapy of Chinese herbal formula and western medicine against gastroesophageal reflux disease (GERD) could significantly improve the clinical effect, reduce the recurrence rate and the side effects of western medicine, and even reduce the dosage and course of treatment of western medicine. This study tried to systematically evaluate the efficacy and safety traditional Chinese herbal formula combined with western medicine in the treatment of GERD.Randomized controlled trials of traditional Chinese herbal formula combined with western medicine for GERD patients will be systematically searched using the PubMed, Embase, Medline, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang database, Chongqing VIP Chinese Science and Technology Periodical Database, and Chinese Biological and Medical database (CMB) until Aug. 28, 2020. Two researchers will perform data extraction and risk of bias assessment independently. Statistical analysis will be conducted in RevMan 5.3.This study will summarize the present evidence by exploring the efficacy and safety of traditional Chinese herbal formula combined with western medicine in the treatment of GERD.The findings of the study will help to determine potential benefits of traditional Chinese herbal formula combined with western medicine against GERD.The private information from individuals will not be published. This systematic review also will not involve endangering participant rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.DOI 10.17605/OSF.IO/RSAVF. The prevalence varies in different areas, and it increases with age.–5 It reduces patients’ quality of life, and it is associated with a strong and severity-dependent increased risk of esophageal adenocarcinoma.,7Gastroesophageal reflux disease (GERD), also known as acid reflux, is a condition in which stomach contents rise up into the esophagus, resulting in typical symptoms of the taste of acid in the back of the mouth, heartburn, chest pain, and dysphagia. Clinical studies have proved the efficacy and safety of Chinese herbal formula in treating GERD, and they appeared to be maintained for a longer period of time.,10The treatment options include lifestyle changes, medications, and sometimes surgery. The primary medications used for GERD include proton-pump inhibitors, H2 receptor blockers, prokinetics, and antacids, in which acid suppression therapy is a common response to GERD symptoms. However, long-term use of the medications could cause acute and chronic kidney damage, magnesemia, and fractures. Also, acid suppression therapy alone can only improve symptoms such as acid reflux and heartburn, but cannot improve gastric motility and cure it. For thousands years, with the advantages of fewer adverse reactions and individualized treatment, traditional Chinese medicine has been widely used against GERD in China.In recent years, it has been discovered that the combined therapy of Chinese herbal formula and western medicine against GERD has great advantages. It could significantly improve the treatment effect, reduce the recurrence rate and the side effects of western medicine, and even reduce the dosage and course of treatment of western medicine. In order to explore the efficacy of the combined therapy in the treatment of GERD, this study tried to systematically evaluate the efficacy and safety traditional Chinese herbal formula combined with western medicine in the treatment of GERD.22.1 Moreover, it has been registered on open science framework (OSF) on August 28, 2020 (Registration number: DOI 10.17605/OSF.IO/RSAVF).This protocol of systematic review and meta-analysis has been drafted under the guidance of the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P).2.2Ethical approval is not required because of no patient recruitment and personal information collection, and the data included in the study are derived from previous published literature.2.32.3.1Randomized controlled trials (RCTs) of Chinese herbal formula combined with western medicine on the treatment of GERD will be included, with the language limited to Chinese and English.2.3.2All the included cases conform to the diagnosis of GERD (diagnosed with any recognized diagnostic criteria in the primary literature), regardless of nationality, race, age, gender, and source of cases.2.3.3The study focuses on RCTs of GERD treated by traditional Chinese herbal formula combined with western medicine versus western medicine only, and the type of western medicine, dosage, and the duration of treatment will not be limited.2.3.4The primary outcome is improvement in the symptom scores, and the secondary outcomes included the symptom scores after treatment, the response rate associated with the treatment, and the rate of relapse and adverse reactions.2.4(1)Studies with unsatisfactory outcome indicators, or the outcomes of interest were not clearly reported;(2)Studies with the most complete data will be selected for duplicate published studies;(3)Extracting the related data from the published results is impossible, and unable to obtain the primary data after contacting the author;(4)Literature with errors in random methods.2.5The literature will be systematically searched using the PubMed, Embase, Medline, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang database, Chongqing VIP Chinese Science and Technology Periodical Database, and Chinese Biological and Medical database (CMB) until Aug. 28, 2020. The reference lists of RCTs will be reviewed for eligible inclusion. The search terms and combination of keywords are “Chinese herbal formula,” “traditional Chinese medicine,” “gastroesophageal reflux disease,” “acid reflux,” etc, which will also be revised according to the rules of different database. The search strategy of PubMed is listed in Table 2.6The literature will be managed by Endnote X7. The literature screening process is shown in Figure 2.7The risk of bias in RCTs will be evaluated independently by 2 researchers in accordance with the Cochrane Handbook of Systematic Reviewers, including: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. The quality of studies is classified as being at of high, unclear or low risk of bias. In case of disagreement, a third researcher will be consulted to make the decision.2.82.8.1Statistical analysis will be conducted with the RevMan 5.3 software provided by the Cochrane Collaboration.1.Relative risk is selected as the statistic for the dichotomous variable. Weighted mean difference is estimated for continuous variables when the tools and units of measurement indicators are the same, and standardized mean difference is estimated with different tools or units of measurement, and all the above are represented by effect value with a 95% Confidence interval.2.Q test is used to qualitatively determine inter-study heterogeneity. A P value ≥.1 is considered as no inter-study heterogeneity, and a P value <.1 is considered as inter-study heterogeneity. At the same time, I2 value is used to quantitatively evaluate the inter-study heterogeneity. An I2 score ≤50%, is considered to be a good heterogeneity, and the fixed-effect model is adopted. An I2 value >50% is considered to be significant heterogeneity, and the source of heterogeneity will be explored through subgroup analysis or sensitivity analysis. If there is no obvious clinical or methodological heterogeneity, it will be considered as statistical heterogeneity, and the random-effect model will be used for analysis. Descriptive analysis will be used if there is significant clinical heterogeneity between the 2 groups and subgroup analysis is not available.Heterogeneity test: 2.8.2If data is missing or incomplete in a study, the corresponding author will be contacted to obtain the missing data. If impossible, the study will be removed.2.8.3In order to reduce the clinical heterogeneity between studies, subgroup analysis is conducted according to the nonerosive GERD and erosive esophagitis GERD.2.8.4In order to test the stability of meta-analysis results of indicators, a one-by-one elimination method will be adopted for sensitivity analysis.2.8.5For the major outcome indicators, funnel plot will be used to qualitatively detect publication bias when the number of included study is ≥10. Egger and Begg test are used to quantitatively assess potential publication bias.2.8.6The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used to assess the quality of evidence, as high, moderate, low, and very low.3 which could improve the quality of life of patients with GERD, but with many adverse events. In China, Traditional Chinese herbal formula has history-proven benefits for GERD, and clinical studies have proved the efficacy and safety of Chinese herbal formula in treating GERD.,10 Mechanism research found that Chinese herbal formula could relieve dilated intercellular spaces and desmosome disruption in esophageal epithelium, protected mitochondria from fragmentation to significantly resist esophageal morphology changes in ovalbumin-induced and acid exposure rat model. Also, they could improve the pH value of gastric contents, decrease the gastrointestinal hormones, and improve the inflammatory damage in rats. A combination of Chinese herbal formula and western medicine against GERD could significantly improve the treatment effect and reduce the side effects of western medicine.Gastroesophageal reflux disease (GERD) is often encountered in clinical practice, and it is considered as one of the most common gastrointestinal diseases. Proton-pump inhibitors, such as omeprazole, are thought to be the most effective western medications, followed by H2 receptor blockers, such as ranitidine,This will be the first systematic review and meta-analysis to comprehensively compare the efficacy and safety of traditional Chinese herbal formula combined with western medicine versus western medicine for GERD. This meta-analysis and systematic review will help to determine potential benefits of Chinese herbal formula combined with western medicine compared with different western medicines to against GERD. However, there are some inevitable limitations. Our search did not include studied in other languages except Chinese and English, which might result in certain selective bias. In addition, the potentially high heterogeneity among different clinical studies might also influence the final results.Data curation: Lin Wuhong, Xirong Liu, Huasheng Lin.Funding support: Guihua Huang.Investigation: Guihua Huang.Literature retrieval: Heng Zhou and Chunbing Feng.Resources: Heng Zhou.Software: Chunbing Feng, Tingshuai Wang, Renjiu Liang.Supervision: Guihua Huang.Writing – original draft: Wuhong Lin.Writing – review & editing: Wuhong Lin, Guihua Huang.


COVID-19 outbreak is a sudden and devastating global pandemic in which the control of the spread is highly dependent on individual reactions, until the development of a vaccine and adequate treatments. Considering that older adults are at high risk for COVID-related medical complications and mortality, the present study focuses on the age-related differences on the adoption of protective behaviors during the initial stages of this outbreak, while accounting for the role of sociodemographic, COVID-related, perceived risk, and psychosocial variables  in this relation. The study sample included 1696 participants, aged between 18 and 85 years old, who completed an online survey during the initial stages of the first COVID-19 outbreak in Portugal. Overall, results reveal that the engagement in protective behaviors declines with advancing age and that older adults show a pattern toward lower perceived risk compared with middle-aged adults. Multicategorical mediation analyses show that anxiety, optimism, fear of death, and social isolation significantly mediate age effects on protective behaviors. Specifically, both anxiety and fear of death increase protective behaviors via higher perceived risk in the middle-aged and in the younger groups, respectively. Optimism directly predicts protective behaviors in the middle-aged groups, while social isolation reduces protective behaviors in the younger and older-aged groups. Results are discussed in terms of its implications for public health policies. On December 31, 2019, the World Health Organization (WHO) was informed of a cluster of cases of severe acute respiratory syndrome of unknown etiology in Wuhan, Hubei province of China . A novelIn European Union, the first cases were reported on January 25 . 2 monthA review of 26 studies  demonstrFrom the evidence on a link between perceived risk and protective behavior, a necessary second step is to search for risk/protective factors that may be mediating and moderating this relation. The current study focuses on aging and psychological individual differences effects in risk perceptions and protective behaviors during the first days of the COVID-19 outbreak. The relevance of these factors for a comprehensive understanding of risk-taking during epidemics, especially in those at high-risk for medical complications and mortality, will be discussed below.In Europe, 18% of the population has more than 65 years old . At 65 yAlthough it is commonly assumed that older adults are more risk-averse than their younger counterparts, the results are mixed. Older adults report lower levels of impulsivity and sensation-seeking e.g., , but do Previous studies conducted during epidemics do not provide clear evidence on this matter. Some studies demonstrate that elders were more likely to undertake appropriate measures against SARS 2003 e.g., , while oFrom this standpoint, the current work intends to analyze the role of risk perceptions on protective behavior as a function of aging during the COVID-19 outbreak. The first evidence on COVID-19 revealed that age does not moderate the link between risk perceptions and protective behaviors , but theAging is associated with a “positivity effect” on cognitive and affective processing. That is, older adults exhibit a decline in the processing of negative stimuli compared to the younger counterparts, with intact or enhanced processing of positive stimuli see . Such fiPrevious studies on SARS, H1N1, and H5N1 reveal that moderate levels of anxiety can lead to appropriate preventive responses to avoid risky behaviors , probablEpidemiologic surveys have systematically found that current and lifetime anxiety disorders are less prevalent in older than younger adults e.g., , a findiThe fear of death is a natural phenomenon during outbreaks. The number of deaths increases exponentially every day, and the acute and severe nature of the disease, as well as the uncertainty around the illness outcomes, inherently raises concerns around death . For insYet, paradoxically, the oldest of the elderly report no fear of death . The larTo anticipate the future is a critical aspect to guide behavior, namely in new situations as outbreaks. One of the most consistent findings is that our brain is not accurate when making inferences about the future. Humans tend to overestimate the probability of positive events and underestimate the negative ones, which is particularly true for health problems . IndividIn a SARS 2003 unaffected area, Few studies to date have addressed the effect of age on optimism, and the results are inconsistent . For insSocial connection among conspecifics is a defining characteristic of humans as social species and thus the lack of stable social bonds naturally threatens human life . Holt-LuIndividuals who are socially disconnected are less exposed to multiple sources of information and normative pressures from their relatives , which cIn Europe, 2 to 16% of the adult population has no one to ask for help if they need it, and over 1 in 10 persons aged 65 or more has no interaction whatsoever with friends, either personally or in other ways . ConsideThe emergence of risk perceptions and protective behaviors during outbreaks might interact with aging and a set of psychosocial dimensions associated with positive and negative affect. From the current state of the art, the present study aims: (1) to analyze risk perceptions and the frequency of protective behaviors in older adults during the initial stages of the COVID-19 in Portugal, (2) to explore age-group differences in sociodemographic characteristics  and COVID-19 awareness  that may influence risk perceptions and frequency of protective behaviors, and (3) to search for the mediating effects of risk perceptions, anxiety, optimism, fear of death, and social isolation on protective behavior as a function of age. This comprehensive analysis is essential to produce scientific knowledge that may be useful to develop prevention strategies targeting psychosocial dimensions explaining the risk-taking behavior in the early stages of a pandemic, especially in groups at risk for medical complications and mortality due to COVID-19.A cross-sectional online survey was developed on Qualtrics Software to access the individual responses to the COVID-19 outbreak. The survey was carried out during the first mandatory quarantine for all national citizens during the Emergency State (March 20–April 02). The responses were collected from March 25 to April 02, to allow the collection of the precautionary behaviors from the previous 5 days and after the imposition of quarantine and behavioral restrictions declared by the Government. Considering the recommendations for isolation and to minimize face-to-face interactions, participants were recruited by online advertisements on social media of the university campus and by a snowball sampling strategy, encouraging participants to disseminate the survey to their older relatives and friends. This study was approved by the Local Ethical Committee. All the participants gave informed consent and had the opportunity to read the study information before starting the survey.A total of 1892 subjects participated in this study. However, 174 participants did not complete any COVID-related section of the survey and were removed from the analysis. From the 1718 responses, we additionally excluded 22 participants: 14 included other information than age on the age entry field, two provided atypical response contents, and six completed the survey with an atypical time duration .M = 41.9 years, SD = 16.5). Most of the sample completed the university (69.9%) or the secondary school (23.9%). For those actively working (62.3%), 69.3% are using teleworking. Only 10.8% of the participants were retired . The zone of the residence covered all the Portugal mainland geographic regions  and archipelagos (Madeira and Azores = 0.5% each) and were represented by both rural (23.8%) and city areas (76.2%). Regarding COVID-19, the mean time of quarantine reported by the included participants was of 14.4 days (SD = 6.3). 15.5% of the sample reported at least one COVID-related symptom in the past two weeks and 6.0% said they know someone with a confirmed diagnosis. 30.4% disclosed having at least one of the high-risk medical conditions for COVID-19 mortality. 41.1% also reported a past traumatic event. The time of search for and exposure to COVID-related information ranged from less than 1 h to around 1–3 h (89.1%) and was mainly accessed through TV newscasts (88.4%) and social media (80.5%), followed by the reports from the Portuguese Government Health Department (77.1%), newspapers (61.1%), WHO (60.3%), and word of mouth (35.3%).The final sample included 1696 individuals  aged between 18 and 85 years old  and COVID-19 . Then, we assessed the perceived risk of COVID-19 based on the estimates of COVID-19 spread compared with the flu , COVID-19 contamination , COVID-19 reactions , and penalties for those not following some important practices to mitigate the risks associated with the COVID-19 dissemination .Regarding behavior, perceived risk was assessed through the classification of high- and low-risk scenarios that were developed based on the local health department and WHO recommendations. Each high-risk scenario was developed to have a corresponding low-risk scenario: (1) to scratch the nose after coming from the street/to scratch the nose after taking bath, (2) to receive visits/to receive supplies at the door, (3) to host a dinner party at home for friends and familiars/to telephone to friends and familiars, (4) to physically compliment someone at the street/to compliment someone at the stress with more than one meter of distance, (5) to go out to meet friends/to go out to practice exercise, (6) to not wash the hands after coming from the street/to not watch hands before waking up, and (7) to use objects that belong to other people/to use personal objects. Participants were asked to move the slider in 0 to 100 scale ranging from “not risky at all” to “very risky.” Additionally, protective behaviors were measured by considering the allowed, but discouraged behaviors during the quarantine as stipulated by a national Decree Law 2-A/2020 of March 20, as well as the most systematically cited protective behaviors by local health authorities .Psychological data encompassed self-report measures of state anxiety, optimism, fear of death, and social isolation. Anxiety was measured using the anxiety subscale from the Portuguese version of the Hospital Anxiety and Depression Scale . As a meThe measures included in the survey are described in more detail in n = 126; 20–29, n = 420; 30–39, n = 233; 40–49, n = 280; 50–59, n = 350; 60–69, n = 208; +70, n = 78)1. In the next sections we will: (1) analyze group differences in terms of sociodemographic characteristics and COVID-related variables; (2) test for linear and quadratic trends when considering protective behaviors and perceived risk as a function of age; and (3) explore the mediation effects of psychological variables and perceived risk in protective behavior for the different age groups. More details on the analytic strategies are described below.Participants were divided into seven age segments, designed to represent the age range in which the daily reports on COVID-19 are nationally presented  = 335.4, p < 0.001, professional status, X2 = 1980.0, p < 0.001, and time of isolation, F = 21.8; p < 0.001. As expected, there was a higher proportion of participants with high school/university level education and currently active (studying/working) in the younger groups. Moreover, younger adults (18–19) reported to be in isolation for a longer period when compared with all other age groups . However, there were significant differences between groups for variables that are not expected to be related with age: geographic region, X2 = 216.6, p < 0.001, and sex, X2 = 26.3, p > 0.001. There were more participants in the middle-aged groups from the center and south regions of Portugal. A MANOVA model showed that the effects of geographic regions were significant for protective behaviors, F = 669.5, p = 0.003, and penalties, F = 4.05, p = 0.003, with less protective behaviors in the South , and higher penalties estimates (p = 0.001), compared to the North . Regarding sex, a higher proportion of man was found in the older groups. The effects of sex were more systematic in behavior and risk perceptions , with men showing less perceived risk and protective behaviors across all variables. For this reason, we included sex as a covariate in the subsequent analyses to correct for its effects. No significant differences were found across age groups on the workplace for those actively employed, X2 = 8.02, p = 0.237, nor rural residence, X2 = 8.73, p = 0.189.X2 = 124.0, p < 0.001, trauma, X2 = 56.3, p < 0.001, and symptoms of COVID-19, X2 = 52.3, p < 0.001  = 7.46, p = 0.281. Additionally, results show a significant effect of age on daily time spent on information about COVID-19, X2 = 73.9, p < 0.001, with an increased proportion of participants in the older aged groups spending 1–3 h searching/consuming information about COVID-19  as between-groups factor and measures of protective behaviors and perceived risk as the dependent variables. Only the best fit for linear or non-linear trends will be reported. Regression coefficients will be presented to linear effects and Bonferroni comparisons will be described to quadratic effects. All these post-analyses were corrected for sex moderation effects.p = 0.002), namely for those behaviors allowed but discouraged under the quarantine regulation  and for those encompassing good practices systematically recommended by the local health authorities . Age predicted total scores on protective behaviors , by indicating a negative association for both quarantine  and health recommendations .The use of protective behaviors  showed aM = 56.3, SD = 16.6) had higher perceived risk, t(1567) = 42.8; p < 0.001, than the low risk scenarios . Participants further underestimated, t(1646) = −11.2; p < 0.001, the probability of becoming infected  compared to the probability of infecting someone .As expected, high risk scenarios (p < 0.001) and low-risk scenarios , as well as for the perceived risk of becoming infected by COVID-19  or contaminating someone with COVID-19 . Lower risk ratings in high-risk scenarios was found for the elders aged above 70, comparing to the 40–49, p = 0.006, and the 50–59 age groups, p = 0.027 (p > 0.052). The same pattern was found for the low-risk scenarios , expect for the 40–49, p = 0.004, and 50–59 groups, p = 0.022. The perceived risk of becoming infected or to infect someone had, respectively, less scores on the +70 group compared to adults aged between 20 and 59 years . Again, the oldest group was not significantly different than the 18–19 and the 60–69  (p = 0.007). However, when correcting for multiple comparisons, no differences were detected between groups .The results revealed an age-related U-inverted quadratic trend for perceived risk in high-  . A quadrp = 0.006) and monetary penalties followed a linear trend  (p < 0.001), and increased monetary penalties .Age effects on the perceived threat of COVID spread in relation to seasonal flu  . Age preA mediation analysis was conducted to assess the mediation effects of psychological processes (mediator 1) and perceived risk (mediator 2) in predicting the total score of protective behavior (dependent variable) across different age groups (independent variable).On the previous section, the effect of age was linearly associated with protective behaviors while quadratic trends emerged in risk perceptions. To better assess non-linear patterns of results, age was entered in the mediation model as a multicategorical indicator.p < 0.019); fear of death showed the same associations with these variables and also with higher penalties for COVID-related transgressions, and higher perceived risk of becoming infected or infecting someone with COVID-19 ; social isolation also covaried with these later perceptions, as well as less perceived risk for COVID-19 spread . In turn, optimism was related to less perceived risk of becoming infected or infecting someone with COVID-19 . However, after accounting for the shared variance between the set of risk perception dimensions with significant associations with age, only the perceived risk on high-risk scenarios predicted the higher frequency of protective behaviors . For this reason, only high-risk perceptions proceeded to the subsequent mediation analysis. This association remained significant in the four mediation models  and modulate protective behavior. Anxiety correlated with high perceived risk in high- and low-risk scenarios, and less perceived overreactions  and the 60–69 age groups , with less reported anxiety in the +70 compared to these age groups; (b) anxiety positively predicted perceived risk , and (c) the regression effect of anxiety with the frequency of protective behaviors was non-significant .The inclusion of anxiety (mediator 1) and perceived risk (mediator 2) as mediators of the age group–protective behaviors relation revealed the following : (a) theOn the mediation effects, the bootstrap CIs for inference about the relative indirect effects of age groups in protective behaviors revealed that anxiety was a non-significant mediator. When considering both mediators in the same model, anxiety and perceived risk mediated the age-related differences in the 50–59 and 60–69 age groups. The indirect effects of anxiety and perceived risk in these groups potentiates the reduced frequency of protective behaviors in the +70-age group, when compared with the 50–59 and 60–69 age groups.p = 0.038), with participants above 70 years reporting less optimism; (b) optimism did not predict risk perceptions , and (c) optimism was associated with increased protective behaviors ,The model exploring the role of optimism (mediator 1) and perceived risk (mediator 2) on the age group–protective behaviors relation showed that : (a) ageOn the mediation effects, the bootstrap CIs for inference about the relative indirect effects of age groups in protective behaviors unveiled optimism as a significant mediator in the 40–49 age range, i.e., diminished optimism potentiated the reduced frequency of protective behaviors in the +70-age group when compared with the 40–49 age group. No mediation effects were found for the bootstrap CIs for inference about the relative indirect effects of age groups in protective behaviors when accounting for both mediators.p = 0.009; 20–29, p = 0.035) (b) fear of death significantly predicted high perceived risk , and (c) the regression effect of fear of death on protective behavior was non-significant .The inclusion of fear of death (mediator 1) and perceived risk (mediator 2) in the model unveiled that : (a) theRegarding mediation effects, the bootstrap CIs for inference about the relative indirect effects of age groups in protective behaviors indicated that fear of death did not mediate this association. For both mediators, this analysis showed a significant indirect effect in the 18–19 age group. Data suggest that reduced fear of death along with reduced risk perceptions in the +70-age group reduce the engagement in protective behaviors in the +70-age group when compared with the 18–19 age group.p = 0.014), with the +70 reporting less social isolation; (b) the regression effect of social isolation on perceived risk was non-significant , (c) but social isolation predicted reduced protective behaviors .Accounting for the mediation effect of social isolation (mediator 1) and perceived risk (mediator 2) on the age group–protective behaviors relation, it was found that : (a) theThe analysis of the bootstrap CIs for inference about the relative indirect effects of age groups in protective behaviors showed that social isolation mediated age effects on protective behavior for the 18–19, 20–29, 60–69 age clusters. The indirect effects suppressed the main effect of age on protective behaviors, suggesting that social isolation reduces the frequency of protective behaviors in younger  and older adults  when compared with the +70 age group. The model including the two mediators did not revealed any significant mediation effect across age groups.The first responses to a pandemic are inevitable preventive and are highly dependent on the individual reactions. Therefore, as the outbreaks spread across the globe, there is an urgent need for psychological studies gathering evidence on variables that may influence protective behaviors, namely for those groups who are at high-risk. From a scientific standpoint, it is unknown how older adults are reacting to an unexpected situation that requires sudden modifications of routines. This study represents an effort to analyze risk perceptions and the frequency of protective behaviors in older adults during the first days of the outbreak while exploring group differences that may underlie these variables.Overall, the results show that protective behaviors decline with advancing age. Specifically, older adults seem to engage more in those routine behaviors that are strongly discouraged during the quarantine, regardless of being allowed, and to engage less in those health practices recommended to prevent the contamination. Considering that younger groups reported longer isolation periods, we should equate whether group differences in protective behaviors are related to specific differences in seeking essential goods from services that remained open during the quarantine . However, it is not possible to simply attribute the older adults’ risk-taking behavior to the active management of the household, since older adults also engaged less in prevention measures related to health practices aiming to prevent infection . Accordingly, the older group was less likely to follow the protective recommendations in previous SARS  and H1N1The interplay between group differences in sociodemographic characteristics, COVID-related variables, risk perceptions, and psychological dimensions will be explored below to provide the comprehensive insight on risk and protective factors that may affect the adoption of preventive measures.The evidence shows that older adults exhibit some protective factors for risk assessment and preventive attitudes. Considering their greater health vulnerability and higher exposure to information from TV newscasts, it would be expected an increased frequency of protective behaviors . No grouAlthough TV newscasts dedicate a significant part of the airtime to daily reports from the local health authorities, there are expressions systematically repeated that may not be very intelligible to individuals with lower educational levels . Thus, communication strategies toward health education not only need to be designed to reach and target vulnerable groups  as also need to use accessible messages for those with lower educational levels. Retirement can also contribute to blurring the significance and urgency of the problem, since a detachment of current issues, or at least a delay in risk perception, is expected when people furthest from the everyday workplace discussions around preventive measures and the possibility of wind up activities. Finally, the traumatic experiences in older adults, namely life-threatening diseases, along with reduced reported symptomatology related with COVID-19, can desensitize for the relevance of the problem. Participants were capable of distinguishing high-risk from low-risk scenarios. In both scenarios, an inverted U-shape revealed that older adults  are not significantly different from younger adults  in risk assessment of scenarios encompassing high  and low-risks  and that these two groups perceive less risk than middle-aged adults . Interestingly, participants underestimated the probability of becoming infected compared to the probability of infecting someone, which is paradoxical but strengthens the assumption that individuals tend to see their chances of having health problems as lower than their peers . These pNevertheless, an opposite pattern was found in risk estimates related to COVID-19 spread. Age linearly predicted increased threat estimates for COVID-19 spread and higher penalties for those not following practices preventing the COVID-19 dissemination. Taken together, our results reveal that older adults appear to be aware of the general COVID-19 threat, but these risks seem to be underestimated when they are assessed at individual and more specific behavioral levels. Of note, lower ratings on high-risk scenarios uniquely predicted reduced engagement in protective behaviors, and older adults showed reduced perceived risks in these scenarios. As such, the response from this group to the outbreak seems to rely specifically on individual risk perceptions. This suggests that subjective beliefs about preventive measures should not be disregarded and that public health messages should be very clear about the outbreak risks in order to reduce subjective interpretation, namely by providing adequate and objective messages targeting those who are at high-risk. This is of high relevance because older adults seem to be capable lo learn under uncertain contexts of decision-making and move to decisions based on known outcomes , albeit in a less effective way than younger adults .The oldest group (+70) reported lower state-anxiety levels associated with the COVID-related circumstances and lower fear of death than 50–69 and 18–29 age groups, respectively. These results, collected during an unfamiliar situation with an ongoing rampant health crisis, are in the same vein of the positivity effect in aging : negativFrom these results, moderated levels of anxiety and fear of death may increase protective behaviors via higher perceptions of risk. That is, moderated levels of anxiety and fear of death may be adaptive by potentiating a defensive response in situations where survival is at risk. The effect of anxiety on protective behaviors was previously observed in SARS, H1N1, and H5N1 outbreaks , particuOptimism was included in the analysis as a positive affective outlook about the future that may compromise the engagement in protective behaviors by reducing the perceived risks, especially in older adults due to the positivity bias. Previous studies found that persons are likely to underestimate the risks of becoming infected by diseases such as SARS  and COVIandrá tutto bene, everything will be alright.The protective role of optimism brings interesting possibilities to counterbalance negative and positive affect when managing both risk perceptions in the adoption of preventive measures and the broad individual reactions to COVID-19 circumstances . The inclusion of optimistic perspectives about the future, namely during psychological interventions, may help to manage expectations toward a reality that is inherently aversive in the short-term, but necessary to avoid the spread of the virus and to return to the (new) normality in the medium-term. Our brain may not be accurate when making inferences about the future , especiaFinally, we explored the subjective experiences of social isolation. Social isolation covaried with estimates of becoming infected or infecting someone and with lower perceived risk for COVID-19 spread. Nevertheless, social isolation predicted protective behaviors such as optimism did . Specifically, social isolation decreased the frequency of protective behaviors in the 18–19, 20–29, and 60–69 age groups, inversely to what was found for optimism. Despite the reduced levels of social isolation reported by the +70 participants, these findings show that social isolation is a risk factor for risk-taking behavior, namely in older and younger adults.There is evidence that individuals lacking social support are less exposed to multiples sources of information and normative pressures from their peers, and may be less motivated to adhere to socially defined standards . AdditioSome limitations should be acknowledged. First, the present study provides a cross-sectional analysis, and data were collected in a single moment during the early stages of the COVID-19 outbreak in Portugal. As so, no follow-up analysis was conducted on how the evolution of the outbreak changes individuals’ perceptions and behavior, no causal inferences can be drawn on the mediation effects, and results may not be generalized to other countries, namely those with different approaches to target the COVID-19 pandemic.This procedure further limited recruitment opportunities and sample size but allowed for circumscribing risk-taking behaviors and perceptions to the first phases of the outbreak. Of note, unbalanced groups did not statistically lead to group size distributions affecting variance of the error distribution, which suggest that group size differences did not affect the overall findings. Second, some carryover effects may be present, especially in optimism and social isolation scales that were administered after the state anxiety measures. Third, the procedure  and online data collection may have biased the included sample and limits the generalization of findings. For instance, surveys show several drawbacks  and individuals with access to technologies may be fundamentally different from those who do not have frequent access to computers, smartphones, and internet, namely in what regards age . However, the quarantine circumstances limited the available options for data collection and, even so, this study was able to find the sociodemographic characteristics that are expected to co-vary with age . Finally, variables related to information exposure and psychosocial dimensions gave important insights. Nonetheless, a more fine-grained analysis on information variables  and the inclusion of other psychological dimensions  would allow for a more comprehensive picture. Also, it is not possible to accurately measure from survey procedures that the reported social media exposure corresponds linearly to the effective attention allocated to the COVID-related news.The present study provides a comprehensive analysis on the sociodemographic and psychosocial accounts for the age effects on risk perceptions and protective behaviors during the early stages of the COVID-19 outbreak. Since an effective response during the early stages of an outbreak is paramount for a successful containment and control of the contagion, the present study provides valuable information for public health policies, in order to promote protective behaviors among particularly vulnerable groups. Results show that the engagement in protective behaviors declines with advancing age and that older adults show a pattern toward lower perceived risk compared with middle-aged adults. They further evidence that anxiety, optimism, fear of death, and social isolation significantly mediate age effects on protective behaviors. Specifically, both anxiety and fear of death increase protective behaviors via higher perceived risk in the middle-aged and in the younger groups, respectively. Optimism directly predicts protective behaviors in the middle-aged groups, while social isolation reduces protective behaviors in the younger and older-aged groups. Therefore, attention should be given not only to the study of the effectiveness of public health communications directed to groups at risk, but also to mental health, as psychosocial variables such as anxiety, optimism, fear of death and social isolation account for age differences in the adoption of protective behaviors. Mental health practitioners, especially psychologists, are also challenged by the current crisis, providing interventions mainly based on digital solutions. The results of the present study provide elucidation on potential risk factors for disruptive behaviors during pandemics, that are fundamental for an effective communication and intervention that promote both protective behaviors and mental health.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 Local Ethical Committee of the Faculty of Psychology and Educational Sciences, University of Porto. The patients/participants provided their written informed consent to participate in this study.All authors contributed to conceptualization and manuscript review. RP, CF, and TP: data collection. RP, TP, and FB: data analysis. RP and CF: manuscript preparation. FB: supervision.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.


This is a case history of a 23-year-old woman suffering from incontinentia pigmenti (IP). The patient’s vision in the left eye started to deteriorate due to cataract progression at the age of 22, and by the age of 23, it dropped from 0.9 to 0.04. Ultrasound examination confirmed tractional vitreoretinal membranes. Vitrectomy was performed, therefore, on her left eye. The histological evaluation of vitreous membrane revealed a complex immunophenotype , vimentin, S-100, anti-pan cytokeratin antibody (AE/AE3), and smooth muscle-specific actin (SMA) to various extents). The right eye remained unsymptomatic throughout this course. Besides being the first to analyze the tractional vitreoretinal membrane in IP with immunohistochemical methods, this case study points out that extreme cases of asymmetric side involvement in IP do exist, even to the point of one eye being completely unsymptomatic. Incontinentia pigmenti (IP) (Bloch–Sulzberger syndrome) is an X-linked, dominantly inherited disease affecting approximately 1 in 50,000 newborns . The diaThe female patient was born with a birth weight of 2900 g. Right after birth, she developed antibiotic-resistant, recurrent vesicular skin lesions on the left side of her body. The diagnosis of IP was made at the third postnatal week by immunohistochemical analysis of the skin biopsy. It revealed the characteristic eosinophil granulocytic infiltration of the vesicles and the superficial layers of corium. The diagnosis was supported from her mother recalling that she had blisters on her skin of unknown origin when she was a baby. She had no other systemic manifestation, but according to the genetic analysis, she also had the same NEMO gene.Hyperkeratotic skin lesions and faint pigmented lines were seen at the age of one. Dentitio tarda (late appearance of teeth) was the only systemic manifestation at that time. The first sign of her vision impairment appeared in 2002, at the age of six, as a mild exodeviation of the left eye. Although the best corrected visual acuity of this eye was 0.9 (the right eye had full vision), ophthalmoscopy revealed dragged optic disc and pigmented alterations on the mid-peripheral temporal retina. IP-related vitreo-retinopathy was diagnosed in her left eye, whereas it was without any alteration in her right eye.One and a half years later, the visual acuity slightly decreased in the left eye (0.7–0.8).The patient’s left eye vision started to deteriorate rapidly due to cataract progression at the age of 22, and by the age of 23 it dropped to 0.04. Ultrasound (UH) and optical coherence tomography (OCT) revealed a tenuous epimacular membrane . PhacoemIn the early postoperative period, no complication occurred, visual acuity improved to 0.5, the retina was flat, and the macular contour normal. Seven days later, her best corrected visual acuity further improved to 0.6 on the operated eye.The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation  and with the Helsinki Declaration of 1975, as revised in 2000.The pathomechanism of retinal changes in IP remains debated. The main question to be answered is whether the retinal vascular abnormalities are primary or secondary to changes in the retinal tissue. Nishimura et al., already in 1980, suggested that arterial obstructions would lead to retinal ischaemia and proliferation , which wIncontinentia pigmenti membrane has been investigated histologically in two IP patients so far ,8, but nKampik et al. described 56 cases of epiretinal membrane with differing etiology, not including IP cases. According to them, epiretinal membranes originate from retinal pigment epithelial cells, fibrous astrocytes, fibroblasts, and macrophages . EdwardsIn the study of Vinores et al.  on cellsAlthough the pronounced asymmetry in the involvement of the two eyes is well documented, the total lack of signs and symptoms of the disease in the less- or un-affected eye of our patient can be considered a rarity.