Background: Cancer and its treatment can cause serious health issues that impair physical and mental well-being in children and adolescents. Exercise may be a valid strategy for managing some symptoms, including fatigue. In the light of our experience, we provide further justification for including exercise as part of routine childhood cancer care.Methods: Forty-four children and adolescents who had solid cancers not contraindicating their movement were invited to join an in-hospital 6-week supervised exercise program, and asked afterwards to complete validated quality of life and fatigue scales. The program consisted of personalized workout sessions of aerobic, resistance and flexibility exercises. The results obtained on the scales were compared between 21 patients who engaged in the exercise program (GYM group) and 23 who refused (No-GYM group), examining the different dimensions of health-related quality of life  and fatigue  in the two groups.Results: Being diagnosed with cancer initially prompted all but one of the respondents to drop-out of previous routine exercise or sports although their continuation had not been contraindicated. After 6 weeks of exercise, the GYM group's scores for quality of life and fatigue showed a statistically significant better perceived emotional functioning, and a trend toward a better social functioning than in the No-GYM group.Conclusion: We suggest that exercise improves the satisfaction of children and adolescents with cancer with their physical, mental and social functioning. We would emphasize the potential benefits of general practitioners discussing and recommending exercise for their young patients with cancer. Children and adolescents with cancer are often treated with chemotherapy, sometimes combined with radiotherapy and/or surgery. We know their disease and its treatments can cause various morbidities, including fatigue, neuropathy, sleep disruption, chronic pain, depression, anxiety, and cognitive impairment –3. OveraThere has been growing interest in studying the value of physical exercise in cancer patients, albeit focusing more on adults than on children so far –11. ReguHealth-related QoL (HRQoL) is a construct that describes a person's perception of their own physical, mental and social well-being –17. PosiPhysical vitality is an important marker of any child's and teenager's physical and psychosocial well-being, be they healthy or ill, and higher levels of physical activity have been found to correlate with better cognitive outcomes –28.The aim of the present study was to assess the effect of an in-hospital training program on the physical vitality and fatigue of children during or after treatment for cancer. The study's findings could help to identify potential barriers to physical activity and participation in sports for children and adolescents with cancer, and to promote exercise programs for children and adolescents with cancer to enhance their physical, psychosocial and emotional functioning.Between April and August 2018, consecutive patients (aged 5–21 years) diagnosed with solid tumors or lymphomas who were receiving or had completed their treatment, and who had no disabilities and/or morbidities severe enough to prevent any form of physical activity, were personally invited by their oncologists to attend exercise sessions at the hospital gym . The sesad hoc questionnaire was used to obtain information on the patients' physical activity levels and habits prior to being diagnosed with cancer, their personal attitudes to participating in sports, and their knowledge and expectations of the institutional physical exercise program.Patients involved in the study formed two groups , which were compared in descriptive terms and on HRQoL scores. An Certified questionnaires on QoL and fatigue were administered: the PedsQL-4.0 Generic Core Scales , 17 Ita, 16, 30 The questionnaires were administered to the GYM group after participants had completed the 6-week training program, and to the No-GYM group at the baseline.The results obtained were analyzed using classical descriptive statistics for the study population as a whole, and by group (GYM vs. No-GYM). The scores were calculated with the PedsQL™ 4.0 scoring algorithm, and the medians and interquartile ranges (IQR) were recorded for each item and each dimension, and for total scores (if any), for each PedsQL scale. Higher scores indicated a better QoL.Differences between the two groups in terms of patients' characteristics, and their scores in the questionnaires  were assessed with Fisher's exact test or the Wilcoxon test. Possible correlations between total scores  were computed using Pearson's correlation index (Pearson's r).Consent to participation in the study was obtained from all patients and/or their guardians. The institutional Ethics Committee approved the study and the data protection methods.P 0.034): 6 of 8 patients with brain tumors refused to attend the gym; and all patients with neuroblastoma joined the GYM group , and 20/44 patients were female. Twenty-one patients (48%) attended the proposed exercise sessions, and formed the GYM group, while 23 (52%) refused to do so and formed the No-GYM group. The two groups differed statistically as regards type of cancer  reported having exercised regularly before their tumor was diagnosed, with no statistically significant difference between the two groups. Excluding three patients who reportedly did not exercise even before they were diagnosed with cancer, 32/41 patients (78%) reported discontinuing any form of physical activity when their disease was diagnosed, 8/41(20%) significantly reduced their level of exercise, and only one continued to exercise as before. The main reasons for discontinuing or limiting their exercise or sports were: fatigue (26/40); lack of time ; physical disabilities ; and the presence of a central venous device (in two cases). Seventeen patients (43%) were discouraged from continued exercising by other people  who regarded their tumor as a contraindication in itself.Seventeen patients who had already attended the hospital gym before this study was launched (12 of whom reported not having exercised regularly or engaged in any sports before their tumor was diagnosed) were asked some additional questions referring to the previous period. Their motives for attending the gym were: to keep fit (8/17); to combat treatment-related side effects (3/17); to take their mind off their situation (12/17); to have an opportunity to socialize with their peers (2/17); to heal their relationship with their bodies (6/17). After starting to attend the hospital gym, they reported experiencing the following benefits: they felt physically fitter (8/17); they were better able to manage their anger (11/17), sadness (12/17), irritability (11/17), or anxiety (9/17); it helped to control side effects of treatment , and it improved their relationships with peers (5/17). Fifteen of the 17 patients said they would come back to the hospital gym even after completing their cancer treatments, during their follow-up as outpatients .p = 0.018), respectively. Specific items associated with this difference were: fear, sadness, sleeping difficulties, and uncertainty about the future, with median values of 100 (IQR: 75–100) vs. 75 (IQR: 50–100), 75 (IQR: 50–100) vs. 50 (IQR: 50–75), 100 (IQR: 50–100) vs. 75 (IQR: 50–100), and 100 (IQR: 50–100) vs. 50 (IQR: 25–75), respectively, for the GYM group vs. the No-GYM group.The median scores (and IQRs) for perceived emotional functioning were 85.0 (62.5–87.5) and 60.0 (45.0–75.0) in the GYM and No-GYM groups , and making friends (median 100 [IQR: 100–100] vs. 75 [IQR: 75–100]). The GYM group scored lower than the No-GYM group for the item about being able to do what peers can do (median 62.5 [IQR: 50–87.5] vs. 75 [IQR: 50–100]).The GYM group also reported a slightly better psychosocial functioning than the No-GYM group (median 76.7 [IQR: 67.5–83.3] vs. 71.7 [IQR: 56.7–76.7]).The median HRQoL scores obtained with the PedsQL Fatigue scale were lower for the GYM group than for the No-GYM group, except for the “general fatigue” dimension, which was a median 66.7 [IQR: 58.3–79.2] for the GYM group as opposed to 62.5 [IQR: 50–83.3] for the No-GYM group. On analyzing the different items, the median scores were higher in the GYM group than in the No-GYM group for perceived sleep quality (median 100 [IQR: 50–100] vs. 87.5 [IQR: 50–100]), and for fatigue in activities of daily living (median 100 [IQR: 75–100] vs. 87.5 [IQR: 75–10]). Overall, scores obtained in the questionnaires are reported in The correlations between total scores  were all from weakly to moderately positive, ranging between 0.51  and 0.68  according to Pearson's correlation index .Physical activity has favorable effects on various levels of functioning in individuals during and after their treatment for cancer, encompassing aspects of QoL, mood symptoms, fitness level, muscle strength, body composition, and active attainment of social roles , 31, 32.The main findings of our study are: that a large proportion of children and adolescents with cancer abandon any physical activity without good reason when their disease is diagnosed; and that engaging in supervised exercise within the hospital improved patients' satisfaction with their emotional and social functioning.When interviewed at the baseline, 97.5% of our patients who were active before being diagnosed with cancer reported a substantial decline in their exercising and sports activities afterwards. The main reasons mentioned for this included fatigue, lack of time, and physical disabilities. It is noteworthy that 42% of these patients had suspended their physical activities because they had been told, wrongly, that they were contraindicated for cancer patients. This is a common misconception, even among general practitioners, and worth reporting because its negative influence can be avoided with proper counseling on how safely such patients can exercise.fear, sadness, sleeping difficulties, and uncertainty about the future. We know that the benefits of exercising and practicing sports go far beyond physical function endpoints alone, but there are still gaps in our understanding of how they benefit the emotional and social spheres, and resilience as well . For adolescents especially, the benefits of engaging in sports might include regaining a sense of having a lively, properly-functioning body, enhancing relationship with peers and a spirit of independence. These findings are in line with research demonstrating positive relationships between physical activity and cognitive outcomes . This may demand adapting certain exercises to patients with disabilities, or providing parallel psychological support in some circumstances. Asking patients to exercise may add to their frustrations if the demands placed on them exceed their expected capabilities, especially if levels of physical fitness are assumed to be similar to those a patient enjoyed before being diagnosed with cancer.On the other hand, our GYM group scored worse than the No-GYM group for the item We have to aknowledge here that including patients both on and off therapy, which is a strength of our work, might also be a confounding factor  because patients no longer receiving treatment might have had more opportunities to interact and compare themselves with their peers, and this might have added to any frustration they experienced with their performance.Our two groups differed in terms of cancer types: patients with brain tumors, who are known to suffer from neuromotor impairments , seemed general fatigue. Analyzing the single items in the questionnaire revealed better median scores in the GYM group for perceived quality of sleep and daily fatigue. The impact of exercise on the severity of fatigue may differ, depending on the type of activity involved [aerobic, neuromotor, or combined exercises might be more effective than resistance exercises in improving a patient's fitness in terms of containing fatigue  probably stems from the fact that patients motivated to exercise and try to overcome their limits also had a more critical awareness of these limits and a better tolerance of their sense of fatigue.In the recently-published paper on the randomized MUCKI trial , the authors found a positive effect of exercise on fatigue . We knowOur study has limitations that need to be acknowledged. Patients were assigned to one of the two groups being compared not randomly, but based on their interest in joining the exercise program. The patients' reasons for attending the gym may have been positively or negatively influenced by their ability (or fear of inability) to cope with the workouts. They might also have been influenced by their attitude to sports before becoming ill . Whatever their reasons, this may have affected their self-assessments and their opinion of the training program.Our patients also formed a very heterogeneous group, with some on and some off therapy at the time of the study, and with ages ranging from 5 to 21 years. They had different types of solid tumor, and received different treatments, sometimes involving surgery and radiotherapy as well as chemotherapy . This means that any differences between the GYM and No-GYM groups may not be attributable to our exercise intervention alone, but also to other factors .The non-randomization of the intervention generated differences in the distributions between study groups of participants' personal and disease characteristics, particularly as regards their type of cancer. Due to the small number of participants involved, we could not usefully apply statistical tools like adjusted models or inverse probability of treatment weighting analysis to try to overcome this limitation.A further limitation concerns the fact that no longitudinal data were available to enable any within-subject comparisons of the self-reported QoL outcomes for patients in the GYM group between before and after the 6-week exercise program.Our findings show the feasibility of promoting more systematic opportunities for young cancer patients to exercise, even while being actively treated, to improve their physical and psychosocial symptoms, their HRQoL, and especially their emotional functioning. Our results also suggest that many young patients with cancer, their parents, and their doctors still assume that a diagnosis of cancer makes it unsafe or unfeasible to exercise and practice sports, but this misconception can be overcome. Being aware that more systematic prospective trials are needed, we believe that our results could help shape the design of such future studies.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 Fondazione IRCCS Istituto Nazionale Tumori, Milano (ref. INT 109/18). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.FS, FB, MMa, MC, MT, GG, and LV performed the literature review, contributed to the conception and design of the study, and contributed to data interpretation. FS, FB, MMu, MC, MT, AF, CM, MMa, and LV analyzed and interpreted the study data. FS and FB drafted the article. FS, FB, MMa, MC, and MMu substantially revised the article. FB, MMu, MC, GG, and LV acquired the data. FS, MMu, MC, MT, GG, CM, and LV recruited the study participants. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.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.


Dental health workers (DHW) are at increased risk of acquiring occupational infections. Due to various protective measures, it can be assumed that infections have decreased over the past 14 years. Secondary data from a German accident insurance company was analyzed in terms of reported and confirmed occupational diseases (OD) in DHW from 2006 to 2019. A total of 271 claims were reported, of which 112 were confirmed as OD, representing an average of eight per year. However, the number of claims and confirmed ODs has decreased by 65.6% and 85.7%, respectively. The decrease was most evident for hepatitis B (HBV) and C (HCV) infections, while tuberculosis (TB) infections were stable. A total of 44 HCV, 33 HBV, 6 TB and 24 latent TB infections were confirmed as ODs. For DHW, 0.05, and for hospital workers, 0.48 claims per 1000 full-time equivalents (FTE) were registered in 2019. In a separate documentation system, between March 2020 and February 2021, 155 COVID-19 claims were registered, and 47 cases were confirmed as ODs. For DHW, 0.7, and for hospital workers, 47.3 COVID-19 claims per 1000 FTE were registered since 2020. Occupational infectious diseases rarely occur among DHW. Nevertheless, new infectious diseases such as COVID-19 pose a major challenge for DHW. Continued attention should be paid to infectious disease prevention. Dental health workers (DHW) carry an occupational risk of exposure to several pathogens due to the special features of dental treatment. Although occupational infections and their prevention have always been an issue for health workers, they are experiencing increasing attention during the current coronavirus disease 2019 (COVID-19) pandemic. In March 2020, The New York Times published data from the U.S. Department of Labor stating that dental hygienists had the highest occupational risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among all occupations analyzed, followed closely by dentists. This high risk is due to exposure to pathogens and physical proximity to patients on a daily basis , since aDentistry in Italy was largely affected by COVID-19 and service was reduced to emergencies . FortunaIn addition to the novel SARS-CoV-2, other pathogens such as influenza viruses  or M. tuIn addition to the abovementioned pathogens, another possible risk of infection is posed by blood-borne viruses. DHW routinely deal with syringe needles and sharp instruments like burs, scalers, scalpels and endodontic files, which makes the risk of injury particularly high ,14,15,16In Europe, the number of infections caused by percutaneous injuries among healthcare workers (HCW) each year is estimated to be 290 cases for HCV, 210 for HBV, and 6 for HIV . ClevelaProtecting DHW as a vulnerable professional group should be a priority from a public health perspective, both ethically and economically. The U.S. Needlestick Safety and Prevention Act, which was passed in 2000 and contained measures for the prevention of needlestick injuries (NSI), was decisive here (Public Law 106–430). Accordingly, employers are required to provide sharps with safety devices when available; additional requirements for a sharps injury protocol have also been added. The European Union followed this example in 2010 by implementing the Framework Agreement on prevention from sharps injuries . MeasureDue to these measures and decreasing infection rates in the general population in Europe, it can be assumed that the incidence of infection in the dental setting has decreased. For example, a decrease of legionella infection in DHW since 1996 was described in a literature review by Petti and Vitalli in 2017 . In GermThis analysis is based on the routine data set of the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW—Berufsgenossenschaft für Gesundheitswesen und Wohlfahrtspflege). The BGW is an accident insurance company for non-governmental healthcare facilities in Germany that insures about nine million employees, of whom 409,427 work in dental settings, including dentists, dental assistants, dental prophylaxis assistants, dental hygienists and dental technicians.If there is reasonable suspicion that an occupational infectious disease is present, this must be reported to the accident insurance institutions. A reasonable suspicion of OD, and thus an obligation to report, exists when exposure-prone procedures are performed and there is evidence of infection. Contact with infectious patients or materials is not reportable. The suspicion can be reported by physicians, health insurers, employers or the insured person. If an employer reports several infections in the course of an outbreak, a claim is documented for every worker concerned. For an infection to be confirmed as an OD, it must be proven that the insured person has an increased risk of infection. This is the case, for example, in surgical activities with blood contact. Furthermore, there must be a plausible connection between the exposure  and the disease itself. The accident insurer then initiates an examination procedure to determine whether an OD as defined by the Occupational Disease Ordinance and thus a claim for compensation exists.p-value < 0.5 was considered statistically significant. The reference year was 2006.In this study, reportable infectious ODs of DHW from 2006 to 2019 are taken into account and compared with those in hospital workers, general practice workers and specialist practice workers. The number of full-time equivalents (FTE) was used to calculate the claim rate per 1000 FTE. The FTE were obtained from BGW. The FTEs are an estimate of the number of workers covered by the compensation board. For example, two half-time workers add up to one FTE. In logistic regression, the odds for a claim by DHW were compared to the odds for hospital workers, general practice workers and specialist practice workers. Besides odds ratios (OR), 95%-confidence intervals were calculated. In addition, tests for trend were performed. A Two data sets were used for this analysis; the standardized documentation system for OD (OD-DOC), and a special documentation system for the assessment of reports related to COVID-19 (COVID-DOC). The OD-DOC data set contains the report date of the occupational disease, information about exposure, the decision, year of the decision and whether there is an entitlement to a pension due to reduced working ability (RWA). A pension is granted if the earning capacity is reduced by at least 20% for more than 26 weeks. As the examination of the claim takes time, the decision is not always made in the year in which the report is received. This results in a discrepancy between the number of decisions and reportable claims filed per year, which means that the average confirmation rate per year cannot be calculated accurately. Therefore, all claims and confirmed ODs for the investigated period were summed up and an average was calculated. Only infectious diseases transmissible from person to person were considered. Tropical infectious diseases or those transmitted by animals were excluded.The OD-DOC allows for a distinction between the following infections: hepatitis B, hepatitis C, tuberculosis (TB) and latent tuberculosis infection (LTBI).LTBI is present when there is a positive interferon-y release assay (IGRA) and active TB has been ruled out by X-ray. All other infectious diseases are grouped as “other infections.” The OD-DOC was analyzed for the time period from 2006 to 2019. Data from 2020 is not yet available in the OD-DOC.The BGW operates eleven different centers nationwide that assess and document OD claims by health and social workers. At the headquarters in Hamburg, a team is responsible for the quality control of assessment and handling of data. German data protection law allows for the analysis of anonymous data from social insurance institutions including the BGW, as long as the study benefits the social security system. No written consent is needed or can be obtained from the claimant once the data set is anonymized.In the OD-DOC system, a total of 271 reportable claims of suspected ODs due to an infection among DHW were registered between 2006 and 2019 . Most clp < 0.01). For DHW, the rate of infections per 1000 FTE decreased from 0.16 in 2006 to 0.05 in 2019 (test for trend: p < 0.001). Compared to hospital workers, the OR of infections per FTE was 0.1 (95%CI 0.06–0.19) for DHW , but the numbers are decreasing overall. Of the 51 claims, none were confirmed as ODs.In the COVID-DOC reporting system of the BGW, 203 suspected occupationally acquired COVID-19 cases were registered between March 2020 and February 2021.Of all claims, 155 (76.4%) were reportable . For allThe number of reportable claims for hospital workers was 28,044, or 47.3 claims per 1000 FTE. For DHW 0.7, claims per 1000 FTE were reported. The OD for DHW was 0.01 (95%CI 0.001–0.3) (no table).To our knowledge, this is the first study to analyze occupational infections in DHW using data from an accident insurance provider in Germany. Occupational infections are rare events in dental settings. In the OD-DOC, 112 ODs were confirmed between 2006 and 2019, representing an average of eight per year. Beginning in 2017, only two to three ODs were confirmed per year. Compared to other health workers, the risk of infection was lower and the positive time trend was even more pronounced. This shows that in relation to infectious diseases that have been confirmed and researched longer, infection prevention and hygiene standards are effective. Our data corroborates the surveys of Hübner et al., which describe improved hygiene management in dental medicine in Germany . NeverthFor the most important infections , the number of reportable infections in the general population decreased over the last 20 years in Germany. For TB, the number of cases per 100,000 population decreased from ten to five. The number of acute HBV infections decreased from more than 1000 cases in 2001 to 531 cases in 2019. The number of HCV infections decreased from 9022 cases in 2004 to 5940 cases in 2019. Therefore, due to the positive trend in the population, the decrease in the infection risk for DHW of up to 50% is likely explained. However, the claim rate per 1000 FTE was seen to have decreased from 0.16 to 0.05 (69%). This additional decrease might be explained by improved hygiene [HCV infections accounted for the largest share of ODs, at 38%. Since 2017, no HCV infections have been confirmed by the BGW as ODs in DHW. The risk of contracting HCV occupationally is therefore very low.Germany is a low-incidence country for hepatitis C infections, with an average prevalence of antibodies against HCV of 0.3%. However, the actual prevalence is likely to be higher, as risk groups such as HCW or drug users are usually not represented in such surveys . A meta-In addition to the burden that HCV infection places on affected individuals, there are high costs associated with therapy and compensation payments. For the treatment of chronic hepatitis C, the average cost in the U.S. healthcare system is $24,176, which increases with the progress of the disease . About tThere is no vaccination or post-exposure prophylaxis against HCV, so prevention in the health sector is aimed at reducing blood exposure. The U.S. Centers for Disease Control and Prevention estimate the seroconversion rate after needlestick injury with blood from an HCV-positive patient to be 1.8% , while aThe requirements of the European Union for prevention of NSI have been implemented in Germany within the framework of “Technical Rule 250—Biological Agents in Healthcare and Welfare Facilities”. This states that the use of pointed objects should be avoided wherever possible . If this is not possible, safety devices that pose a low risk of needlestick injuries should be used . Even thHepatitis B is the second most common OD among DHW and accounted for 29% of all ODs. Since 2014, however, the infection rate has been stable, at zero to two infections per year. This decrease can be explained by a low prevalence in the general population and by the HBV vaccination. In Germany, the prevalence for acute or chronic HBV infection is 0.3% (anti-HBc positive with detection of hepatitis B virus surface antigen). 5% of the population have experienced an infection (antibodies against the core antigen of the hepatitis B virus) . HoweverThe number of confirmed active TB infections among DHW is very low, varying from none to two cases per year. With a total of seven cases between 2006 and 2019, TB infection is the rarest OD among DHW. Germany is a low-incidence area for tuberculosis, with 5.8 new infections per 100,000 population in 2019. Two-thirds of cases were in foreign-born individuals. In the past 20 years, the incidence has dropped sharply and has almost halved compared to 2002, with a significant increase in 2015 and 2016 . In the LTBI is the third most common OD among DHW, with a total of 24 cases.A meta-analysis in low-incidence countries showed a pooled LTBI prevalence of 16.2% with a range from 0.9% to 85.5% for HCW in Europe . Hermes Our data shows that COVID-19 is currently the biggest health threat to DHW. Forty-seven cases of SARS-CoV-2 infection alone were confirmed as an OD by the BGW between March 2020 and February 2021. In comparison, in 2019, a total of only two ODs were confirmed, namely one HBV and one TB infection. Of the infected DHW with known disease status, 17.4% had a severe course of COVID-19. The prevalence of SARS-CoV-2 infection among DHW was estimated to be 0.8% to 2.5% in studies conducted in France , the UniThese results imply that infection control in dental offices and clinics is sufficient. The low number of infections at the beginning of the pandemic may also be due to suspension of elective treatments, as many practices only offered emergency care, while some ceased all dental treatment ,64. A suTo protect DHW from SARS-CoV-2 infection, the use of appropriate PPE is essential. In February 2020, the WHO recommended that DHW wear N95 or FFP2 respirators, gowns, gloves, eye protection and aprons when performing aerosol-generating procedures . HoweverSince December 2020, several vaccines against SARS-CoV-2 have been licensed in the European Union , providiAlthough COVID-19 has led to a significant increase in reported ODs, the disease is still likely to be underreported. In many cases, infection is asymptomatic or results in only mild symptoms, making it unlikely that those affected will be compensated by the BGW. This may result in infections not being reported at all.Secondary data were used for this analysis, with some limitations. Only reported cases are recorded, and limited social demographic data on insured DHW is available. For example, it is not possible to distinguish between DHW with and without immigrant backgrounds based on our data. Only DHW from non-governmental facilities are insured by BGW; employees from governmental facilities such as university hospitals with dental clinics are not included in the data.Our data are likely subject to underreporting, since they are dependent on infections being reported. DHW with subjectively mild infections often do not find it necessary to present to a physician and thus to report the infection to accident insurance. In addition, for mild infections, there is no monetary incentive to report the infection because it is unlikely that compensation will be paid. Thus, the number of infectious ODs is likely to be higher than the available figures suggest.A limitation of this study is that dentists are underrepresented among insured DHW at the BGW. While dental assistants, dental hygienists and dental technicians are subject to compulsory insurance with the BGW, dentists can choose their insurer. No data are available on the exact number of insured persons from the respective occupational groups. However, one advantage of secondary data is that trends can be observed over a long period of time. The data provide an overview of which occupational diseases are relevant to DHW. The inclusion of COVID-19 provides the study with additional topical relevance.Infectious ODs occur very rarely in DHW. Overall, the number of confirmed ODs decreased from 2006 to 2019, which is particularly evident in blood-borne infections. Regarding older infectious diseases such as HBV, HCV and TB, universal precautions seem to be effective and to protect against transmission. The decreased prevalence in the general population in Germany also contributes to the low infection rates. Although ODs are rare among DHW, continued attention should be paid to infectious disease prevention. The greatest challenge in the dental field lies in preventing emerging infectious diseases such as COVID-19.


The COVID-19 pandemic has forced changes in patient care in Mental Health Day Hospitals (MHDHs).To study the interventions performed in MHDHs during the pandemic in comparison with those performed in other facilities and to analyze the new hospital admissions in both groups.A retrospective multicenter cohort study comparing the interventions received by a group of 161 patients admitted in MHDHs during the lockdown period in Spain with the interventions of another group of 109 patients who were treated at other facilities during lockdown.MHDHs reduced their face-to-face interventions during lockdown just as much as other facilities but implemented telematic intervention methods to a greater extent. Patients attached to MHDHs during lockdown were admitted significantly less and presented fewer urgent consultations in the following 6 months.The use of telepsychiatry made it feasible to adapt MHDHs to periods of lockdown, being useful to improve the continuity of care during the pandemic. In addition, it was possible to maintain a reduction in hospital admissions in patients treated at MHDHs. On March 14, 2020, a state of alarm was declared in Spain , with peDuring this period, psychiatric facilities had to reorganize their care in a matter of days , promotiResearch into telepsychiatry has in general produced positive results in terms of acceptance and satisfaction levels among both patients and health professionals. The viability and efficiency of such treatment have been proven . EvidencHowever, telepsychiatry also raises a number of concerns, the risk of deterioration in the therapeutic relationship, teamwork, confidentiality, and privacy, for example . FurtherSeveral studies have demonstrated the efficacy of MHDHs in the clinical improvement and stability of patients admitted to such units , reportiThe aim of this study was therefore to test whether the implementation of telematic tools in MHDHs effectively reduces the number of visits to the emergency or hospital admissions in the context of the decline in face-to-face interventions brought about by the COVID-19 pandemic.A multicenter retrospective cohort study.The study was carried out with people over 18 years of age, of both sexes, who had been under follow-up in MHDHs at some time during the year 2020. Fifteen hospitals in Spain participated and data were collected from a total of 270 patients: 120 men and 150 women, all aged between 18 and 67 years (average age 39.90). The most common diagnoses were psychotic disorders (30.4%), personality disorders (27.8%), and bipolar disorder (10.4%). Most of the participants had primary (35.6%) or secondary (41.5%) levels of education, while 14.8% had studied at university level. They lived with their family of origin (28.9%), in their own family home (28.9%), or alone (17%). A total of 29.3% were retired, 26.3% were unemployed, 20% were temporarily unable to work due to disability, and 16.7% were working.Interventions in MHDHs during the lockdown period were received by 161 patients while 109 patients were treated in other facilities in that same period .The data were collected retrospectively during the months of October and November 2020 by the collaborators at each MHDH, from the patients’ clinical histories. To guarantee capacity, coherence, and correctness in the collection of data from the 15 centers, three online training sessions were held for the professionals involved. A password-protected database was designed and clinical data were processed without patient identification data.The sociodemographic variables studied were age, sex, composition of the household where the patient lived, employment status, and level of education.Having been treated in an MHDH during the period of lockdown following the outbreak of the COVID-19 pandemic in Spain (March 16–May 15) was used as an independent variable.Psychotherapy, occupational therapy, and nursing interventions received face-to-face, by telephone, by videoconference, or by other telematic means  were studied as dependent variables. This information was coded dichotomously according to whether or not the different forms of treatment were received during this period.To compare relapse rates, full hospital admissions at two, four, and 6 months after lockdown were collected (dichotomously: admission/non-admission), and the mean number of emergencies per patient at two, four, and 6 months was used as a secondary response variable.p < 0.05.The data were analyzed statistically using the IBM-SPSS V.21.0 program and the level of statistical significance used was The results of the categorical variables were expressed as percentages and those of the quantitative variables as mean and standard deviation.t-test was used to compare quantitative variables.Chi-square was used in the between-group analyses to analyze categorical variables and Student’s χ2 = 1.685; p = 0.194), age , household composition , educational level , adherence to treatment . There were significant differences in employment, with only 10.6% of the MHDH patients working compared to 25.7% of the group treated in other facilities . The most common diagnoses in both groups were schizophrenia and other psychotic disorders, followed by personality disorders .There were no differences between the two groups in sex (p = 0.243), occupational therapy (p = 0.744), or nursing (p = 0.679). Significant differences were, however, found in all online psychotherapy, occupational therapy, and nursing interventions in MHDHs. Telephone interventions differed significantly in psychotherapy , occupational therapy , and nursing . The numbers of videoconference interventions were higher in MHDHs in psychotherapy , occupational therapy , and nursing . The use of other telematic tools was also greater in MHDHs in psychotherapy , occupational therapy , and nursing .p < 0.001), at 4 months , and at 6 months . In terms of emergency consultations, patients who were at MHDHs during lockdown had on average 0.327 fewer emergencies at 2 months , 0.881 fewer emergencies at 4 months , and 1.067 fewer emergencies at 6 months  adapted to the needs and possibilities of each patient.In summary, these results support the feasibility of adapting the functioning of MHDHs to the constraints of lockdown periods by using telepsychiatry and of preserving these services in order to maintain their effectiveness. With this in mind, day hospitals should be provided with sufficient telematic resources to be able to address similar situations in the future.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 research ethics committees of the different participating hospitals. The principles of the Helsinki Declaration were complied with at all times. Data confidentiality was respected in accordance with the latest European Union (EU) legislation. The patients/participants provided their written informed consent to participate in this study.AS-G contributed to conception and design of the study. AT, VM-L, and AC-B organized the database. VL performed the statistical analysis and wrote sections of the manuscript. AS-G and IB wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The research was funded under the FPS 2020—R&I call for projects in primary care, county hospitals, and CHARES, under project code AP-0028-2020-C1-F2. Fundación Pública Andaluza para la Investigación Biosanitaria de Andalucía Oriental.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We examined associations between job strain and trajectories of change in cognitive functioning  before and after retirement.SD = 8.5).Data on indicators of job strain, retirement age, and cognitive factors were available from 307 members of the Swedish Adoption/Twin Study of Aging. Participants were followed up for up to 27 years , speed , and spatial ability  at retirement. Greater job strain was also associated with less improvement in general cognitive ability before retirement and a somewhat slower decline after retirement. The sex-stratified analyses showed that the smaller gains of general cognitive ability before retirement  were only observed in women. Domain-specific analyses revealed that greater job strain was associated with less improvement in spatial  and verbal  ability before retirement in women and a slower decline in memory after retirement in women  and men . Neither preretirement nor postretirement speed was affected significantly by job strain.In growth curve analyses controlling for age, sex, education, depressive symptoms, cardiovascular health, and twinness, greater job strain was associated with general cognitive ability , worse memory  may slow the rate of cognitive aging. Reducing the level of stress at work should be seen as a potential target for intervention to improve cognitive aging outcomes. Work environment plays an important role in health and aging, with research consistently attributing late-life aging outcomes at least partially to differences in the work environment. This is not surprising given the amount of time people generally spend working over the course of their lives. Work-related stress is one aspect of the work environment that has been receiving increased attention , with grWork-related stress is one type of chronic stress, which is thought to accelerate the aging process , likely The job strain model of stress  is one eThe job strain model has also been applied to the study of cognitive health. Low job control and greater job strain have been associated with both reduced cognitive function  and demeStress, including work-related stress, may be different for women and men, potentially leading to gender differences. For example, experiencing stressful life events in midlife was recently related to a greater memory decline in women than men . TherefoWhile there is some evidence for the association between work-related stress and subsequent level of cognition and risk of dementia, less is known about how specifically work-related stress may affect the trajectory of cognitive aging. Few studies investigated job strain in relation to cognitive change. A related area of research involves examining the association between retirement and subsequent cognitive performance. This research builds on the idea that work, regardless of job characteristics, offers sense of purpose, daily structure, social interaction, and mental activity that may help support cognitive function with age. Removal of these positive aspects of work at retirement may lead to worsened cognitive functioning above and beyond the effect of age alone . HoweverHowever, little is known about how the association between job strain and cognitive change may be influenced by retirement. So far, to the best of our knowledge, only We build on previous research by using data from the Swedish Adoption/Twin Study of Aging (SATSA) to examine job strain and cognitive change before and after retirement, using nine in-person testing (IPT) sessions across 27 years of follow-up. Ours is the first study to explore this question with a comprehensive assessment of cognitive function with multiple waves of in-person data collection across four domains  and general cognitive ability. Based on existing evidence, we hypothesized that individuals with greater job strain would show more negative cognitive aging outcomes, including poorer cognitive function at retirement and an accelerated age-related cognitive decline. Given that both cognitive outcomes and work characteristics often differ by gender , we alsot[849] = 15.2, p < .001) and more likely to be women  = 11.7, p < .001).Ascertainment procedures for SATSA have been described previously . In brieThe number of participants in each wave is given in n = 159), the power for the assessment of the cross-sectional association between job strain and cognition revealed a power estimate of 0.99 and for the longitudinal association between job strain and cognition revealed a power estimate of 1.00. For men (n = 148), the power for the assessment of the cross-sectional association between job strain and cognition revealed a power estimate of 0.98 and for the longitudinal association between job strain and cognition revealed a power estimate of 1.00.Post hoc power calculations were conducted in G*Power separately for women and men with job strain defined as a dichotomous variable. For women , and job demands from 1.25 to 9.29 with an average of 4.73 . The quotient of demand over control was used to measure job strain, which ranged from 0.23 to 1.71 with an average of 0.95 .In the 1984 SATSA-mailed questionnaire, the respondents were asked about their main lifetime occupation, “What kind of occupation did you have during the major part of your working life?” The answers were coded by Statistics Sweden according to categories from the 1980 Swedish Population and Housing Census, the same coding scheme as used in the previously validated psychosocial job exposure matrix . The matuthority . Weighten = 94] and 99.14% of women [n = 115]) of the participants had retired by the age of 65. Mean retirement age for the 307 participants was 63.39  with a range of 48–75 .Questions about retirement were included in SATSA questionnaires in 1987, 1990, 1993, and 2004. In addition, the same set of questions was included as part of questionnaires administered at IPT2 (1989–1991) and IPT3 (1992–1994). Included in the set of questions were items that asked respondents whether they were retired and if so, the year in which they retired. Combining this information with the birth year, we were able to calculate the retirement age for 222 individuals out of 307. Swedish retirement policy includes full-retirement benefits at age 67 without any earnings test. Between the years 1975 and 2000, the age for full benefits was 65 and was raised to 68 during 2020. The median retirement age in this sample was 64 , the most common retirement age was 65 , and 209 , 2 , 3 (high school), and 4 (university or higher). Depressive symptoms were measured at baseline assessment for each participant with the mental health subscale from the Older Americans Resources and Services Depression scale (CVD (yes/no) was measured at baseline based on self-reports regarding the presence or absence of angina pectoris, heart attack, claudication, high blood pressure, stroke, diabetes, or any other cardiovascular dysfunction  occurring at least once during the study period.All covariates are known to be related to job strain and cognition. on scale  which inz-scores, all covariates were mean centered, cognitive outcomes were expressed as T-scores (M = 50 ± 10), and time was measured in decades. The random and fixed effects parameter estimates were obtained using PROC Mixed in SAS 9.4.A growth curve model was used to examine the impact of work-related stress on cognitive aging. The structural model can be considered as a multilevel random coefficients model. The model provides an estimation of fixed effects, that is, fixed population parameters as estimated by the average growth model of the entire sample, and random effects, that is, interindividual variability in intra-individual change in growth model parameters. Growth curve models consider missing data by giving more weight to individuals with the most time points. We used a two-slope growth curve model: centering age was set at each individual’s retirement age with one linear slope before retirement age and a separate linear slope after retirement age. As a result, retirement age serves as the pivot point between the two estimated slopes. For ease of interpreting the results, job strain indicators were converted into ps > .05) and the quadratic effect of time was not statistically significant (ps > .05) for any of the models. Using the model estimating the association between job strain and general cognitive ability as an example, the difference in model fit corresponded to χ 2 = 20.7, p = .190. The quadratic slope was not significant before (p = .839) or after (p = .186) retirement. Therefore, the final models estimated linear change in cognitive outcomes before/after retirement.Both linear and quadratic change in cognitive performance before and after retirement was examined. We compared model fit by using the −2 log-likelihood fit statistic. The results were the same when using the Akaike’s information criteria (AIC) or Bayesian information criteria (BIC) fit statistics. Adding quadratic terms for time to the models did not significantly improve model fit , an average of 15.4 years (SD = 8.5 years), and up to 27 years. Descriptive characteristics of the sample and covariates are presented in Participants were followed up for an average of 5.7 waves . For comparison, the estimate for baseline age was −0.40 , as well as slower decline after retirement , although this last result did not reach statistical significance after Bonferroni correction for multiple comparisons. For comparison, in fully adjusted models, age alone was associated with improvement by 0.11 points per decade before retirement and a decline of 0.06 points per decade after retirement.Results from fully adjusted models that include job strain  as the main predictor of general cognitive ability before, at, and after retirement are given in SE = 0.39, p = .005; SE = 0.25, p = .008).In the sex-stratified analyses, we observed that the association between greater job strain and smaller gains in general cognitive ability before retirement was only observed in women , speed , and spatial ability  at retirement. The last two results did not reach statistical significance after the Bonferroni correction. A similar pattern was observed between greater job strain at retirement and poorer scores on verbal ability, although this result did not reach statistical significance . The same patterns were also observed in the sex-stratified analyses; however, the association between greater job strain and poorer speed at retirement was stronger for men than women.Results for the fully adjusted associations between job strain indicators and cognitive aging before, at, and after retirement are given in SE = 0.52, p = .010) and verbal ability  preretirement among women but not among men. Note that both results are at or above the Bonferroni corrected p value of .01. Supplementary analyses indicated that the association between job strain and preretirement verbal and spatial ability was mainly driven by job control scores , a pattern that was also found among women  and men , although the result for men was not significant after Bonferroni correction. Supplementary analyses indicated that the association between job strain and postretirement memory was foremost driven by job control  and general cognitive ability with up to 27 years of follow-up. The unique features of the SATSA data include data collection well before age 65 and a long follow-up using IPT, which allowed us to use a two-slope growth model centered around the age at retirement that provides a simultaneous assessment of change in cognitive ability as a function of job strain pre- and postretirement. Overall, we found that, after adjusting for study covariates, greater job strain was associated with less improvement in general cognitive ability prior to retirement, worse memory, speed, spatial ability, and general cognitive ability at retirement age, and a slower decline in memory and general cognitive ability in the years following retirement (more so for men). The smaller gains in general cognitive ability prior to retirement were more pronounced for spatial and verbal ability in women.SD performed at an overall cognitive level indicative of someone with the same personal characteristics (but lower job strain) who was about 3 years older (job strain estimate = −1.33 vs. age-at-retirement estimate = −0.40). In the same fully adjusted models, the longitudinal results indicated that being 1 year older was a related improvement in the general cognitive score by 0.11 points/decade preretirement and a decline by 0.06 points/decade postretirement. In comparison, job strain higher by 1 SD was related to cognitive scores improving by 0.79 points/decade less preretirement but also worsening at a slower rate by 0.37 points/decade postretirement. These results underscore the role of job strain in cognitive aging.These findings highlight the importance of work-related stress in cognitive aging. Specifically, individuals retiring from jobs with high levels of stress, those having jobs with less control over work tasks and decision-making authority in combination with greater task pressure  and Swedish Council for Working Life and Social Research . SATSA is supported by the National Institute of Aging ; the MacArthur Foundation Research Network on Successful Aging; Swedish Research Council ; and the Swedish Council for Working Life and Social Research .None declared.Data, analytic methods, and materials will be made available to other researchers if requested. The study has not been preregistered.gbab033_suppl_Supplementary_Table_1Click here for additional data file.gbab033_suppl_Supplementary_Table_2Click here for additional data file.


The results show that complex influence of classical massage therapy on human organism may be reflected in parameters of the oxidative stress. To understand this mechanism clearly, further research is needed.Classical massage is one of the most popular forms of conservative treatment in various diseases. Despite the wide scope of research, the mechanisms of massage are not fully known and understood. Apart from the well-described effects on individual body systems, there are few scientific reports on the effects of massage on the human body at the subcellular level. The study was designed to assess changes in oxidative stress parameters in healthy volunteers after a single session of classical massage. 29 healthy volunteers aged 22.24 ± 3.64 participated in the study. Before and 30 minutes after the massage procedures, blood samples were taken by experienced personnel. Biochemical markers of oxidative homeostasis were assessed with highly specific methods for each parameter: oxidase ceruloplasmin, glutathione, malondialdehyde, glutathione peroxidase, glutathione S-transferase, and superoxide dismutase. The study demonstrates that massage therapy caused statistically significant decrease in the concentration of glutathione peroxidase (red blood cells) and increase in the level of glutathione peroxidase (plasma), superoxide dismutase, and malondialdehyde. In contrast, statistically significant changes in the hematocrit, glutathione, NO The results were expressed in mmol/LRBC. The coefficient of variation for this method was 2.4%.The concentration of reduced glutathione (GSH) was assayed using the Beutler method . The priThe activity of glutathione peroxidase (GPx) in erythrocytes was assayed by a two-stage Paglia and Valentine method . In the −1 × l × cm−1], was used. The results were expressed in U/g Hb, where 1 μmol oxidation of NADPH in one minute at T = 25°C was adopted as a unit of enzyme activity. The coefficient of variation for this method was 2.9%.cGPx activity was calculated based on the loss of the reduced form of coenzyme in time (test Wartburg). In the calculations, millimolar absorption coefficient for NADPH at 340 nm, equal to 6.22  was used. The result was expressed in mmol/g Hb. The coefficient of variation for this method was 3.5%.The concentration of malondialdehyde (MDA) in the erythrocytes was determined by the Placer et al. method, which is based on the reaction of thiobarbituric acid and certain products of lipid peroxidation, mainly MDA, in an acidic environment and at elevated temperature . This reμml/L.The concentration of nitric oxide was determined using the indirect method according to Marlett, determining the concentration of nitrate/nitrite in plasma. The method is based on the reaction between the nitrate anion and anion from N-(1-naphthyl)ethylenediamine, in the sulfanilic acid environment (Griess reaction) . This reCeruloplasmin oxidase activity was determined using the method of Ravin . The priTo evaluate the significance of changes after intervention, paired Student's t-test was performed. The Shapiro–Wilk test was performed to evaluate the normality of the variables. The results were shown as mean and standard deviation (SD). Additionally, ±95% confidence intervals (CIs) were calculated for the changes after intervention. The effect size of the observed changes was estimated using Cohen's d statistics, were values below 0.1, 0.3, 0.5, 0.7, and 0.9 indicate trivial, small, moderate, large, and very large effect, respectively . Statist2-/NO3-, and CP. Contrary, it was shown that after massage, there was a significant decrease about 8% and 13% in the level/concentration of GPxRBC and MDA, respectively as shown in As a result of the therapy, no changes in the levels/concentration of the measured parameters of the oxidative stress were observed in HT, GSH, NORBC, GPxp, SOD-1, and MDA.The internal balance of the organism is perceived systemically, but also at the cellular and subcellular level. Lifestyle, leisure activities, improper diet, and application of stimulants may provoke generation of various oxygen forms in the organism. On the other hand, every prohealth initiative such as physical activity, optimal diet, and physiotherapy (including massage) may decrease the risk of free radical-related diseases. Systemic and local antioxidant systems depend also on age—they are less efficient in children and adolescents than in middle-aged people, which indicates also age-related immaturity of antioxidant mechanisms . Our resIntegrated and effective human defense system is needed to control the production of free radicals as well as counteract their biological consequences. Extensive production of ROS may be limited/balanced. Aforementioned defense system should consist of both enzymatic and nonenzymatic mechanisms that dispose ROS.Physiotherapy may play a significant role in this process . CurrentStudy by Amano et al. showed that overall health care program, including body massage (cupping and vibration), may significantly improve health status (including oxidative stress) of the preobese or mildly obese middle-aged women. It is difficult to point to the key factor that had impact on health of the examined women. The influence of massage alone was not investigated in the aforementioned findings, yet it may play an important role in comprehensive approach .Presented outcome may support evidence that classical massage may prove helpful in neutralizing radical superoxide by enzymatic defense system , which iThe mechanism of the observed reaction may be due to the microdamage of the muscles after the massage. Activation of monocytes, increasing the expression of inflammatory cytokines leads to the activation of endothelial leukocyte adhesion molecules P-selectin and E-selectin. Neutrophils intensify the breakdown of tissue, leading to the release of free radicals in the environment and, consequently, a change in the studied parameters .Main limitations of our study included a relatively small group of volunteers and no placebo group; thus, we regard our study as preliminary. Only immediate results of the massage therapy on selected biochemical parameters of the oxidative stress were assessed during the study. Long-term results will be assessed during further studies. Moreover, we assessed only the influence of the single session of the therapeutic massage. Cumulative effect of the subsequent massage therapy sessions may be stronger or longer-lasting.Further studies require randomized controlled trials on bigger number of volunteers, as well as taking into consideration such factors as sex, age, previous lifestyle, diet, and body mass index. Such detailed approach would allow assessment of possible prognostic signs and provide scenarios for prohealth prevention in various groups of patients.Other parameters of oxidative stress may be used in treating disease-related complications as well as in the interdisciplinary treatment. Intensity of the massage , its duration, and used techniques may also influence development of the oxidative stress and its long-term consequences. The ultimate goal is optimization of classical massage in prevention and treatment of oxidative stress in both healthy and ill people, including elderly patients –43.


Results: Seventy-two subjects (58.3% girls) with a mean (standard deviation (SD)) age of 10.2 (3.4) years were included. Baseline diets were imbalanced in macronutrient composition. Significant improvements were observed in their compliance with dietary reference values (DRVs), where 50% of the subjects met fat requirements after the education and 67% and 49% with those of carbohydrates and fiber, respectively (p < 0.001). Celiac children decreased red meat and ultra-processed foods consumption (p < 0.001) and increased fruits and vegetables intake (p < 0.001), leading to a reduction in saturated fat (p < 0.001) and sugar intake (p < 0.001). Furthermore, 92% of the patients achieved a normal bowel habit, including absence of hard stools in 80% of children constipated at baseline (p < 0.001). Conclusions: RD-led nutrition education is able to improve eating patterns in children with celiac disease (CD).Background: Elimination of gluten-containing cereals and consumption of ultra-processed gluten-free foods might cause an unbalanced diet, deficient in fiber and rich in sugar and fat, circumstances that may predispose celiac children to chronic constipation. Aim: to evaluate if counseling with a registered dietitian (RD) was capable of improving eating and bowel habits in a celiac pediatric population. Methods: Dietetic, lipid profile and stool modifications were analyzed, comparing baseline assessments with those twelve months after receiving heathy eating and nutrition education sessions. At both time points, 3-day food records, a bowel habit record and a lipid panel were conducted. Calculated relative intake of macro- and micro-nutrients were compared with current recommendations by the European Food Safety Authority (EFSA). Student’s paired  Celiac disease (CD) is an autoimmune enteropathy based on genetic susceptibility and triggered by the exposure of gluten . TreatmeThe exclusion of gluten-containing cereals, together with the consumption of poor nutritional quality, ultra-processed gluten-free foods, might contribute the GFD to induce a negative impact on health ,7,8,9,10Besides, low fiber is related to lower quality of health in CD patients , the conThe objective of our study was to analyze the modifications in the diet and in the bowel habits of pediatric patients with CD after the implementation of a dietetic education program managed by an experienced registered dietitian (RD), focusing on achieving a healthy GFD that provides adequate amounts of nutrients. It should be rich in fruits and vegetables, whole grains, fish, legumes and nuts, but low in refined grains and simple sugars. We hypothesized that this intervention would help celiac pediatric patients to improve their dietary patterns to meet the requirement for protein, carbohydrate, fat, vitamins and minerals for healthy children and to prevent disease further in life as through diet. The study was conducted in the Pediatric Gastroenterology and Nutrition Unit of a tertiary hospital, from February 2018 to November 2019.The inclusion criteria were as follows: children aged from 1 to 18 years with CD diagnosed according to the ESPGHAN 2012 criteria , followeThe exclusion criteria were: subjects diagnosed with gluten allergy, individuals who refused to sign the informed consent form or who abandoned the clinical follow-up and any who had received previous dietetic education from the RD at the clinic.Blood lipid profile and stool information were collected together with a dietetic evaluation. The measurements of total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides were obtained from medical records.The bowel habit was obtained by asking the subjects their stool consistency according to the Bristol stool scale , which wDietary evaluation was undertaken using a 3-day food record, which included all the meals consumed by the individual over a 3-day period, including one weekend day. Their caregivers weighed foods using a scale with a precision of 1 g and also used estimated household supported with a list of typical portion sizes of common food items. The survey was analyzed using a Spanish dietary analysis website (ODIMET)  and the Children with CD and their caregivers received oral and written food and nutrition education. They were taught about healthy gluten-free eating and a healthy lifestyle through individualized nutrition advised based on the Healthy Eating Plate recommendations, adapted according to celiac needs, by the Harvard School of Public Health . WrittenSix months after the intervention, the subjects returned to the pediatric nutrition unit where the RD again collected the stool data. Further education was given to motivate and reinforce behaviors and to support previously established dietary modifications. They were also provided with a further 3-day food record for complementation by the next visit.Twelve months after receiving nutrition counseling, the third and last visit with the RD took place. The participants submitted the second completed 3-day food record and underwent the same complete nutritional assessment performed at baseline.p-value < 0.05 was considered statistically significant. The linear relationship between quantitative variables was evaluated with Pearson or Spearman correlation tests, depending on whether the normality hypothesis was verified or not. Correlation coefficients were considered strong (above 0.7) moderate (0.4–0.6) or weak (0.2–0.4) [Statistical analysis was performed using R program, version 3.6.0  . A descr0.2–0.4) .Seventy-two individuals  met the inclusion criteria. The mean (standard deviation (SD)) age of the participants was 10.2 (3.4) years and they were on a GFD for 2.5 (1.8) years. The nutritional state of the participants and changes in body composition from baseline to the end of the study has already been published elsewhere .p < 0.001), 45.7% for carbohydrates (p < 0.001) and in 58.1% (p < 0.001) for fiber (p < 0.001) and sugar intake (mean (SD) –10.17 (26.74) g/day, p < 0.001).According to European DRVs, baseline diets were imbalanced in macronutrient composition for fat, carbohydrates, proteins and fiber. All participants followed a high-protein diet both before and after the nutrition education, but a significant decrease was observed . After tor fiber . Signifip = 0.014) and 43.1% for iron, at the end of the study. Compliance with zinc and iodine recommendations by 54.2% and 1.4% respectively, remained constant. In contrast, the percentage of compliance with magnesium and copper recommendations increased by 66.7% and 63.6%, respectively. Compliance with sodium recommendations was decreased . An increase was observed for the rest of the vitamins, including vitamin A, B2, folates, vitamin C and D  at six months and a 53.3% increase , LDL (p = 0.990) or HDL (p = 0.810).Consumption of biscuits, saturated fat and total sugars was weakly positively associated with total blood cholesterol levels. Intake of processed meats, sugary soluble cocoa and saturated fat were weakly related to an increase in LDL cholesterol. A weakly negative association was observed between consumption of sugary breakfast cereals and skimmed yogurt and HDL cholesterol levels. Consumption of sugary breakfast cereals was weakly positively associated to triglyceride levels . No corrA GFD is currently the only available therapy for CD. This restriction implies the substitution of cereals with gluten and its derivatives by other foods with similar nutritional characteristics. If celiac children choose ultra-processed substitutes instead of traditional homemade meals, it could induce a negative impact on health . Ultra-pFurthermore, prior literature has shown that the diet of CD children is nutritionally less balanced than the diet of healthy children, richer in fat and poorer in fiber intake ,49,50,51These unbalanced eating patterns were also observed in our study. Baseline diets were high in fat and protein and low in starches and fiber. The present study showed that dietetic intervention based on the Healthy Eating Plate  resultedKnowing that constipation is associated with a low fiber intake , it was GFD can also be deficient in micronutrients. In particular, it is characterized by low levels of vitamin B, folic acid, vitamin D, calcium, iron, zinc and magnesium ,19,58. ZCoinciding with these findings, when comparing the European recommendations with the diets of our patients, we also observed that it was deficient in magnesium in most cases, in iron in 47% and in calcium in 60%. This last observation is striking, although it coincides with the widely reported calcium deficiencies ,21,22,23Öhlund et al.  found thFinally, we observed that the results obtained regarding sodium in the diet, which was not sufficient, was due to the fact that the salt added to the dishes was not included in the dietary analysis. This coincides with the low levels of iodine found, since in the western population, the main source of iodine is iodized salt .Regarding vitamins, deficiencies in GFD were also observed, with vitamin B12, folate and vitamin D being the most affected. Hallert et al.  observedContrary to the results reported in the current evidence, the recommendations for vitamin B12, folates and vitamin C were covered by most of our patients. However, almost none of them met their vitamin D requirements despite having been on GFD for some time. While most of the children covered the recommendations for group B vitamins  and vitamin A, in the case of vitamin E, these recommendations were reached by only a few.The achievement of this change in dietary habits coincides with the significant increase in complex carbohydrates, fiber, vitamin C and folic acid. The requirements of vitamins D and E continue not to be covered by the majority of the study population. A decrease in vitamin E compliance is observed by avoiding the use of culinary technologies that require a greater amount of oil for their preparation, such as fried and battered ones. The dietary intake of vitamin D increased slightly, but it remained insufficient, so it is necessary to insist on continuing to increase the consumption of oily fish.With regard to minerals, increasing the consumption of plant-based foods also increased the amounts of magnesium, copper and dietary selenium. However, ingested calcium decreased by 125 mg on a daily basis, increasing by 32.6% the percentage of coeliac patients who did not meet the European recommendations for this mineral. The cause of this decrease in our population lies in the reduction in the consumption of sugary breakfast cereals enriched with micronutrients.Probably, in order to meet the calcium requirements, it would be necessary to guarantee the intake of 3 servings of dairy products daily, and in turn, have an extra contribution from other sources rich in this mineral, such as fish in which the thorn can be eaten, shellfish, soybeans, chickpeas, almonds, etc.Finally, it should be noted that a slight decrease of 18.4% was observed in the percentage of patients meeting iron requirements. The possible causes of this non-significant change, together with the fact that half of the patients did not met the requirements of this mineral both at the beginning and at the end of the study, can be several. First, it should be noted that, even tripling the recommended meat consumption, half of the celiac children in the study did not meet iron recommendations. In addition, there are other dietary sources richer in this mineral that are less consumed in the general child population, such as shellfish, especially molluscs and prawns. Lastly, the decrease in the consumption of iron-fortified sugary breakfast cereals is also responsible for this slight decrease.With these observations, we believe that, instead of recommending increasing the consumption of meat, we should insist on increasing the consumption of fish, shellfish, eggs and nuts to meet the iron recommendations. Taking into account the high sugar content that these products usually have, their consumption should not be recommended to achieve a greater iron and calcium intake.Studying the relationship of dietary intake by CD patients with their lipid profile, we found some outstanding findings. Significant relationships were found between the consumption of biscuits, the intake of saturated fats and sugars, by children with CD, with the increase in their total blood cholesterol. With processed meats, rich in saturated fat, a relationship was found between their intake with the elevation of LDL cholesterol. Elevated triglycerides were associated with higher consumption of sugary breakfast cereals. However, though the correlations were significant, the correlation coefficients were weak.It should also be noted that, coinciding with the evidence , we founThe present study, together with the review of the literature, highlights the importance of referring all diagnosed CD patients to an RD , who focAppropriate food and dietetic education for children with CD and their caregivers should focus on a healthy GFD by opting for natural, unprocessed gluten-free cereals , which pHowever, consumption of processed and ultra-processed foods has increased in the last decades in both developed and developing countries. This disproportionate consumption is adversely impacting general health. A European study found that dietary energy from ultra-processed foods ranked from 10.2% to 50.7%, and its consumption positively correlated with the prevalence of obesity . MoreoveThe negative effects of ultra-processed foodstuffs on children can be even more dangerous, influenced by aggressive marketing. These products, in addition to the high total, saturated and/or trans-fat, free sugars and sodium , have adEffective nutritional strategies to improve eating habits in children should be a priority to reduce the high prevalence of chronic NCDs in adulthood. Numerous scientific research studies in nutrition end with these recommendations, concluding that prevention education is necessary to improve the current situation of obesity and erratic eating habits, and specifically with CD .However, no studies have been found that evaluate this part fundamental of nutritional treatment in the disease. This is the first RD-initiated study evaluating the efficacy of dietetic education among celiac Spanish children. There are no other comparable studies by which its efficacy can be assessed. All subjects were seen by the same RD, with uniform dietetic advice in all cases. We emphasize the importance of continuous nutritional education as a fundamental part of dietary treatment in these patients.A major limitation of the present study is that there was no control group. For this reason, it is not possible to know if values at the beginning of the study represent a characteristic of celiac patients or reflect the habits of the general population. Also, participation bias is a possibility because parenteral motivation, socio-economic status, accessibility to fresh produce/gluten-free products, cooking ability, literacy level and number of family members with CD in the household may have impacted on the willingness to take part.Our study demonstrated that RD-led nutrition education is able to improve eating patterns in CD pediatric patients. Food and dietetic education aiming to promote a healthy lifestyle should be part of the dietary treatment in order to meet macro- and micro-nutrients requirements. It is also important for improving the quality of diet during childhood, and therefore their future health, in addition to preventing other pathologies associated with a poor diet.


This study aimed to identify the 15-year trends of handgrip strength-to-weight (relative HS) and assess the association between relative HS and hypertension among Chinese adults aged 20–69.Using a complex, stratified, multistage probability cluster sampling, we analyzed data collected from 712,442 adults aged 20–69 years in four successive national surveys (2000–2014). We used a handheld dynamometer to measure strength and divided by body weight to calculate the relative HS. Blood pressure was recorded with a sphygmomanometer and hypertension was defined as resting systolic blood pressure at least 140 mmHg or diastolic at least 90 mmHg. The Mann-Kendall trend test examined trends in relative HS over time. We also computed odd ratios (OR) and 95% confidence intervals (95% CI) by tertile of relative HS and examined the association between relative HS and hypertension.ptrend <0.001). In each of four surveys, one interquartile decrease in relative HS was associated with an increased risk of hypertension by 44% , 58% , 48% , 43% , respectively.The relative HS level decreased with the increase of age in both male and females (In the Chinese adult population, the relative HS level decreased from 2000 to 2014 across all ages in both males and females. A lower relative HS was associated with a higher risk of hypertension. The findings provided evidence for the association between muscle strength and hypertension in large-scaled population. Hypertension is a common health problem worldwide . The ChiRegular exercise is an essential component of a lifestyle intervention for the primary prevention of hypertension . AbsolutThe evidence regarding the association between absolute HS and hypertension is inconclusive. A meta-analysis summarized that an increase of absolute HS exercise was associated with a lower risk of hypertension in adults, but these findings had limitations given the small number of low-quality randomized controlled trials . Two croThe above studies had one common feature: they used absolute HS, rather than relative HS (handgrip strength to body weight or BMI ratio), which might be more comparable among people with different body mass , 14. WheIn the present study, we analyzed the Chinese National Survey on Adults’ Fitness in 2000, 2005, 2010, and 2014. The study aimed to identify the 15-year trends of relative HS in different age and sex groups from 2000 to 2014 and assess the association between relative HS and hypertension among Chinese adults aged 20–69.We used the data from 2000, 2005, 2010, and 2014 Chinese National Survey on Adults’ Fitness, the largest nationally representative survey of civilians in China, using a complex, stratified, multistage probability cluster sampling design. The detail of the recruitment has been described elsewhere .In brief, the 31 provinces, autonomous regions, and municipalities in mainland China were covered in the first stage. At the second stage, subject to their economic positions weighted by GDP assessment, three sub-provincial or prefectural-level cities  were randomly selected from each province. At the third stage, three urban districts  of each city were picked out. At the fourth stage, three city streets  were chosen. At the fifth stage, two street community societies (or villages) were selected. At the final stage, at each street community society (or village), eligible participants living there for more than three years were selected by systematic sampling method.The study protocol had approval from the ethical review committee of the China Institute of Sport Science. Each enrolled participant signed an informed consent form.Through the questionnaire survey and standard physical and physiological measurement, the trained investigators collected the data. We investigated career, education, urban and rural place, nationality (Han or minority) with the questionnaire. For exercise time, the participants were asked to recall the number of days and the exercise duration in the usual past week during the last year. The questionnaire was validated among Chinese adults  .Participants’ weight and height were measured using a calibrated digital scale, stadiometer , Before the measurement, participants with lightweight clothes took off their shoes. The measured weight was rounded up to 0.1kg and height was rounded up to 0.1cm, respectively. The blood pressure measurement was conducted by the auscultatory method by qualified medical staff. The Riva-Rocci sphygmomanometer, and a medical stethoscope  were used for the measurement. The systolic pressure was defined as the first sound heard after releasing the occluded artery. The diastolic pressure corresponded to the final sound heard . SystoliThe subjects were asked not to engage in vigorous physical activity within 1–2 hours before the test.The subjects were asked to sit on the chair in silence for 10–15 minutes before the test, and relax.The mercury column of the sphygmomanometer was checked before measurement. If the column was not at the “0” position, the position was corrected. Furthermore, the mercury column was inspected for the presence of bubbles, and if there were bubbles, it was not used.When measuring blood pressure, it was ensured that the upper arm was not pressed tightly by the sleeve of the jacket. It was ensured that the lower edge of the cuff was located at least 2.5 cm above the cubital fossa.When re-testing was needed (the first test was failed by some reasons), it was ensured that the mercury column of the sphygmomanometer dropped to zero before re-testing. Blood pressure re-testing was carried out 10–15 minutes rest on chair after the initial test. Hypertension was defined as resting systolic blood pressure at least 140 mmHg or diastolic at least 90 mmHg according to the common standard .The following measures were taken before and during the data collection:We used the handgrip meter  to measure the dominant hand handgrip strength. Before the measurement, the subjects held the grip handles with dominant hand and adjusted the grip width to the appropriate force grip. During the measurement, the participants’ body was upright, feet were naturally separated at shoulder width, while arms were inclined and drooping. After three consecutive tests, with adequate rest interval in between, we recorded each participant’s best score as the final result. The grip strength test value is in kg, rounded up to 0.1kg.We used the Skinfold Thickness Meter  to measure the skinfold thickness from three different body sites . We measured three times for each body position and took the median value or two of the same value as the final result. We added three different skinfold thickness measurements to reflect the body fat (skinfold thickness).We described the median  of relative HS (HS to body weight ratio) in different survey years since relative HS was not normally distributed. In the study, the bootstrap percentile method (the number of bootstrap replicates is 500 times) was used to calculate confidence intervals for medians , 19. We To explore the relationship between relative HS and hypertension, we used the tertiles to separate the subjects into three groups  according to the different sex, survey year, and age group, then calculated the prevalences of hypertension in different relative HS groups. The Mann-Kendall trend test was used to examine the trend of hypertension prevalences in different years among different tertiles of relative HS.We used the general linear mixed model to estimate the effect value and odd ratios. Relative HS was analyzed both as a continuous variable and a categorical variable . We presented the results of two statistical models, in which the province of each participant was used as the random effect. We only put exposure and outcome varibales in the crude model. In model 1, we adjusted with age and sex as covariates; In model 2, we further adjusted for the region , the inner-province socio-economic status , the nationality , the education level , career, and exercise level  as covariates.2 for underweight group, between 18.5 kg/m2 and 23.9 kg/m2 for normal group, above 24.0 kg/m2 for overweight and obesity group) [In the sensitivity analyses , 22, we p-value <0.05 was considered as statistical significance.All the statistical analyses were performed with R software, version 3.6.1. A two-sided We included 712,442 participants , while 8,838 participants were excluded for missing main outcome and exposures. The general characteristics and HS levels of the study population in each of the four national surveys were shown in p trend <0.001, p <0.001). It also decreased in urban and rural areas from 2000 to 2014 . In addition, the prevalence of hypertension increased with increasing age groups (p trend <0.001) and was higher in men than in women in different survey years  and this is a strength of our study. Finally, relative HS significantly decreased during the past 15 years in both men and women in China. A similar trend was seen in different age groups, in both urban and rural areas.The finding of a 43–58% reduction of risk in hypertension with one interquartile decrease in relative HS is of public health significance. High blood pressure is the leading modifiable risk factor for cardiovascular disease and premature death worldwide . In our The decline of HS, which may reflect the change in whole body strength , has beeOur findings suggested that relative HS is inversely associated with the risk of hypertension. Furthermore, in the sensitive analysis, stratified BMI groups’ analysis showed that the body mass index did not affect the negative association between relative HS and hypertension, which was in agreement with a rescent study . One posWe found that relative HS has been decreasing among Chinese male and female adults in both urban and rural areas since 2000. The results extended findings from the previous study, which reported the decreasing trend in absolute HS in these successive national surveys . In receThis is the first national study to display the difference of relative HS between male and female in China, and its result, higher relative HS in male adult was consistent with the studies of relative HS in other populations , 46. MorThis study had notable strengths, identifying epidemiological characteristics of relative HS with a sizeable nationally-representative sample size in China and repeated measures during the past 15 years. However, the study had several limitations that should be noted. First, the cross-sectional nature of the national representative data precluded causal inference. Longitudinal studies should be conducted to demonstrate the relationship between relative HS and hypertension using a stronger experimental design. Second, we did not collect hypertension-related risk factors such as energy intake, sodium and potassium intake. It was infeasible to collect comprehensive diet information in large-scale national surveys. However, the consistent association results was found in different survey years and stratified analyses by gender, urban / rural, normal-weight /overweight or obese, indicating the potential bias due to unadjusted factors might be minor. Third, we used body weight and BMI to calculate relative HS and hence we were unable to distinguish between lean and fat mass. Although the sensitive analysis with adjusting for skinfold thickness has confirmed the main results, future studies should include precise measurements such as dual-energy X-ray absorptiometry to study the association between relative HS  and hypertension.The relative HS level decreased during the last 15 years in urban and rural areas across different sex- and age-groups of the Chinese adult population. Lower relative HS was associated with a higher risk of hypertension. Considering the relative strength reflected the overall strength level, the findings provided evidence for the association between muscle strength and hypertension in large-scaled population.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(DOCX)Click here for additional data file.S10 Table(DOCX)Click here for additional data file.S11 Table(DOCX)Click here for additional data file.