This cross-sectional study aimed to analyze the association between burnout, work-related factors and metabolic syndrome (MetS) among various health-care workers (HCWs) at a tertiary hospital in Taiwan.Relevant demographic data were obtained through written questionnaires. Information about psychosocial and work conditions, including assigned department, working hours, shifts, and sleep condition, was obtained. Burnout was evaluated according to the Chinese version of Maslach Burnout Inventory–Health Services Survey. MetS was analyzed according to the criteria of the National Cholesterol Education Program of Taiwan–Treatment Panel for Adults III.p = 0.01). Other factors, such as night shift and seniority (>10 years), led to a higher OR of MetS, but a decreased risk was observed based on seniority (2–4 years). Further, young female participants and young doctors/nurses with burnout had a higher OR of MetS compare to other groups .A total of 1,055 non-doctor/nurse and 2,078 doctor/nurse staff with a median age of 45.2 and 36.1 years participated in this study. The incidence of burnout was nearly 6.42 and 6.68% and that of MetS was 31.4 and 13.5% in non-doctor/nurse and doctor/nurse staff, respectively. The results showed that burnout induced a higher Odds ratio (OR) of MetS in the doctor/nurse group (OR = 1.96, The study results suggested positive relationship between burnout and MetS in young female staffs and young doctors/nurses. For doctor/nurse staff with higher seniority or more night shifts, strategies are needed to prevent burnout and MetS. Health care workers (HCWs) need to respond immediately to patients and families, making their jobs stressful . HCWs arAccording to Schaufeli et al., health professionals, police officers, and teachers have a high risk of burnout . If theiThe association between age and burnout is not frequently explored in studies. Akkuş et al. analyzed the association between age and burnout and observed a decrease in the scores of the three domains of burnout with increasing age . In a meIn a study that analyzed a sample of the adult working population in Finland, Ahola et al. found that women with burnout had a U-shaped distribution. A negative association was observed between age and burnout in the first years of work age: 18–40 years) and around the age of 60–64 years. In young women, a higher prevalence of burnout was found among younger workers  . AnotherIn addition, age and sex have always been adjusted factors; however, in real-world setting, there are different proportions of hospital staff, including doctor/nurse and non-doctor/nurse groups, male and female groups and different age groups. Earlier studies have reported that age and profession affect burnout and MetS, respectively –10. TherThis cross-sectional study was conducted at the Health Evaluation Center, a 2,000-bed tertiary hospital in Northern Taiwan. MetS data were obtained from yearly routine physical examinations by HCWs.2 for other confounding factors = 0.5) . In addition, a sample size of 2,533 achieved 90% power using the two tailed test  . In totaInformation was obtained through structured questionnaires, designed according to the Institute of Labor, Occupational Safety, and Health Ministry of Labor . In thisData on following baseline characteristics were collected, age, body height, body weight, waist circumference (WC), and blood pressure (BP). Height was measured with a standard stadiometer with an approximation value of 0.01 cm. Weight was measured using a set of calibrated electronic scales. The participants wore light clothes weighing ~0.01 kg. WC was measured at the anatomical region of the midpoint between the lower rib and the upper point of the iliac crest at the end of expiration. After the blood was drawn, rest for 10 min, and then start to use the digital electronic sphygmomanometer  to measure the two arms. The arm with the higher blood pressure was taken as the measuring arm, and the first value was taken. Then, after a 10 min rest, measure the second time again, and average the two times to the final measured value . Height,Information concerning personal habits, including smoking status (yes/no: current or past/never), alcohol consumption (yes/no: ≥2 drinks per week/0–1 drink per week), exercise , fruit intake , and vegetable intake , was collected . InformaStudy participants were asked to provide information on the following during the past month before the survey: total weekly working hours and work style. The work style was divided into three classes according to the work shift that starts in the morning (D means day class: 8:00–16:00), evening (E means evening class: 16:00–24:00), and night (N means night class: 24:00–8:00). Night shift included the midnight work schedule. Participants were categorized into the following three types of work: regular class (D), night shift , and three shifts  .TM  sample collection tube. Sample collection and analysis principles were based on the standard requirements mentioned in the Clinical and Laboratory Standards Institute guidelines .Sample collection and analysis were performed in a standard laboratory with international accreditation (ISO-15189). All participants were informed to start fasting at 10:00 PM the night before and started blood draw at 8:00–10:00 AM the following day. at the Health Evaluation Center. The blood samplings were collected in a BD Vacutainer SSTA Hitachi 7170 Automatic Analyzer  was used to measure the levels of fasting glucose, lipid markers .Burnout domains were evaluated using the Chinese version of the MBI-HSS test  by Lu etTo analyze the metabolic score, we used the National Cholesterol Education Program–Adult Treatment Panel III (NCEP-ATP III) classification with specific cutoff values for abdominal obesity in the Taiwanese population.For the standardization of the MetS criteria, individuals should meet at least three of the following five criteria to be included:  WC ≥90 cThe study protocol was reviewed and approved by the Research Ethics Committee on Human Beings of MacKay Memorial Hospital (research project number 18MMHISO150).All participants provided written informed consent. Confidentiality in data collection was preserved, considering ethical issues, individual autonomy, and respect. This study was conducted in accordance with all guidelines of the Declaration of Helsinki. To ensure data confidentiality, patient identification information was replaced with a sheet number.Descriptive analysis was performed to characterize the population sample. Data are presented as mean ± standard deviation for continuous variables and numbers and percentages for categorical variables. According to the cutoff value of the NCEP-ATP III, the MetS factors were classified into two categories. For each factor, frequencies and percentages were calculated.t-test was used to compare continuous variables between groups. For the analysis of categorical variables, the chi-square test was used. Spearman correlation coefficient matrix was used to analyze the relation between seniority with working hours and night shift. Multivariate logistic regression was used to investigate associations between MetS, burnout, and factors associated with work after adjusting for age, sex, educational level, and lifestyle characteristics and determine the association of burnout and prevalence of MetS in the age group stratified by sex and profession.Student's p < 0.05 was considered bilateral.For statistical analysis, SPSS Statistics version 22  for Windows was used, and p < 0.001). The educational level in the doctor/nurse group was significantly higher than that in the non-doctor/nurse group. Vegetable and fruit intake, exercise, and smoking behavior tended to be higher in the non-doctor/nurse group than in the doctor/nurse group. The seniority of the doctor/nurse staff was mostly ≤10 years. In contrast, seniority of 41% of the non-doctor/nurse staff was >10 years. The working hour was obviously higher in the doctor/nurse group than in the non-doctor/nurse group. Moreover, 44% of the doctor-nurse staff worked for >46 h per week, and nearly 61% of the doctor/nurse group needed to perform three shifts and night shift. No statistically statistic different was observed between the non-doctor/nurse and doctor/nurse groups in terms of the sleep duration .A total of 2,078 doctors/nurses and 1,055 non-doctors/nurses were included in this study. p < 0.001). In the non-doctor/nurse group, hyperglycemia and central obesity ranked by the prevalence as the first and second, respectively. In the doctor/nurse group, central obesity and high BP ranked by the prevalence as the first and second, respectively. Regarding the prevalence of burnout , no statistically difference was observed between the groups. However, the analysis of the three domains showed that the score and prevalence of emotional exhaustion and depersonalization were higher in the doctor/nurse group than that in the non-doctor/nurse group.p = 0.01). In addition, the risk of MetS according to seniority was higher in participants working for >10 years ; but lower participants working for seniority of 2–4 years . Night shift increased the risk of MetS in the doctor/nurse group .After adjusting for age, sex, educational level, lifestyle characteristics, and sleep quality , the resThe results obtained after stratification according to age and sex suggested that female participants with burnout had a higher prevalence of MetS than female participants without burnout in the younger stratum  . When stIn our study, doctor/nurse staff with night shifts and seniority >10 years had a higher OR of MetS, but those with seniority of 2–4 years had a decreased OR of MetS. In a further stratified analysis, it was found that female participants aged 20–40 years had a higher OR of MetS after adjusting for the burnout factor than those in other age and sex groups. At the same time, our results showed that young doctor/nurse staff with burnout had a higher OR of MetS compared to older doctor/nurse staff and non-doctor/nurse staff. Therefore, burnout associated with an increasing OR of MetS among young female professionals and doctors/nurses.Our results showed that overall prevalence of MetS in all HCWs was 19.0%, higher than reported in another previous study in a tertiary hospital in Taiwan (12%) . The prep = 0.88). However, in a previous regional hospital study in Taiwan, a higher prevalence of work-related burnout was observed in nurses (66%) and physicians (38.6%)   , thus co= 0.001) , 35.A study by Chou et al. conducted with a sample from a Taiwanese hospital revealed that being in the younger age group, working overtime; being a nurse or doctor, and having a high-tension job were associated with high burnout . The burp = 0.325), and poor self-assessment sleep quality was higher in the doctor/nurse group than in the non-doctor/nurse group (p < 0.001). Previous studies extensively review the published literature and provide a comprehensive overview on sleep quality in MetS, the results showed the sleep quality played an important role to be as a modulator of metabolic homeostasis  and central obesity (40.14%) in the non-doctor/nurse group and central obesity 28.38%) and hypertension (21.17%) in the doctor/nurse group. Similar findings were reported by Yeh et al., Pietroiusti et al., and Basei Rossa et al., who corroborate the hypothesis that blood glucose control, WC, and BP are important to improve the health status of hospital employees 8% and hy, 44.A previous study reported that burnout level reduced with increasing age in men, but the association was bimodal in women, with women aged 20–35 and >55 years showing the highest burnout level . When asIn the early stages of their careers, younger workers need to master their job requirements and face a greater risk of burnout . In addiAssociations between age and burnout were strongly moderated by sex. Men and women have different levels of exposure to work and non-work stressors . GeneralIn a further stratified analysis, we found that female professionals aged 20–40 years had a lower prevalence of MetS from previous studies but had a higher risk of MetS after adjusting for the burnout factor than professionals in other ages and sex groups. According to the above findings, burnout, shift work, and poor sleep conditions induce MetS. Different ages and sex induce burnout, which can further lead to MetS. This fact suggests that acquiring work mastery (such as a doctor/nurse job) combined with work–family conflicts  is often higher in women than in men , 52. In An analysis of the association between burnout and MetS in hospital HCWs, between the different professions, and an analysis stratified by age, sex, and profession were the strong points of this study. A unique feature of this study is that we draw on previous MetS analysis and burnout prevalence in medical teams, including younger age , nutrition department 64 (2.0%), pharmacy department 98 (3.1%), and administration 410 (13.1%). We cannot perform a more detailed departmental analysis. Fourth, the actual response rate was a little low . Most of the HCWs felt tired and dull to answer the questionnaire. They did not fill out the questionnaire more than third/fourth. Fifth, sparse effects that may increase the probability of monotone likelihood in this study [OR in In the future, prospective studies involving multiple medical centers are needed to confirm the evidence of this research. In addition, we hope to use the occupational health education and training program to let HCWs understand that a lot of information can be obtained through questionnaire analysis, which will help us improve our policies. More details about working conditions, work–family conflicts, and biochemical biomarker can be added to accumulate more knowledge about the causal relationship and mechanism between work stress, burnout and MetS.A significant association between burnout and MetS was observed in young female professionals and young doctors/nurses. For the doctor/nurse staff with higher seniority or more night shifts, strategies are needed to prevent burnout and MetS. Agencies need to incorporate stress management into current guidelines to prevent the MetS, especially in the hospital workplace.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Human Research Ethics Committee at Mackay Memorial Hospital (project research number 18MMHISO150). The patients/participants provided their written informed consent to participate in this study.M-TT participated in the design and conception of the study and its coordination, acquisition of data, carried out statistical analysis, and drafted the manuscript. H-JT participated in the conception and design of the study and reviewed the analysis and manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


To explore the interrelationship between post-traumatic stress symptoms (PTSS), illness uncertainty (IU), and anticipatory grief (AG).Structural equation modeling with bootstrapping estimation was conducted using data from a convenience sample of 254 family caregivers of patients with advanced lung cancer in China. Participants were recruited from a public cancer hospital in Shenyang, China. The family caregivers completed the Impact of Events Scale-Revised, Uncertainty in Illness Scale Family Caregiver Version, and Anticipatory Grief Scale.p = 0.002). Moreover, IU was found to mediate the relationship between PTSS and AG . The mediating effect of IU accounted for up to 30.1% of the total effect.The measurement model has good reliability and validity, and the final model fit the data well. PTSS positively influenced AG (direct effect estimate = 0.391, IU mediated the relationship between PTSS and AG. Healthcare professionals should continuously assess PTSS, IU and AG levels in FCs and provide effective intervention options for mitigation. Lung cancer is the leading cause of cancer-related morbidity and mortality in China, and according to statistics, the number of newly diagnosed lung cancer cases in 2015 was 787,000 and the number of deaths was 630,500, with lung cancer deaths accounting for 27% of all cancer deaths, equivalent to one out of every four cancer-related deaths . HoweverTherefore, an increasing amount of attention has been paid to exploring the antecedents of AG, which is required to enhance FCs quality of life and helping them to improve negative emotion. Faced with the imminent loss, FCs react with anxiety, depression, concerns about the future, fear, sadness, feelings of helplessness, compassion fatigue or even Post-traumatic Stress Symptoms (PTSS) –11. PTSSIn addition, exposure to PTSS may cause family caregivers to avoid any scenarios that may trigger traumatic memories, such as avoiding information related to the illness, may interfere with their ability to access health-related knowledge and increase their illness uncertainty (IU). IU is defined as “the inability to determine the meaning of illness-related events and accurately anticipate or predict health outcomes” . The stuThe present study was inspired by Stroebe's integrative risk factor framework  for the This study is a descriptive cross-sectional study. A convenience sample was recruited from a public cancer hospital in Shenyang, China, between January and October 2021. Inclusion criteria were as follows: (1) FCs of patients with a clinicopathological histological or cytological diagnosis of lung cancer and TNM stage III or IV; (2) Age ≥ 18 years; (3) awareness of the patient's disease condition; (4) undertaking the primary care of the patient's daily life and being identified by the patient as their primary caregiver; (5) good reading and communication skills in Chinese; (6) and volunteer for this study. We excluded those who were unable to complete the questionnaire due to psychological or cognitive impairment and those who had <1 month of care. We estimated the sample size according to the requirements of the structural equation modeling (SEM), and the ratio of observed variables to sample size ranged from 1:10 to 1:15, with a sample size between 200 and 400 being appropriate . We distThe study team members were first trained before the start of the study, and a uniform guideline for participants to fill out the questionnaire was clarified to ensure the reliability of the questionnaire. The questionnaire was distributed by members of the study team and completed independently by FCs of patients with advanced lung cancer and consisted of four main sections: Sociodemographic Characteristics of FCs, Impact of Events Scale-Revised, Uncertainty in Illness Scale Family Caregiver Version and the Anticipatory Grief Scale. The assessors collected on the spot the completed questionnaires, and asked the participants to complete any missing options.A self-designed questionnaire was used to collect sociodemographic characteristics of FCs including gender, age, education, marital status, relationship with patients, and length of care.PTSS was assessed using the Chinese version IES-R, which was developed by Weiss and Marmar  and modiCaregivers' IU was assessed using the Chinese version UIS-FC, which was developed by Mishel  and modiThe AG was assessed using the Chinese version AGS, which was developed by Theut  and modi2), degrees of freedom (df), value of χ2/df, goodness-of-fit index (GFI), adjusted GFI (AGFI), comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR). The recommended value for GFI, AGFI, CFI, and TLI is 0.90 or higher. The RMSEA would be “close to” 0.09 or lower, SRMR would be “close to” 0.05 or lower, and χ2/df would be “close to” 5.00 or lower, indicating a good model fit  was used for data analysis. The sociodemographic characteristics of the participants were examined by computing frequencies and percentages. One-way ANOVAs and t tests were used to determine the relationship between FCs' characteristics and the three variables, and Pearson correlations were used to test for unadjusted associations between variables. Statistical significance was set at 0.05. The hypothesized model was tested using SEM with IBM SPSS AMOS version 26.0 . The maximum-likelihood estimation of the entire system in a hypothesized model, and enables the assessment of variables with the data . In our odel fit . FinallyThe study was approved by the Ethics Committee of Liaoning Cancer Hospital and Institute. Based on the Declaration of Helsinki, participants had the right to leave the study at any time. Written informed consent was obtained from all participants.A total of 254 FCs of patients with advanced lung cancer participated in this study. The majority were females (63.4%), age 36–59 years (58.7%), high school (53.1%), married (85.0%), parents of the patients (52.4%), and length of care <6 months (58.7%).P < 0.05 or 0.001). FCs aged ≤35 years reported significantly higher IES-R and UIS-FC scores than those aged 36–60 years and ≥60 years (P < 0.05). FCs with a bachelor's degree and above reported higher IES-R scores than those with high school education, primary school education and below (P < 0.05). FCs who were married reported lower IES-R, UIS-FC, and AGS scores than other (P < 0.05 or <0.01). Regarding relationships with patients, spouses reported lower IES-R, UIS-FC, and AGS scores than compared with parents and children . There were significant differences in the AGS scores for FCs with different lengths of care (P < 0.05)  .P < 0.01). Additionally, AG were significantly correlated with UI. The Pearson's correlation coefficients ranged from 0.13 to 0.54 (P < 0.01 or 0.05) (P < 0.01).AG were significantly and positively correlated with PTSS. The Pearson's correlation coefficients ranged from 0.25 to 0.62 (or 0.05) . The PTSP < 0.001), giving preliminary evidence for the convergent validity of the measurement model. Meanwhile, the average variance extracted (AVE) of all constructs ranged from 0.517 to 0.592, exceeding the AVE threshold value of 0.50 .As with all self-reported data there is a potential for common method variance (CMV) resulting from multiple sources . Therefonificant , 32. Giv2 = 124.507, df = 74, χ2/df = 1.683, GFI = 0.937, AGFI = 0.910, CFI = 0.971, TLI = 0.964, RMSEA = 0.052, SRMR = 0.047). We use a causal step strategy to investigate the first mediation condition with respect to hypothesis 1 (P < 0.01). In addition, the results of the direct effect of PTSS on AG  was statistically significant. Therefore, hypothesis 1 was supported.The structural modeling results showed that the hypothesized model fit the data well (χthesis 1 . As showP < 0.01), IU was significantly and positively associated with AG . In addition, the results of the direct effects of PTSS on IU , and the direct effect of IU on AG , were all statistically significant (P < 0.01). Hypotheses 2 was thus supported.To test hypothesis 2, we measured the second condition of mediation. The correlation coefficients indicated that PTSS was significantly and positively associated with IU . We. WeP < 0nificant . The resFCs assume the primary responsibility for the care of patients with advanced cancer in China. However, due to the irreversible nature of advanced cancer patients' disease, FCs may experience varying degrees of AG when faced with the imminent death of the patient . AG not The present study found significant differences in IES-R, UIS-FC and AGS when PTSS, IU and AG were examined according to sociodemographic characteristics. Culturally, women are the primary source of caregiving. Meanwhile, female FCs have been found to be more likely to use emotion-focused coping strategies. Therefore, it was not amazing to find that women reported significantly greater PTSS, IU and AG than men. In this study, FCs aged <35 years reported higher levels of PTSS and IU. Similarly, Elisavet et al. found that younger age was significantly associated with higher PTSS . Young FWe found a possible causal relationship between PTSS, IU and AG and FCs in 254 patients with advanced lung cancer based on the theoretical basis and SEM analysis. The results demonstrate PTSS had a direct effect on AG. Meanwhile, IU was shown to have a mediation effect in FCs' PTSS and AG. In a full mediation model, the direct effect of PTSS would have become insignificant when the role of IU was added to the model. The model illustrates only partial mediation as the path between PTSS and AG remains significant in the full model. Overall, the results explain well the hypotheses proposed in this study.The first aim of this study was to examine the associations between PTSS and AG in FCs of patients with advanced lung cancer. Consistent with previous studies , the preThe second aim was to determine to what extent IU mediates the association between PTSS and AG. The significance of the finding is that intervening in IU is an important strategy to alleviate AG. The present study showed that IU scores of FCs of patients with advanced lung cancer was positively correlated with PTSS and AG scores. FCs often have the stressful event of the patient's cancer in their minds and are reluctant to face reality and avoid any cancer-related information, which may lead to a lack of information for FCs and further interfere with their ability to acquire health-related knowledge. Due to the lack of information and ability, FCs do not predict the course of cancer, coupled with the various complex treatments, which these uncertainty factors often overwhelm FCs and thus deepen IU. IU can further increase the physiological and psychological stress of FCs, reducing their confidence in coping with and overcoming traumatic events. Moreover, FCs are at risk of losing a loved one, which makes the experience of caring for a palliative care patient unique and complex, ultimately leading to AG for FCs. Therefore, AG levels can be mitigated by reducing the IU of FCs. It is recommended that healthcare professionals should provide more care and communication to FCs, disseminate cancer-related knowledge, and satisfy FCs' information needs. It is also necessary to strengthen FCs' mental health education, assist them in establishing a correct concept of death, understand that death is an inevitable law of nature, and help them cope with the pain and grief of the impending loss of a close relative.There are still some limitations in this study. First, the participants in this study were all from the same hospital and a convenience sampling method was used, thus limiting generalization due to potential selection bias. In addition, this study is a preliminary cross-sectional study does not enable causal inferences to be made yet. Although we used SEM to conduct a simultaneous testing of our proposed model in FCs of advanced lung cancer patients, the results still need to be treated with caution. It is desirable that future longitudinal studies will be conducted to further clarify the causal relationship between them.FCs need practical and emotional support to deal with the mental trauma they endure while providing palliative care. FCs of advanced lung cancer patients may experience reduced quality of care due to AG, and interventions for FCs from the perspective of their PTSS and IU are recommended.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 Liaoning Cancer Hospital and Institute. The patients/participants provided their written informed consent to participate in this study.DS, ZM, XZ, and LZ: material preparation, data collection, and analysis were performed. DS and ZM: the first draft of the manuscript was written. JL commented on previous versions of the manuscript. All authors contributed to the study conception, design, read, and approved the final manuscript.This work was supported by the Research Project on Humanities and Social Sciences of Liaoning University of Traditional Chinese Medicine (2021LNZYQN007).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.


Pancreatic ductal adenocarcinoma (PDAC) is a fatal malignancy with a low resection rate. Chemotherapy and radiotherapy (RT) are the main treatment approaches for patients with advanced pancreatic cancer, and neoadjuvant chemoradiotherapy is considered a promising strategy to increase the resection rate. Recently, immune checkpoint inhibitor (ICI) therapy has shown remarkable efficacy in several cancers. Therefore, the combination of ICI, chemotherapy, and concurrent radiotherapy is promising for patients with potentially resectable pancreatic cancer, mainly referring to locally advanced (LAPC) and borderline resectable pancreatic cancer (BRPC), to increase the chances of conversion to surgical resectability and prolong survival. This study aims to introduce the design of a clinical trial.2 and nab-paclitaxel 125 mg/m2via intravenous (IV) infusion on days 1 and 8, along with tislelizumab  200 mg administered through IV infusion on day 1 every 3 weeks, concurrently with stereotactic body radiation therapy (SBRT) during the third cycle of treatment. After surgery, patients without progression will receive another two to four cycles of adjuvant therapy with gemcitabine, nab-paclitaxel, and tislelizumab. The primary objectives are objective response rate (ORR) and the R0 resection rate. The secondary objectives are median overall survival (mOS), median progression free survival (mPFS), disease control rate (DCR), pathological grade of tumor tissue after therapy, and adverse reactions. Besides, we expect to explore the value of circulating tumor DNA (ctDNA) in predicting tumor response to induction therapy and survival outcome of patients.This is an open-label, single-arm, and single-center phase II trial. Patients with pathologically and radiographically confirmed LAPC or BRPC without prior anti-cancer treatment or severe morbidities will be enrolled. All patients will receive induction therapy and will be further evaluated by the Multiple Disciplinary Team (MDT) for the possibility of surgery. The induction therapy consists of up to four cycles of gemcitabine 1,000 mg/mThis is a protocol for a clinical trial that attempts to evaluate the safety and efficacy of the combination of anti-PD-1 antibody plus chemotherapy and radiotherapy as the induction therapy for LAPC and BRPC. The results of this phase II study will provide evidence for the clinical practice of this modality.http://www.chictr.org.cn/edit.aspx?pid=53720&htm=4, identifier ChiCTR2000032955. Pancreatic ductal adenocarcinoma (PDAC) is a highly fatal disease with increasing incidence rates. It is predicted to become the third leading cause of cancer-related death in the United States by 2030 . The majThe purpose of adjuvant therapy is to reduce postsurgical recurrence and prolong survival . HoweverRecently, immune checkpoint inhibitor (ICI) with PD-1/PD-L1 antibodies has displayed remarkable efficacy in several cancers, particularly lung cancer, melanoma, and renal cancer . NeverthCirculating tumor DNA (ctDNA) containing tumor-specific DNA mutations can be detected in the cell-free component of peripheral blood in most patients with PDAC . For res2 and nab-paclitaxel 125 mg/m2 administered on days 1 and 8 via intravenous (IV) infusion, along with tislelizumab 200 mg administered via IV infusion on day 1 every 3 weeks. Concurrent chemoradiotherapy is administered after two cycles of systemic therapy. Patients will undergo CT simulation for radiation treatment planning about one week after two cycles of chemotherapy plus immunotherapy. We create a gross target volume (GTV) following the complete extent of the tumor delineated in each CT phase, and a clinical target volume (CTV) is an expansion of 0.5 cm around the GTV, including lymph node area. The planning organ at risk volume (PRV) is a 1-cm expansion of the gastrointestinal tracts. We generate planned gross tumor volume (PGTV) as a 0.3-cm expansion from GTV and subtract PRV. The planning target volume (PTV) encompasses a 0.5-cm expansion of CTV. Patients will be administered SBRT every day with a total dose of 30 Gy/10 f at PTV and 50 Gy/10 f at PGTV, simultaneously with the third cycle of chemotherapy and immunotherapy, about one week after CT simulation. Patients with disease progression (PD), including local progression, will change drugs and withdraw from the trial. For subsequent treatment, radiotherapy may be added to the second-line treatment. However, the patients will not continue the clinical trial. An imaging evaluation will be performed every 6 weeks. When induction treatment is completed, surgery will be decided by the Multiple Disciplinary Team (MDT). The MDT consists of multidisciplinary experts in pancreatic cancer, including medical oncologists, pancreatic surgeons, gastroenterologists, radiologists, pathologists, imaging specialists, and a coordinator. Patients without PD will continue to receive two to four cycles of adjuvant treatment with the same systemic regimen as in the induction phase. However, if the MDT team believes that the tumor remains unresectable, the patient will continue the existing treatment until there are indications for surgery. In addition, patients who do not undergo surgery after eight cycles of treatment will receive maintenance treatment, which consists of gemcitabine 1,000 mg/m2, nab-paclitaxel 125 mg/m2, and tislelizumab 200 mg once a month. The main process of this trial and the treatment schedule are demonstrated in This is a prospective, open-label, single-arm, and single-center phase II study. We enrolled patients aged ≥18 years with histologically or cytologically and radiographically confirmed LAPC or BRPC. We classified LAPC and BRPC according to the National Comprehensive Cancer Network Guidelines, as indicated in The combination therapy of tislelizumab plus AG and concurrent radiotherapy as the induction therapy improves the ORR and R0 resection rate and prolongs the PFS and OS for patients with locally advanced and borderline resectable pancreatic cancer with an acceptable safety profile.The primary objectives of the study included evaluating ORR and R0 resection rates in the intent-to-treat (ITT) population. ITT refers to patients who complete the treatment as planned. ORR is defined as the proportion of patients with the best overall response of complete response (CR) or partial response (PR) according to the Response Evaluation Criteria in Solid Tumors (RECIST). R0 resection is defined as no tumor cells visualized at the surgical margin under the microscope.The secondary objectives of the study included evaluating OS and PFS in the ITT population. Disease control rate (DCR), pathological response rate, and adverse reaction rate are included. OS is defined as the time from the date of randomization to the date of death due to any cause. PFS is defined as survival without any progressive disease and distant metastases from the date of randomization. DCR refers to the number of cases with remission and stable disease accounting for the ITT population. Safety evaluation includes the tolerance of patients to this regimen and the influence of these drugs on the skin, digestive tract, and electrolyte balance of patients. The reasons for dropouts include PD, death, adverse reactions, and the wishes of the patient. For patients with surgical resection, pathological response is one of the observed objectives.via next-generation sequencing will be investigated in the induction therapy. Peripheral blood samples will be collected from each patient in ethylene diamine tetra acetic acid (EDTA) vacutainer tubes at four time points, i.e., before induction therapy (baseline), two cycles after the initiation of induction therapy, after radiation treatment or before surgery (preop), and within 1 month after surgery (postop) or at the time of progression. All the extraction procedures will be performed following the instructions of the manufacturer. DNA was quantified on a Qubit Fluorometer with a Qubit dsDNA HS Assay Kit (Thermo) and its quality was evaluated by the Agilent 4200 TapeStation (Agilent).The exploratory objectives of this trial are to further investigate the predictive biomarkers for the efficacy of the combination therapy. Genomic mutation features and the serial ctDNA status The main process of the trial is summarized in For patients with PR after finishing at least four cycles of SBRT, the feasibility of surgical resection will be discussed by MDT. The patients who successfully receive resection need to recuperate for almost one month and are further evaluated using imaging for therapeutic efficacy. If the patient recovers well, we will treat them with another two or more cycles of adjuvant therapy.The course of the trial mainly consists of four phases: screening, baseline evaluation, treatment, and follow-up.The screening of patients will be accomplished within one week before the initial treatment. Patients are screened mainly according to the inclusion and exclusion criteria. We record medical history, family history, and ECOG score and conduct physical examinations, including weight, height, etc. Patients also undergo blood tests to detect liver and kidney function. Before enrollment, the examination results of patients will be re-assessed to assess their eligibility. All treatments are provided after receiving informed consent from the patients.The baseline evaluation of the patient will be completed within two weeks of the treatment. It mainly includes medical history, physical examination, hematological examination, and other laboratory tests , pathological examination, CT or MRI scan, and ECOG score. Positron emission tomography/computed tomography (PET-CT) and gene detection are optional for the enrolled patients.2 and gemcitabine 1,000 mg/m2 will be administered through IV on days 1 and 8, and tislelizumab will be administered through IV as 200 mg on day 1, and will be repeated every 21 days. Protocol-specified treatment modifications will be undertaken when severe toxicity occurs, and all the side effects will be recorded. Patients with no progression after two cycles will receive concurrent radiotherapy in the third cycle. The planned dose of SBRT is 30 Gy/10 f at PTV and 50 Gy/10 f at PGTV. When four cycles of medication and radiotherapy are completed, surgeries will be carried out as discussed by the MDT. All patients who undergo pancreatectomy must receive another two or more cycles of adjuvant therapy. Patients with PD during the treatment will be evaluated for possible second-line therapy. All combined treatments should be recorded in the case report form (CRF).According to the treatment schedule, nab-paclitaxel 125 mg/mvia face-to-face visits or phone calls every two or three months. For patients with PD during treatment, we will still perform their follow-up every two or three months and record the latest treatment and survival.For patients who complete the scheduled treatment, including induction and adjuvant therapy, follow-up will start one month after the end of the treatment. Furthermore, we will record survival and progression status Comprehensive information about eligible patients will be collected before the initiation of the treatment according to baseline assessment. AEs and severe adverse events (SAEs) will be evaluated according to NCI-CTCAE v5.0 during the therapy. Patients are subjected to imaging evaluation every two cycles. After four cycles of chemoimmunotherapy and completion of radiotherapy, MDT will comprehensively evaluate whether the surgery can be performed based on the tumor size and its relationship with surrounding vessels on CT scan and the change in tumor markers. Exploration for resection is considered if there is a decrease >50% in the CA19-9 level according to the National Comprehensive Cancer Network (NCCN) Guideline. We will also compare the standard uptake value (SUV) and observe no distant metastasis through PET/CT. Additionally, the postsurgical pathology of patients will be graded according to the American Joint Committee on Cancer (AJCC). The patients are scheduled for re-examination almost one month after the surgery and further receive at least two cycles of adjuvant treatment.To explore the value of ctDNA as a tumor biomarker in clinical settings, peripheral blood samples of patients are collected to detect ctDNA in four periods, including before treatment, after two cycles, after radiotherapy, and after surgery. We will screen out several hot spot genes through ctDNA detection and evaluate the roles of these gene mutations in different treatment stages. Finally, we will use the Cox proportional hazard regression analysis to investigate the relationship between tumor response and gene mutations.Adverse events will be summarized and graded according to general standards. Laboratory parameters will be reported with descriptive statistics. We will observe and record all AEs ). In this study, the following AEs are mainly considered: hematological and non-hematological toxicity, postoperative complications, death, and life-threatening AEs. Once the above adverse events occur, we will take relevant treatment measures, including dose or drug adjustment, and in severe cases, the current treatment will be temporarily stopped and symptomatic treatment will be given first.This is an open-label, single-arm, phase II clinical trial and a planned 25 eligible subjects will be enrolled. There was no statistical hypothesis to determine the sample size. All demographic and clinical characteristics recorded at baseline will be displayed using descriptive analyses employing lists and tables. Observed rates and the exact binomial confidence interval (CI) of 95% will be calculated for ORR when the induction phase is completed. After a phase is accomplished, time-to-event variables, such as PFS and OS, will be estimated using the Kaplan–Meier method and plotted over time. Median PFS and OS will be presented along with their 95% CI, if estimable. For patients who undergo surgery, the pathological response rate and the R0 resection rate will be recorded and calculated. The T-test, Fisher’s test, and other appropriate tests will be used wherever applicable. The level of significance is P <0.05.This trial aims to explore the efficacy and safety of the combination of a PD-1 inhibitor plus chemotherapy and radiotherapy as the induction therapy for patients with potentially resectable PDAC. Neoadjuvant therapy is a promising strategy to increase opportunities for undergoing surgery and an R0 resection rate for patients with potentially resectable pancreatic cancer. One of the largest meta-analyses of 111 studies , including 56 phase I-II trials from 1966 to 2009, revealed that almost one-third of initial patients with unresectable PDAC may require surgery after neoadjuvant therapy . A smallIt is widely accepted that PDAC is immunotherapy-resistant and checkpoint inhibitor monotherapy is limited to a few patients with PDAC mismatch repair (MMR) deficiency . The denAdditionally, we expect to explore more clinical biomarkers that can predict tumor response to induction therapy, monitor tumor burden, and estimate the prognosis for survival after treatment. Currently, the only prognostic biomarker for PDAC approved by the US Food and Drug Administration is CA19-9, which is low positive in patients who are asymptomatic or Lewis-negative , 44. GenThe original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.CL and YZ have contributed equally to this work. BL, YQ, and JD are responsible for the conception of the trial. WK, LW, MT, JC, QL, JH, and AL were involved in the design of the trial. CL, YZ, XQ, QG, and LZ were involved in the acquisition and analysis of data for the trial. CL and YZ were involved in drafting the manuscript. JY, FM, and DC were involved in revising the manuscript. All authors have agreed the final version of manuscript.The study was supported by the National Key Research and Development Program of China (2020YFA0713804), the National Natural Science Foundation of China (82072926), the Special Fund of Health Science and Technology Development of Nanjing (YKK20080), and the Beijing Medical Award Foundation (YXJL-2020-0236-0050).We thank all the investigators who have contributed to this study, and we are grateful for the understanding and cooperation of patients.Author DC was employed by Jiangsu Simcere Diagnostics Co., Ltd.The remaining 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.


The relationship between periodontal diseases and Sjogren’s syndrome were found inconsistent in current studies. Our objective is to clarify the relationship between periodontal diseases and Sjogren’s syndrome.A systematic review was performed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Electronic databases  were searched. The Newcastle-Ottawa Scale (NOS) and Agency for Healthcare Research and Quality (AHRQ) were applied to evaluate the quality of studies. Quality assessment of the certainty of evidence was performed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. When the output is the ratio, Odds ratio (OR) of periodontal diseases with Sjogren’s syndrome were calculated. When the output is the mean, weighted mean difference (WMD) of periodontal diseases with Sjogren’s syndrome was calculated. We conducted meta-analysis and estimated the pool sensitivity. Begg’s test was used to test the possibility of publication bias. We also carried out meta-regression to clarify the source of heterogeneity (I2 > 50%). Finally, we performed a trial sequential analysis (TSA) to identify the false positive or false negative outcomes that might occur during repeated updates.21 studies were included in this systematic review, with a total of 11435 subjects. Meta-analysis of 5 studies showed that there is a positive correlation between periodontitis and Sjogren’s syndrome . Meta-analysis of 16 studies showed that the periodontal condition of patients with Sjogren’s syndrome was worse compared with the control group, and the scores of clinical periodontal parameters were relatively high.Sjogren’s syndrome patients seem to be more likely to be diagnosed with periodontal diseases. However, our results should be interpreted with caution considering the high heterogeneity.https://www.crd.york.ac.uk/prospero/], identifier [CRD42021261322].[ Periodontal disease is an inflammatory and infectious disease. In the early stages of periodontal disease, the main symptoms are red, swollen and bleeding gums. As the disease progresses, the teeth become loose, mainly due to the development of periodontal pockets and absorption of alveolar bone . GingiviSjogren’s syndrome (SS) is an autoimmune disorder with secretory gland dysfunction charactered by dryness of the main mucosal surfaces including the mouth, eyes, nose, and vagina , 12. It P = 0.001) and frequency  of dental visits were found higher in patients with pSS and the risk of gingivitis  and periodontitis  was also significantly higher them P (patient/participants): subjects aged ≥ 14 years and without other related diseases (such as head and neck tumors);(2)E (exposure): Sjogren’s syndrome ;(3)O (outcome): periodontal disease percentage or clinical periodontal parameters;(4)S (study design): observational study .We conducted a systematic literature search in the PubMed, EMBASE, Web of Science, and Cochrane Library (from their inceptions until 24 November 2021) to investigate the relationship between SS and periodontal diseases. To identify all related datasets and the relevant articles, we used search strategies shown in All retrieved studies were independently assessed by two researchers (XP and JG) based on inclusion/exclusion criteria. For studies whose titles and abstracts might meet the inclusion criteria, the full text was selected for further evaluation. A third author BY was involved when there was a disagreement between the two researchers (XP and JG).After identifying the included studies that met the criteria, XP and JG extracted the following information: study characteristics ; periodontal diseases assessment ; and SS assessment .The Newcastle-Ottawa Scale (NOS) was applied for assessing case-control studies and cohort studies. The evaluation criteria were Selection, Comparability and Exposure. Stars were awarded each study (up to 9 stars) for quick visual assessment, Studies awarded with 6 or more stars were defined as high quality research , 23. ForThe results of NOS and AHRQ scores can be used for reference in the quality of evidence grading. Two reviewers (XP and JG) independently evaluated the quality of the articles, and a third author (BY) evaluated the articles in case of disagreement.Forest plots were generated to assess the ORs and corresponding 95% CIs or WMDs and 95% CIs across the studies for meta-analysis. The data reported in some studies were standard error of mean (SEM) and we converted them into SD (SEM = SD/√N) . Forest Q test. If the p-value was lower than 0.1, the I2 statistic was used to quantify the statistical heterogeneity. The threshold was determined as Cochrane recommended, that is 0% to 50%: may not be important; 50% to 100%: may represent substantial heterogeneity  guidelines were used for rating the quality of evidence . The degWe identified 2511 articles in PubMed, EMBASE, Web of Science, and Cochrane Library. After screening the titles and abstracts of all the articles, 72 articles were selected for further evaluation. Then we reviewed the full text of these articles and excluded 51 articles based on inclusion criteria. In the end, there are 21 articles with 11435 participants meeting the inclusion criteria for the meta-analysis .Among these 21 articles, 5 articles evaluated the percentage of periodontal diseases in SS subjects and non-SS subjects, and 16 reported the diagnostic criteria scores of clinical periodontal parameters (mean ± SD) in SS subjects and non-SS subjects. Among these latter 16 studies, 7 reported BOP scores, 12 reported PI scores, 12 reported PPD scores, 10 reported GI scores, and 6 reported CAL scores. All included studies were observational, including 3 cohort studies, 4 case-control studies, and 14 cross-sectional studies. The total number of participants was 11,435 (9597 SS patients and 1838 non-SS patients). With regard to the age of the participants, the average age of all studies was over 30 years old. 6 of the studies assessed women separately –31, whilThe NOS scores and the AHRQ methodology checklist for quality assessment of these studies are shown in 2 = 77.5%) (Five studies recording the incidence of periodontitis in SS subjects . In the = 77.5%) .2 = 58.8%) and GI  was found. However, subjects with SS had no significant difference in the clinical periodontal parameters scores PPD . Finally, the relationship between the SS and the clinical parameters scores CAL  and PI  is not very clear  and the pooled WMD s with corresponding 95% CIs , indicating that our meta-analysis is relatively stable .p = 0.537), GI (p = 0.721), and PPD (p = 0.086) between subjects with SS and healthy controls , PI (p = 0.050), and GI (p < 0.001) age was one source of heterogeneity. When the outcome variable was PPD, the diagnostic criteria for SS was at least a source of heterogeneity (p = 0.025).Meta-regression was used to investigate potential sources of heterogeneity between the studies. We found that when the outcome variable was the percentage of periodontitis  and GI . However, there is no significant difference in the clinical periodontal parameters scores PI  and PPD  in SS patients. TSA trail showed that for dichotomous variables, the meta-analysis can be declared as conclusive with regard to the anticipated effect leading to the required information size. Similarly, the continuous variable BOP also drew significant conclusions with enough information size. For GI, PI, PPD, and CAL, more tests need to be included for confirmation.There are several strengths in Our meta-analysis. First, we searched all relevant databases as thoroughly as possible to include more studies that met the criteria. Second, we performed GRADE evidence quality grading to reflect the accuracy of the effect estimates. Third, we conducted TSA Trail to manage the risk of type I and II errors and to help determine whether additional trials are needed. Therefore, our analysis could well reflect the trial effect and illustrate the clinical guiding significance of the indicator.2 = 77.5%, 58.8%, 71.9%, 92.2%, 97.2%, and 66.7%) across the studies. Although we tried meta-regression to explore the sources of heterogeneity and obtained some sources of heterogeneity, we did not find more sources of heterogeneity due to the lack of more detailed description of research characteristics in the included studies. Second, although some positive conclusions are reached in TSA Trail results, some conclusions are still unstable and lack sufficient information. Therefore, the current conclusions may change with the increase of studies. Third, because a small part of the included study data came from dental clinics, patients from dental clinics may have some dental diseases or have some symptoms, so these patients are more likely to suffer from periodontal disease. In contrast, patients from other places such as Sjogren’s Syndrome Service of the Hospital Clinics showed no such bias. All in all, the results we get may lean toward “correlation.” In addition, we tried to search the studies on the incidence of Sjogren’s syndrome in patients with periodontal disease. Unfortunately, due to the retrieval of only two articles (There are also limitations in our study. First, the results had relatively high statistical heterogeneity (Iarticles , 48, metAggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. Furthermore, alterations in cytokine networks may act as an intermediate factor between periodontal diseases and SS. More inflammatory cytokines were also found in the oral cavity of patients with SS, which can stimulate the differentiation of immune cells, thus affecting the occurrence and development of periodontal diseases (According to previous studies, periodontal diseases and SS have been considered to be related , which hdiseases , 52. Howdiseases . UnfortuDespite the lack of clear evidence, our meta-analysis still has its value for the clinical prevention and treatment of periodontal diseases and SS. The first consultation department of many SS patients is the dental department because dry mouth and dental caries are the initial symptoms of them. This meta-analysis is the first to explore the correlation between periodontal diseases and SS from the perspective of dentists and patients. From the perspective of dentists, the periodontal condition of SS patients should also be paid attention to when they are diagnosed and treated. If timely measures are taken to improve the periodontal condition, SS patients are expected to reduce or even avoid the progressive loss of periodontal tissue. From the patient’s point of view, the symptoms of periodontal disease and SS may serve as reminders of each other, and patients should pay close attention to the other when one is diagnosed. We believe that the treatment of SS is helpful in alleviating periodontal diseases, and the awareness of patients and clinicians on SS may contribute to the successful treatment of periodontal diseases. Future scientific studies should further verify the correlation between these two diseases and explore the mechanism and molecular pathway of their association.This systematic review indicated that SS patients were more likely to be diagnosed with periodontal diseases, and the periodontal index is more likely to be abnormal, suggesting that the treatment of SS has a positive effect on periodontitis.The original contributions presented in this study are included in the article/BY and XP put forward the ideas, searched the literature, filtered the information, analyzed the data, and wrote the manuscript. JG prepared the figures and tables and checked for errors. XuL, XiL, YW, ZC, and BC reviewed the manuscript, put forward the constructive comments, and participated in its design and coordination. All authors contributed to the article and approved the submitted version.


Since the outbreak of the COVID-19 pandemic in the United States, Latinos have suffered from disproportionately high rates of hospitalization and death related to the virus. Health disparities based on race and ethnicity are directly associated with heightened mortality and burden of illness and act as underlying causes for the staggering impacts of COVID-19 in Latin communities in the United States. This is especially true in the city of El Paso, Texas, where over 82% of the population is Hispanic. To ascertain the level of danger that COVID-19 poses in El Paso, we constructed a point-in-time risk assessment of its Latin population and assessed a Latin individual’s likelihood of hospitalization or death related to COVID-19 by comparing relevant health profiles with high-risk co-morbidities that the Centers for Disease Control (CDC) identified in 2020. Data for this risk assessment come from 1152 surveys conducted in El Paso. The assessment included comprehensive demographic, socioeconomic, and health data to analyze disparities across Hispanic sub-populations in the city. Results revealed that around 49.3% of Hispanics in the study had been previously diagnosed with a high-risk co-morbidity and therefore have an increased likelihood of hospitalization or death related to COVID-19. Additional factors that led to increased risk included low income, homelessness, lack of U.S. citizenship, and being insured. The findings from this study additionally demonstrate that structural inequality in the U.S. must be addressed, and preventive measures must be taken at local and state levels to decrease the mortality of pandemics. Baseline population health data can help with both of these goals. Existing health disparities have been exacerbated by COVID-19 . Long beInstitutions that place lesser value on the lives of Black and Hispanic people not only turn a blind eye to health disparities but restrict minorities to riskier jobs where they work in dangerous conditions. Research in the United States, Canada, and Europe shows that immigrants and other minority communities bear higher rates of work-related accidents, illnesses, and deaths because of their over-representation in high-risk occupations . BecauseThis article examines COVID-19 risk factors in the context of the Hispanic-majority border city of El Paso, Texas. To ascertain the level of danger that COVID-19 poses for the Hispanic community in El Paso, we constructed a point-in-time risk assessment of its Latin population. We assessed a Latin individual’s likelihood of hospitalization or death related to COVID-19 by comparing relevant health profiles with high-risk co-morbidities that the Centers for Disease Control (CDC) identified in 2020 . El PasoOur study contributes to understanding how racial, ethnic, socioeconomic, and other intersectional experiences are predictive of health outcomes within regional and historical contexts. First, we provide a brief overview of how the COVID-19 pandemic has unfolded in El Paso and its “sister city” of Ciudad Juárez, Mexico. Then, we describe the methodology employed in gathering comprehensive survey data on Hispanics living in El Paso and compiling our risk assessment. The subsequent section analyzes significant demographic, socioeconomic, and health factors that encompass essential determinants of health and risk associated with COVID-19. These measures allowed us to predict Hispanic El Pasoans’ high risks of hospitalization and death related to COVID-19 before the pandemic struck El Paso, and thus demonstrate the foreseen impact of COVID-19 on the Latin community in the U.S. ,9,10,11.In the early months of 2020, cities and entire regions around the world declared public health emergencies while COVID-19, also known as coronavirus, stole millions of lives and disabled many more . Its arrThe great loss that the U.S. experienced in 2020 was also reflected in local cities’ rates of hospitalization and death related to COVID-19, which tracked demographic data and allowed researchers to glimpse the differences in rates across ethno-racial groups. In New York, the Bureau of Communicable Disease Surveillance System reported that, as of 16 April 2020, the death rates for Blacks were 92.3 per 100,000 people, and 74.3 per 100,000 for Latinos . In compAs the COVID-19 pandemic continued to unfold and healthcare workers fought to save lives, a familiar pattern arose that concerned researchers and advocates: Black and Hispanic individuals were not only suffering from more infections but also dying at incredibly higher rates than White and Asian people ,15.El Paso is city in the western corner of Texas, bordering Las Cruces, New Mexico, and directly to the south, Ciudad Juarez, Mexico. El Paso City’s population was around 649,000 in 2010 and 679,000 in 2020 and El Paso County has over 800,000 residents. El Paso is around 83% Hispanic. El Paso is a majority Latin city, with over 24% of the population being foreign-born . It alsoEl Paso experienced mounting pressure as time passed in the first months of the pandemic. Sixty-five people were hospitalized in El Paso in the first week of May 2020, and 17 were put on ventilators . Local pCiudad Juárez, which sits on the Mexican side of the border right next to El Paso, was also grappling with an upward trajectory of COVID-19 cases. El Paso and Ciudad Juárez are sister cities that are economically and socially intertwined. The first case of COVID-19 in the Mexican state of Chihuahua was confirmed in Ciudad Juárez on 17 March 2020, not long after cities in the U.S. began issuing public health mandates, mandatory quarantines, and other lockdown procedures . Since tThe border cities of Tijuana and Juárez, where Mexican and U.S. nationals travel to and from every day, and the popular destination of Cancún, had the three highest rates of documented COVID-19 cases in Mexico between January and May 2020 . Things The data used in this study were collected through ethno-surveys, which provided close-ended and open-ended data regarding health, employment, socioeconomic status, housing, transborder habits, and citizenship. These surveys were conducted in 2011–2012, nine years before the start of the pandemic, as part of a study funded by the National Institutes for Health (NIH) conducted by Dr. Ernesto Castañeda and research teams who trained for several months as part of a research methods course. The sample consisted of 1152 Hispanic respondents aged 18 and over residing in El Paso, Texas. All surveys were conducted and recorded in Spanish and/or English (at the preference of the respondent) in a variety of locations in El Paso, such as at individual’s homes, shelters, and workplaces. Only close-ended questions from the ethno-surveys are referenced in this study. All researchers who participated in data collection were certified to work with human subjects, and the project had IRB approval from the University of Texas, El Paso. The NIH’s National Institute on Minority Health and Health Disparities further reviewed and approved the project before releasing funds.The risk assessment comprises several analyses conducted using the IBM SPSS 27 statistical package. Notably, we used purposeful sampling techniques  that speUndocumented Hispanics and those experiencing housing insecurity were over-sampled because of their relative exclusion across census counts and research studies . TherefoThe data precede the COVID pandemic, but when we embarked on this analysis, we wondered whether they could be used as a baseline to calculate population risks before the pandemic struck El Paso. It is safe to assume that most of the people who participated in the survey still reside in El Paso and that the demographic and health profile has not changed much; if anything, it may have worsened as the people in the sample have aged, but this also depends on the health status of the younger generations for whom comparative data do not exist. Health data are seen as a personal attribute, and patients’ data are protected by HIPA. Even if hospitals engage in big data analysis with their anonymized patient data, they do not have access to all types of populations in a city; thus, the importance of databases such as this. Risk is not only related to physiological factors but also socioeconomic, cultural, racial, and ethnic ones. The CDC distinguishes racial and ethnic minorities, as well as people who are currently homeless, pregnant, and breastfeeding, as individuals who are “high-risk” for COVID-19 . This isThe Latin population in the United States has received relatively little attention in relation to the pandemic despite its vulnerability to COVID-19. This is especially true in the city of El Paso, Texas, where Hispanics constitute over 83% of the population and have suffered disproportionately from the pandemic’s damage . On 28 MThe Hispanic community is an integral part of the U.S. labor force. In 2018, 17% of the national labor force was comprised of documented Hispanic citizens, 61% of whom were Mexican . HoweverFurthermore, the CDC reports that at least 25% of the Hispanic population in the U.S. is employed in the service industry, including hospitality, transportation/travel, delivery, food, healthcare, and education services . UnfortuThen, there are those who were considered “essential” employees, including people working in grocery stores, mail services, agriculture, city maintenance, and construction, in addition to the service industries mentioned earlier, who were legally required to work in person during the pandemic. Laws surrounding “essential and emergency employees” require that such employees continue working through national emergencies, including those who are immunocompromised or have pre-existing health conditions . This maIncarcerated populations in prisons, jails, and juvenile delinquent centers are also at higher risk of severe illness related to COVID-19. The close quarters, shared spaces, and lack of comprehensive medical care in correctional institutions create a breeding ground for the virus. The Marshall Project reports that there were at least 9437 cases of positive COVID-19 diagnoses in state and federal prisons across the U.S. as of 25 April 2020 . As a reIn the second year of the pandemic, the institution’s reporting habits had not improved. The Federal Bureau released information indicating that 799 federal inmates tested positive for the virus, along with 319 staff members. Although no staff member was among the deceased, 27 inmates died from virus-related complications. Furthermore, three inmates died at Fort Worth Federal Medical Center alone, and all federal prisons in Texas currently had at least one positive diagnosis within the facility . The MarThis puts racial and ethnic minorities at further risk, given the mass incarceration of communities of color. In the U.S., Hispanics are imprisoned at a rate 1.4 times higher than that of Whites . In 2016Juvenile delinquent centers incarcerating children ages 10 to 17 share similar demographic trends with adult correctional institutions. The Department of Justice revealed that Latino youth in the U.S. have a 65% higher chance of being detained and incarcerated than their White counterparts . This prImmigration status dramatically impacts an individual’s access to healthcare and medical treatment. Our data revealed that the likelihood of being medically insured increased with the stability of immigration status, as detailed in These data were obtained before the Affordable Care Act was passed. Still, the Affordable Care Act does not provide coverage for all immigrants and excludes the undocumented community from nonemergency services . RecipieUpon assessment of Hispanics who fulfilled the CDC criteria for individuals at high risk of severe illness related to COVID-19, our data, as shown in The U.S. struggles to provide affordable housing and address homelessness. In 2019, over 500,000 people were estimated to have been homeless on any given night nationwide . People People experiencing housing instability are also less likely to have access to masks, gloves, and other materials that prevent the spread of the virus. This also includes basic hygienic facilities and necessities, such as soap . They caAdditionally, Hispanics experiencing housing instability constituted only 0.3% of those with a high-risk medical condition. However, they are still considered particularly vulnerable because of their heightened likelihood of contracting COVID-19 and limited access to medical providers. Individuals and families experiencing homelessness who are uninsured have a decreased likelihood of being tested for COVID-19 and adequately treated for potentially fatal symptoms see . FurtherAltogether, experiencing homelessness can almost guarantee poorer health outcomes. Compared to housed individuals, people who have ever experienced homelessness are more likely to face health issues, have unmet healthcare needs, and be subject to accelerated health erosion ,48,49. TOf the total sample, 52.1% could be classified as low-income and 7.1% as high-income. Racial and ethnic minorities who are low-income are at heightened risk of severe illness related to COVID-19. As shown in It is vital to analyze the risks associated with socioeconomic status, race, ethnicity, and pre-existing health conditions because they are often co-occurring factors that influence an individual or community’s well-being and life expectancy. Similarly, among immigrants, income and employment are intimately associated with citizenship, immigration status, and health insurance. The same is true for people experiencing homelessness, who are typically low-income and vulnerable to COVID-19 . In May 2020, the CDC stated that “older adults and people of any age who have serious underlying medical conditions” are at highest risk of severe illness from COVID-19 . It defip < 0.01 or significantly exceeding the average percentage of the sample population. In the section below, we outline a set of analyses that explore the prevalence of high-risk pre-existing health conditions as they relate to medical insurance status, socioeconomic status, medication, age, and homelessness. We included data on medical insurance, socioeconomic status, and age for all conditions. We included information on medication and homelessness only when the findings were at least statistically significant at Two variables were created to paint a clearer picture of Hispanics’ COVID-19 risk profiles. Individuals who had been diagnosed with one or more of the above diseases were categorized into an “at-risk” group, and then further sorted according to their pre-existing condition. Those with two or more, as well as three or more, conditions were grouped into their respective categories because of their compounded physiological vulnerabilities to severe illness related to COVID-19. Emphysema, tuberculosis, and HIV/AIDS were not included in these variables, and because their prevalence is very low, this does not have a significant effect on the results. The table below outlines the percentage of the Hispanic population of El Paso in 2011–2012 that is considered high-risk according to an individual’s number of pre-existing conditions see .Obesity, hypertension, asthma, and type 2 diabetes were the most common illnesses to render Hispanics at high risk. Most notably, however, is that the majority of Hispanic individuals had been diagnosed with one or more health conditions that put them at risk of dying from COVID. Altogether, those with compounded risk comprised about one-third of the total Hispanic population of El Paso at the time that the survey was taken. This indicates poor widespread health outcomes in the community overall and the importance of extreme public health precautions in dealing with respiratory pandemics. Additionally, differences in disease prevalence arose when risk was cross-analyzed with place of birth. In These disparate health outcomes were more closely examined by separating each specific illness according to individuals’ birthplaces, shown below in These findings challenge previous research on what scholars have labeled the “Immigrant Paradox”. A close cousin of the Hispanic Health Paradox, this contradiction arose when researchers began seeing an unexpected pattern in the health outcomes of foreign-born people in the U.S. In general, the Paradox asserts that immigrants exhibit significantly better physical and mental health compared to their native-born counterparts, even within racial and ethnic subgroups of the country’s population ,53,54,55In El Paso, 16.0% of Hispanics reported a high blood pressure diagnosis, and 59.5% of them were low-income. High blood pressure, also known as hypertension, has been coined the “silent killer” given the absence of symptoms that accompany it. Many people go unaware of their high blood pressure, which can lead to the development of kidney disease, cardiovascular diseases, or fatal cardiac events, such as heart attack or stroke . AccordiAlthough high blood pressure is a cause of serious health conditions, medical coverage varied greatly among those with diagnoses. Our analysis revealed that 33.7% of Hispanics were aware of their high blood pressure but were not medically insured. Even though these individuals knew of their diagnosis, they either chose not to enroll in medical insurance or could not because of cost or citizenship status. High cholesterol was almost equally as common as hypertension within our sample, as 12.9% of Hispanics reported being diagnosed by a health professional. Similar to high blood pressure, people are often unaware of their cholesterol levels until a serious or fatal event occurs. High cholesterol is a predicting factor of heart disease, hypertension, and type 2 diabetes . Low-lipThis analysis showed that 28.8% of those diagnosed with high cholesterol did not have medical insurance at the time. More than half (52.8%) of those who had been diagnosed were low-income, whereas 10.2% were high-income. Because of these disparate figures, it is possible that socioeconomic status plays a role in the stress and diet, both of which impact cholesterol levels of Hispanic El Pasoans. Age was also an important factor in analyzing cholesterol, as the majority of cases occurred among people between the ages of 46 and 65. The study revealed that 7.6% of Hispanics reported asthma diagnoses. When treated and closely monitored, asthma is not life-threatening. However, if someone with asthma has an asthma attack and lacks access to an inhaler or ventilator, then it can be fatal. An attack is caused by severe inflammation that constricts and narrows the air passages that lead to the lungs . CommuniOut of this portion of the Hispanic population in El Paso, approximately half (51.7%) did not have medical insurance to help them manage their asthma diagnosis prior to the Affordable Care Act. An individual’s socioeconomic status also informed the likelihood of receiving an asthma diagnosis, given that 56.3% of Hispanic residents with asthma were low-income and 42.1% middle-income. A small percentage (2.6%) of Latin individuals in El Paso reported a previous heart attack or stroke. Given the significance of socioeconomic status and medical insurance in the previous analyses, it is perhaps unsurprising that 27.4% were not medically insured, and an overwhelming percentage (72.8%) were low-income. Socioeconomic status was also associated with the use of medication to treat heart attack or stroke, as half (50.2%) of low-income Latin individuals who received this diagnosis reported being on medication compared to 83.2% of middle-class Hispanics. When examining the age groups most affected by these conditions, our data showed that 27.2% of heart attacks or strokes were reported by people between the ages of 60 and 80. Deaths caused by COVID-19 are highest among those over the age of 64, so Latin individuals in this age group who have suffered a heart attack or stroke have compounded risk factors that render them disproportionately vulnerable to COVID-19-related complications .Heart attack and stroke are often caused by high cholesterol, as the low-lipid cholesterols create buildups of plaque that block proper blood flow to the heart and brain . A heartThe physiological processes leading to stroke are similar to those that result in heart attacks, although the life-long impacts may differ greatly. Depending on the part of the brain that was depleted of blood, stroke can cause paralysis, memory loss, changes in behavior, speech issues, and/or vision impairment. In extreme cases, individuals lose entirely the ability to speak or move their body . Those wA minority (1.3%) of survey participants had received an emphysema diagnosis. Emphysema is a chronic lung disease that heightens one’s susceptibility to severe illness . SmokingOur data revealed that about one-quarter (27.4%) of those who were diagnosed with emphysema was not medically insured. Furthermore, emphysema was associated with lower socioeconomic status, as 54.5% of those with emphysema were low-income, whereas none were high-income. Regarding age, emphysema most commonly affected people ages 60–85, an age group that has been classified as particularly susceptible to severe illness or death related to COVID-19 [A total of 2.2% of the Hispanic population of El Paso reported a diagnosis of hepatitis, cirrhosis, or both. All hepatitis infections  are inflammatory and occur in the liver, as well as cirrhosis, as cirrhosis is technically the progression of any liver disease . HepatitOf those who received a diagnosis, 33.6% are not medically insured. This diagnosis was distributed unequally across socioeconomic classes, given that low-income Hispanics once again constituted the majority at 77.8%, which is also the highest percentage across the illnesses in this risk assessment. Clearly, hepatitis and cirrhosis diagnoses are impacted by an individual’s financial and social standing. This diagnosis also happened to almost exclusively strike young people between the ages of 18 and 30, indicating that younger people may be more susceptible to contracting hepatitis or developing cirrhosis.Around 2.3% of Hispanic study participants reported kidney disease, of whom 42.2% did not have medical insurance and therefore struggled to receive regular care. Many of those with kidney disease diagnoses were middle-income (52.8%) and low-income (41.3%). Kidney disease is an illness that does not exhibit symptoms until the occurrence of a potentially fatal event, such as kidney failure. It is intimately linked with heart disease, diabetes, high blood pressure, and certain forms of cardiovascular disease known to cause or evolve into kidney disease. Further, it is a chronic disease, meaning that the kidneys are permanently damaged and cannot properly filter blood. Unless the patient immediately changes their diet and seeks medical treatment, their condition will worsen with time . A shareThose with cancer diagnoses amounted to 1.4% of the Hispanic population, which is approximately equal to the proportions of kidney disease and heart attack/stroke. The ethno-surveys also revealed that 16.8% of Hispanic residents of El Paso who had cancer were uninsured, one of the lowest rates of lacking medical insurance across this report. This could be because the culture surrounding cancer in the United States is serious and fearful, which encourages people to remain insured after a diagnosis. People who are nearing remission, are in remission, or may have been diagnosed as a child are also among those who are likely to be insured. Approximately half of the Hispanic residents diagnosed with cancer at some point in the past are of low socioeconomic status (50.1%), whereas 40.9% are considered middle-class. However, the ages of people who reported cancer diagnoses at one point in their lives varied greatly: 8.3% were ages 18–25, 16.6% were ages 31–35, and 8.3% were ages 46–50. Ultimately, the highest rates were reported by people between the ages of 51 and 65, who constituted 58.2% of the diagnosed population. This is significant because people ages 65 and older are considered “high risk” by the CDC for COVID-19. Hispanics who also have cancer are more likely to be negatively impacted by COVID-19. Nonetheless, this overall assessment shows how uncommon it is for older Hispanic people in El Paso to have cancer.The unweighted sample with over-representation of people experiencing homelessness has a 0.2% HIV rate. In our survey, 100% of those with HIV/AIDS were homeless at the time of the survey. Given the high-risk status associated with being homeless and having a positive HIV/AIDS diagnosis, respectively, this portion of the Latin population is extremely vulnerable to health complications or death related to COVID-19.The percentage of those with HIV/AIDS in our weighted data constitutes about 0.00002% of all Hispanics living in El Paso, which is significantly lower than the 2019 national percentage of 0.34% ,68. HoweNone of the HIV/AIDS-positive Hispanic residents in the sample were medically insured. Although the number of HIV/AIDS-positive people in the data is small, it is nonetheless worrisome, considering that HIV/AIDS killed over 37,000 people in the U.S. in 2018 . The yeaThe rates of tuberculosis are falling 2% each year globally, but it is still one of the top 10 leading causes of death worldwide . A quartThe prevalence of tuberculosis is low in the El Paso community. Only 0.2% of the Hispanic community of El Paso reported having tuberculosis at one point in their lives, approximately half (49.6%) of whom have medical insurance. This is concerning because all of the tuberculosis diagnoses occurred among Hispanic people of low socioeconomic status who might not be able to afford the proper treatment or medicines without pharmaceutical or medical insurance coverage. Individuals over the age of 45 recalled no previous bouts of tuberculosis—instead, almost half of the reported diagnoses occurred among people aged 18–25. According to our survey data, 7.3% of Hispanics in El Paso reported a diabetes diagnosis, 60.1% and 3.3% of whom were low-income and high-income, respectively. More than half (65.5%) had medical insurance, but 34.5% were not insured. According to the CDC, diabetes puts one at considerably higher risk of severe health complications related to COVID-19 given that nearly half (49.7%) of people hospitalized with severe virus-related illness as of 30 March 2020 had a previous diabetes diagnosis .Low insulin adherence, which puts individuals in danger of unregulated and dangerous blood sugar levels, can be attributed to multiple factors such as access, affordability, willingness, and guidance on self-administered injection. This was a concern with our sample because only 31.2% of Hispanics with diabetes took insulin at least once. Positive diabetes diagnoses varied considerably according to age, and Hispanics over the age of 60 constituted 29.3% of total cases. This presents evidence that an insulin adherence barrier affected multiple different age groups. Previous research has drawn connections between low insulin usage and depression, embarrassment, a busy schedule, and travel among people living with type 2 diabetes ,72. PatiThe survey data draw awareness to a persistent problem affecting the Hispanic community’s well-being. Individuals with diabetes who are not receiving proper insulin treatment, if receiving any at all, will likely be hit harder by a positive COVID-19 diagnosis than those who follow regular schedules and guidelines outlined by a health provider. These are significant findings that reveal the disproportionately poor health experienced by Hispanic individuals living with chronic diseases and inform us of who might be especially vulnerable to COVID-19. Just over one-quarter (26.2%) of survey participants were considered obese, of whom 3.4% were considered severely obese with a Body Mass Index (BMI) of 40 or higher . Almost Obesity, characterized by a body mass index of 30 or higher, increases a person’s vulnerability to severe illness related to COVID-19 . The CDCThroughout this paper, we dissect the socioeconomic factors that tie into health and well-being and their detrimental effect on racial and ethnic minorities. The COVID-19 pandemic, albeit unexpected, further exposed and reproduced health disparities that were previously less discernible to the general public. The Hispanic community across the United States is already at higher risk of COVID-19 because of institutional discrimination across the sectors of employment, housing, and health. In El Paso, where more than half of Hispanics were of low socioeconomic status, and 48% lacked medical insurance a decade before, their chances of suffering from severe illness related to COVID-19 are even higher. This is particularly dangerous for those with pre-existing health conditions, such as type 2 diabetes, cardiovascular disease, HIV/AIDS, and cancer. It remains unclear whether more Hispanics living in the U.S. will die from COVID-19 than other racial and ethnic groups, as the pandemic has not run its full course. However, preventive measures must be taken in order to protect the Hispanic community in El Paso from tragedy, including the proper allocation of health resources and financial support for low-income, homeless, undocumented, and medically uninsured individuals.Although discussion of racial disparities is critical, it is just the tip of the iceberg. Health disparities explain how communities of color disproportionately suffer from poor health, but not why state and federal institutions do not properly allocate health resources. The heart of the problem lies in systemic racism, discrimination, and state-sanctioned violence against minorities. Given that communities of color face many structural inequalities, such as poverty, residential segregation, racism, and access to healthcare, they are not to blame for pre-existing or virus-related health disparities . We shoupromotoras de salud and provide referrals to critical medical care for sub-populations at higher risk. In addition, further research should investigate the lasting effects of COVID-19 infection and “long-COVID” on these groups.In this study, we have outlined how it is not a coincidence that infection and death rates of COVID-19 among Native American, Black, and Hispanic populations in the U.S. have been among the highest in the world since the beginning of the pandemic. Structural inequalities incurred by institutional racism have created, and continue to create, underlying medical conditions and enable increased exposure to the virus, which puts Native American, Black, and Hispanic citizens in far more vulnerable positions regarding COVID-19 than their non-Hispanic White counterparts. When assessing preventative and recovery measures, policymakers and public health officials should consider pre-existing health disparities and their heightened likelihood of working essential or frontline jobs ,32. CitiThe dataset used to assess the risk that the population of a city had to COVID was collected much before the pandemic started. Nonetheless, this paper shows how similarly detailed data about a city or population can and should be used by public health officials in a preventive fashion to reduce deaths. Public health data should not be limited to prevalence rates, and epidemiology, but should also include social variables and cultural and sociological insights to include the role of beliefs and ideas in health-seeking behavior and the role of socioeconomic factors in producing different health outcomes between and among ethnic and racial groups. Migration and immigration status are essential determinants of health and well-being. Longitudinal health and social data of large and diverse samples that oversample minority, immigrant, and unhoused individuals are an important tool in creating a healthy population.