Among brominated flame retardants (BFRs), polybrominateddiphenyl ethers (PBDEs) and hexabromocyclododecanes (HBCDs) were the most widely used in past decades. BFRs not being chemically bonded to polymers means they can easily leach from the products into the environment and bioaccumulate. Humans are exposed to flame retardants mainly through food consumption, especially fish and fish products. In the present study, the occurrence of PBDEs and HBCDs in freshwater fishes and crayfish from Lake Trasimeno  was assessed according to monitoring plans recommended by European competent authorities. The dietary exposure of the central Italian population to such molecules was calculated, and the risk characterization and the benefit–risk evaluation were also assessed. A total of 90 samples were analyzed by means of gas and liquid chromatography associated with triple quadrupole mass spectroscopy. A total of 51% of samples were found positive for at least one of the congeners; the most frequently found molecule was BDE-47. The data on dietary exposure ranged from 0.138 to 1.113 pg/kg body weight/day for ∑PBDE and from 0.805 to 0.868 pg/kg body weight/day for ∑HBCD. The data show no health risks for the central Italian population consuming freshwater fish products from Lake Trasimeno in relation to exposure to PBDE and HBCD. The term flame retardants (FRs) refers to a diverse group of chemical compounds which are added to manufactured materials, such as plastics, textiles, circuitry and building materials, in order to prevent or delay flames . One of Since the early 1970s, the most widely used BFRs have been polybrominated diphenyl ethers (PBDEs), a class of 209 congeners which differ in the number and position of the bromine atoms in the two phenyl rings and are commercialized as three technical mixtures characterized by different bromination degrees: penta-BDE, octa-BDE and deca-BDE . As theyDespite the advances in the prevention of fire incidents reached by using FRs, the prolonged, extensive and frequently unrestricted use of these compounds in the past has resulted in their ubiquitous diffusion in various environmental matrices ,17. As aPBDEs can cause hepatocellular hypertrophy, developmental and reproductive impairments, perturbation of thyroid hormone regulation and fetotoxic effects . SimilarIn this context, the present study aimed to define the dietary exposure to PBDEs and HBCDs of a population in central Italy in relation to the consumption of freshwater fishes and crayfish caught in Lake Trasimeno . The consumers’ risk related to dietary exposure to such molecules was characterized, and a benefit–risk evaluation associated with the consumption of these selected food products was also performed.2, but it is quite shallow with a maximum depth of 6 m , goldfish , tench , eel , perch , and crayfish . Fishes and crayfish were collected within the framework of the official monitoring program during the years 2018–2021 according to the EC Regulation 2017/644  × 1000 × WL, where AX is the EPA or DHA area, AIS is the internal standard area, CRFx is the theoretical correction factor for EPA and DHA, CNFx is the conversion factor from FAME to the corresponding fatty acid (EPA and DHA), WIS is the weight of the internal standard  added to the lipids, Ws is the weight of the derivatized lipids and WL is the percentage of sample lipid.The dietary exposure was evaluated through the definition of the estimated daily intake (EDI) of PBDE and HBCD flame retardants .In this scope, EDI was obtained by multiplying the LB and UB concentration of such molecules in food by the amount of fish consumed daily by an average adult weighing 70 kg ,28. A qu10) for neurodevelopmental effects in mice, identified as the critical endpoint for some PBDEs [10 was not defined, and the LOAEL was used to define the chronic human dietary intake [In order to quantitatively estimate the severity of potential adverse health effects in the given population, the risk characterization of PBDEs and HBCDs was performed by means of the margin of exposure (MOE) approach as reported in the literature ,11,29. Tr,h), which reflects the steady state body burden at the calculated BMDL10 or at the LOAEL, considering the fraction of the daily intake that absorbed and the body constant rate of the elimination of the compounds [The chronic human dietary intake ;DEDI—estimated dietary intake (µg kg—1 b.w.).10 of 0.172, 0.0042 and 0.0096 µg/kg b.w./day for BDE-47, -99 and -153, respectively, were considered. In contrast to the other PBDE, for BDE-209, the BMDL10 of 1700 µg/kg b.w./day expressed as an external dose can be compared with the estimated human dietary exposure [According to EFSA, relevant toxicity data were available only for BDE-47, -99, -153 and -209; therefore, in the present study, the risk assessment was carried out exclusively for these four PBDE congeners [exposure . The calexposure .Beneficial and adverse effects may occur simultaneously in a specific food item within the same range of dietary intake. In order to weigh the benefits and risks associated with food consumption, they should be evaluated and expressed in a comparable way in accordance with the benefit–risk assessment (BRA) paradigm .In the present study, the benefit assessment of fish consumption refers mainly to the ingestion of omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), identified as active factors in cardiovascular disease prevention ; risk faAiming to perform a quantitative estimation of the health benefits of Lake Trasimeno fish consumption, the EPA and DHA content of these fishes was determined analytically as above mentioned, and the exposure assessment of such nutrients in the target population was performed as mentioned above for toxicologically relevant contaminants . SubsequFA is defined as follows:FA (mg/day) is the recommended dietary intake of EPA + DHA. In this study, the RDI of 250 mg/d for a healthy adult [FA (mg/g) represents the concentration of EPA + DHA in fish muscles. The maximum allowable fish consumption related to toxic effects (QT) can be defined according to the following equation:T were 100 ng/kg b.w./day for BDE-47 and -99, 200 ng/kg b.w./day for BDE-152, 7000 ng/kg b.w./day for BDE-209 and 200 ng/kg b.w./day for HBCDs [The benefit–risk quotient (BRQ) was applied to integrate benefit and risk assessment outcomes for the simultaneous ingestion of omega-3 fatty acids and contaminants through freshwater fish consumption, as reported in the literature ,33:(2)BRhy adult  was applor HBCDs ,36,37,38BRQ values below 1 suggest that achieving the recommended intake of EPA + DHA poses no evident risk to human health linked to the intake of flame retardants through fish consumption ,33. Perca fluviatilis) collected from lake Piediluco (Umbria region) were analyzed for PBDEs and HBCDs contamination as well as for EPA and DHA content by means of the above-mentioned analytical methods. The risk characterization and benefit–risk assessment were performed, and the results were compared to those of Lake Trasimeno in order to assess the impact of the pollution pressure in relation to the specific habits of the fish species.A comparative assessment was performed to evaluate different contamination patterns related to aquatic environments situated in the same geographical area  but characterized by different conformation, ecology and pollution pressure. For this purpose, samples of the same species inhabiting two different waterbodies were considered. A total of 10 samples of perch  and for three HBCD isomers . BFRs were detected in 46 of the 90 (51%) samples analyzed: 17  were contaminated with one analyte (involving mainly perch) and 29 (32%) with more than one; samples below the LOQ for all BDE and HBCD were 44 , represented mostly by goldfish and tench . The average PBDEs’ and HBCDs’ LB and UB concentrations in each species considered are shown in The food consumption survey shows that the average consumption of freshwater fish species for average adult consumers was 0.47 g/kg b.w./day.In Concerning HBCDs, the total EDI was 0.805 pg/kg b.w./day (ranging from 0.001 to 0.344 pg/kg b.w./day) and 0.868 pg/kg b.w./day (ranging from 0.014 to 0.455 pg/kg b.w./day) for LB and UB, respectively. The highest value recorded is attributable to eel for α-HBCD LB and UB (0.337 pg/kg b.w./day). Additionally, for the other species, α-HBCD represented the highest of the three isomers with the exception of crayfish, which showed relevant levels of γ-HBCD . The mai10, in accordance with EFSA scientific opinions [In the present study, the risk characterization of toxicologically relevant PBDE congeners and ∑HBCDs was performed by means of the MOE approach by comparing the minimum LB and maximum UB dietary intake for the different molecules with the estimated human intake associated with the body burden at the BMDLopinions ,11. The opinions ,11.The beneficial and adverse effects that may occur simultaneously in the selected freshwater food matrices have been weighted in a comparable way, in accordance with the benefit–risk assessment . The benThe comparative assessment of different contamination patterns through the study of the same species from different water bodies (Lake Piediluco and Lake Trasimeno) showed in perch from Lake Piediluco average LB values of PBDEs ranging from 0 to 130 pg/g w.w. and of HBCDs from 0 to 748 pg/g w.w. Average UB values ranged from 10 to 130 pg/g w.w. and from 12 to 748 pg/g w.w. for PBDE and HBCD, respectively. The most represented PBDE was -47 followed by -99. The exposure values to toxicologically relevant congeners ranged from 0.001 to 0.373 pg/kg b.w./day for LB values and from 0.001 to 0.378 pg/kg b.w./day for UB values . Values for BDE 209 have been divided by a factor of 1000 and those of ∑HBCD by 10 to allow for a correct interpretation of the graphic.Despite the ubiquitous distribution of PBDEs and HBCDs, the results of their occurrence in edible species from Lake Trasimeno were characterized by a high proportion of non-detects in accordance with that reported in the literature ,11. As mPBDE and HBCD concentrations found in the present study are similar or lower than those observed in previous studies in freshwater species from different countries, albeit the comparison of contamination levels could be difficult due to the different number and type of congeners and isomers analyzed. For eel, Malarvannan et al.  in BelgiThe characteristic biology of eels as bottom dwelling predators with high body fat makes this fish particularly vulnerable to chemical pollution . For insFor common carp harvested in Chinese freshwater basins, ∑PBDEs have been found in concentrations of 19.78 ng/kg l.w. in 2009, 16.48 ng/kg l.w. in 2010 and 5.54 ng/kg l.w. in 2011 . In the In crucian carp from south China, the registered ∑PBDEs were 1430 ng/kg l.w. . Much loConcerning perch from Czech rivers, in a study by Hajslova et al. , the amoAs regards goldfish, an average value of 2.83 ng/g w.w. ∑HBCD and of up to 0.69 ng/g w.w. for α-HBCD was registered for fishes caught in the Czech Republic ,51. Qiu As shown, a comparison between studies is likely to result in large variations in BFR concentrations in fish meat, as these largely depend on the pollution pressure at the sampling site, on the year of sampling, on specific metabolic differences and on the age of the fish and lipid content as well as other physiological differences among fish species ,54.Furthermore, another reason for the different contamination patterns observed for species inhabiting the same aquatic environment may be found in the different feeding habits of fishes. A previous study found that carnivorous fish species may present higher amounts of contaminants than herbivorous and detritivorous ones, suggesting the potential for biomagnification of BFRs via the trophic chain . In partThe dominance, among the other congeners, of BDE-47 shown in the present study is congruent with the general pattern found in fish species in the literature ,15; thisIn HBCD technical mixtures, the γ- isomer is the major component ,15; howeConcerning the average amount of fish consumption, the data reported in the present study are lower than those of the literature ,66. EFSACongruent with the data on occurrence and with the literature, the exposure of the general population is evidently highly variable among different parts of the world and also within some individual countries . The valAs shown in a previous study on exposure assessment to PBDEs, the highest estimated intake in the present study was from BDE 47 and BDE 209 ,66,67,68The observed exposure data and risk characterization according to the EFSA approach resulted in calculated MOE values remarkably higher than the critical values for PBDE-47, -99, -153 and -209, as well as for ∑HBCDs, indicating that that the estimated dietary exposure through consumption of fish from Lake Trasimeno is unlikely to be a significant health concern for the central Italian population. It should be pointed out that the presented risk assessment was performed only for toxicologically relevant congeners and for a specific population subgroup; therefore, the cumulative EDI for the potential presence of various BFRs and their possible metabolites in foodstuff is likely to be under-considered. Zacs et al.  defined The comparative assessment between perch samples from the two different lakes revealed higher values of toxicologically relevant contaminants in Piediluco Lake. The reasons for these results probably lie in the fact that this basin is connected to the Rivers Nera and Velino, becoming a reservoir subjected to pollution load due to the discharge of the two rivers, while Trasimeno Lake is characterized by the absence of a tributary and the absence of industry and industrial pressure.After the ban on or restricted use of PBDE and HBCD commercial mixtures in the EU, recent exposure to these contaminants is most likely due to the release of such molecules that have accumulated in environmental matrices, such as soils and sediments, and to those still present in manufactured materials. The fact that HBCDs and PBDEs are still found in fish also indicates their high bioavailability and bioaccumulation potential. The level of fish contamination and, consequently, the general population’s exposure to them are characterized by high variability among different areas of the world and even within the same country. Overall, based on currently available toxicological data, it can be concluded that PBDE and HBCD show no health risks for the central Italian population consuming freshwater fish products from Lake Trasimeno. However, for fish species inhabiting an ecosystem characterized by a relevant pollution pressure, an appropriate monitoring plan by means of official control activity is crucial to ensure the health of consumers.


Non-muscle-invasive bladder cancer (NMIBC) still poses a heavy load for resulting in many new cases which contribute significantly to medical costs. Although many NMIBC guidelines have been developed, their implementation remains deficient.This study was conducted in order to analyze the knowledge of and compliance with the guidelines for NMIBC of Chinese urologists and to identify associated factors.We conducted an online survey between August 2019 and January 2021. Respondents who were more than 65 years old or did not give informed consent were excluded. Linear/logistic regressions were performed to identify factors associated with the knowledge of and compliance with the guidelines of urologists, respectively. McNemar’s tests were used to explore the divergence between knowledge and compliance.p < 0.001).A total of 814 responses were received, and 98.77% of urologists acknowledged the positive effects of high-quality guidelines. The average knowledge score was 6.10 ± 1.28 (out of a full score of 9), and it was positively associated with educational level and the number of guidelines consulted. Only 1.61% and 39.36% of the respondents realized that the guidelines did not recommend further chemotherapy or BCG infusion for low-risk patients. There were 38.87% and 51.84% respondents “often” or more frequently utilizing BCG therapy for intermediate- and high-risk NMIBC patients, respectively. Divergence between knowledge and compliance in performing a second TURBT after incomplete initial resection reached statistical significance (Although the vast majority of urologists acknowledged the positive effects of guidelines, knowledge of and compliance with some recommendations of NMIBC guidelines are still inadequate. Factors associated with guidelines, individual professionals, patients, organizations, and the environment jointly contributed to the non-compliance. NMIBC sFor the universal coverage of high-quality medical services, institutions and academies worldwide have invested substantial resources in developing treatment guidelines. The European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and American Urological Association (AUA) have published guidelines relating to NMIBC, and all of them updated their guidelines last year. However, although the positive effects of guidelines have been demonstrated , 6, manyThe knowledge, attitude, and behavior of urologists have a great impact on the process from guideline to practice . Howevervia a QR code posted on several national urological specialist forums in China. Meanwhile, we requested respondents to help us disseminate the questionnaire. Information for informed consent included the statement that individual responses would remain anonymous. Respondents who were more than 65 years old or did not give informed consent were excluded. No incentive was offered for participation.Applying convenience and snowball sampling, we conducted an online survey on the knowledge of and compliance with NMIBC guidelines of Chinese urologists from October 2019 to January 2021. The questionnaire link was sent An exhaustive online literature review of NMIBC guidelines worldwide was conducted. We had appraised the quality of NMIBC guidelines within the past 5 years and compared the similarities and differences of therapeutic recommendations between guidelines previously . Based oFinally, the questionnaire consisted of the following six sections: i) demographic characteristics of urologists; ii) attitude toward guidelines in general, where the information of preferred guideline developers were gathered; iii) clinical utilization of chemotherapy and BCG; iv) knowledge of guidelines, in which the knowledge score of recommendations in NMIBC guidelines was assessed by nine items, while each item scored 1 point. Regarding the indications for surgery, given that all of them were extracted from the guidelines, 1 score was divided equally among each option ; v) compliance with guidelines, which focused on the strategy of chemotherapy and BCG for patients of each risk classification ; and vi) barriers in clinical practice, which involved the barriers that respondents met in the clinical practice of a second TURBT, BCG, and radical cystectomy , and a two-sided A total of 814 responses were received, 2 of which were excluded for overage and informed disconsent, respectively. The vast majority of respondents were working in tertiary hospitals (78.45%), had been in practice for more than 15 years (63.18%), and had a master’s degree or above (56.28%) Table 1.There were 79.25% of the respondents who reported that low-risk NMIBC patients agreed to have chemotherapy for immediate course together with maintenance course. Respondents who reported that they “often” or more frequently utilized BCG therapy for intermediate- and high-risk NMIBC patients were only 38.87% and 51.84%, respectively.For patients from each risk classification, at least 49.32% respondents scheduled induction course of intravesical chemotherapy instillations of 4 to 8 weeks, and 47.62% or more respondents scheduled a maintenance course of 6 to 12 months (The average knowledge score of respondents was 6.10 ± 1.28 (out of a full score of 9). “The range of initial TURBT” (97.40%) and “whether to perform an immediate postoperative instillation” (96.77%) got the highest correct rate Table 2.plow < 0.001). For intermediate-risk patients, although BCG was widely recommended in the guidelines, the compliance rate (67.62%) was much lower than that for chemotherapy (92.99%). More respondents (89.00%) suggested further chemotherapy for high-risk patients even though it was not supported by many guidelines.There were 98.39% of the respondents who tended to utilize further chemotherapy instillations for patients with low-risk NMIBC Table 2.p < 0.001), so did “pathology analysis results of initial TURBT failed to determine stage or risk grading” .Divergence between knowledge rate and compliance rate also existed in some items of surgery indications. In a second TURBT, the compliance rate was relatively lower than knowledge rate for the indication of “after incomplete initial TURBT” . Besides, respondents from the Middle may gain lower scores than those from the East and the Northeast  .We used multiple linear regressions to assess characteristic factors associated with knowledge score of the respondents Table 3.p < 0.001). In some items, respondents who consulted more guidelines were more likely to comply with the guidelines, such as further chemotherapy and BCG therapy for patients with intermediate-risk NMIBC . However, the result of BCG therapy for low-risk patients was reversed . Regarding further chemotherapy for intermediate-risk patients  and BCG for high-risk patients , respondents from the Middle were more likely to gain less score than those from the East and the Northeast.Univariable and multivariable logistic regressions were performed to identify factors associated with the compliance of the respondent with guideline recommendation 5. KnowlThere were 70.63% of the respondents who reported that “patients rejected the operation because of risk or side effects” prevented the implementation of a second TURBT in clinical practice, followed by “patients rejected the operation for economic reasons” (50.43%) and “urologist didn’t suggest it because of risk or complications” (37.55%) , or detail the situations for the recommendation, such as “clear visual field in operation” and “the histopathology of the tumour base was negative”.Knowledge of guideline is an essential prerequisite for compliance . For patWe got feedback from the respondents that the capability of communication with patients is of vital importance in clinical practice, especially when persuading patients to agree to have a second TURBT, or eschew further chemotherapy installations for low-risk NMIBC. Maintaining a harmonious relationship between patients and clinicians based on mutual trust and communication was essential .Furthermore, the capability and training of urologists determined whether they could implement the recommendation in practice. In the study of Witjes et al., only 17.3% of intermediate-risk patients received BCG therapy in their group, which conformed to our results . Under tIn our study, the lack of drug accessibility was the primary barrier to the utilization of BCG. Not only some respondents reported no local supply of BCG, but also the requirements for the transportation and storage of BCG are strict, which presents a challenge to the ability of a hospital to source the medicine. Actually, BCG shortage was a global problem, especially comparing with increasing demands . DesoukyA survey conducted in Europe also reported wide overuse of additional adjuvant intravesical chemotherapy instillations for low-risk NMIBC patients . For patMeanwhile, the financial resources of patients also influenced the implementation of recommendations. The price of BCG was much higher than chemotherapy, but it was included into the scope of reimbursement only in a few provinces of China. Our study showed that a second TURBT and radical cystectomy were also limited by the financial resource of patients. For instance, patients need to pay the cost of operation, postoperative urine collection bag, skin protection materials, and others. However, BCG therapy could achieve cost savings by decreasing the risks of local recurrence and its attendant treatments . A cost-This is the first nationwide survey on the compliance of urologists with NMIBC guidelines in China, and it reveals the reasons for non-compliance in detail. The questionnaire development and distribution were carried out under the guidance of methodological experts. Through detailed analysis, it provided reliable information for guideline developers to improve the guideline implementation. However, this study still has some limitations that have to be considered. Recall bias might exist as the results were based on the subjective feedback of urologists, especially in the self-reported barriers to guideline implementation. Respondents might overstate the impact of patients and reduce their own responsibilities in non-compliance. Meanwhile, the results might be affected by the sample size of the questionnaire as well as the unknown response rate.This survey revealed that although the vast majority of urologists acknowledged the positive effects of guidelines, the knowledge of and compliance with some recommendations in NMIBC guidelines were still not high enough. It highlights the overuse of further intravesical instillations for low-risk NMIBC patients and the underuse of BCG for intermediate-risk and high-risk patients. Guideline factors (lack of readability and feasibility), individual professional factors , organization or environment factors , and patient factors  jointly resulted in the non-compliance.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 Ethics Committee of Wuhan University School of Medicine. The patients/participants provided their written informed consent to participate in this study.Study concept and design: Y-HJ, D-QW, and X-TZ. Acquisition of data: Y-XS, Y-YW, S-YY, LY, and B-HL. Analysis and interpretation of data: QH, D-QW, and XH. Drafting of the manuscript: D-QW, QH, and Y-HJ. Critical revision of the manuscript for important intellectual content: XH, Y-HJ, and T-ZL. Obtaining funding: Y-HJ and X-TZ. Administrative, technical, or material support: LY and X-TZ. Supervision: T-ZL and X-TZ. All authors contributed to the article and approved the submitted version.This work was supported (in part) by the Planning Project of Innovation and Entrepreneurship Training of Undergraduate of Wuhan University (S2019303011), the National Natural Science Foundation of China (82174230), and the National Key Research and Development Program of China .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.


No significant total effects of KT on isometric muscle strength, time to complete functional tasks, or ROM improvement were found. KT or KT plus conventional therapy has a significant effect on pain relief and isokinetic but not isometric muscle strength improvement in patients with knee OA. KT can be an effective tool for treating knee OA pain and is especially valuable for aiding in isokinetic muscle strength. (PROSPERO register ID: CRD42021252313)This study investigated the effects of kinesio taping (KT) or KT plus conventional therapy on pain, muscle strength, funrefction, and range of motion in patients with knee osteoarthritis (OA). Data sources: Databases included PubMed, Ovid Medline, CINAHL, Airiti Library, EMBASE, and WOS search engines. Search terms related to KT and knee OA were combined and searched. Articles that met the inclusion criteria and were graded with a Jadad score ≥3 were included in a meta-analysis to calculate the total effect. The exclusion criteria were non-English-language articles, non-original articles, non-full-text articles, no description of the intervention, or articles with a Jadad score ≤2. Eleven articles were included in the meta-analysis. KT treatment had a significant small total effect on pain reduction ( Knee osteoarthritis (OA) is a chronic progressive disease commonly seen in the elderly. The main symptoms include pain, joint stiffness, reduction in the range of motion (ROM), crepitus during activity, inflammation and swelling. Furthermore, patients with knee OA may suffer from joint deformity, muscle atrophy of the lower extremities, abnormal gait, or even ambulatory inability . As the Common treatments of knee OA include lifestyle adjustments, physical therapy, anti-inflammatory medications, intra-articular injections, and knee arthroplasty . The usaSeveral systematic reviews and meta-analyses of KT or non-elastic taping treatment in different knee or musculoskeletal problems have been published in recent years. A meta-analysis by Parreira et al. found that the therapeutic effects of KT were no better than those of the sham-taping groups or comparison groups treated with conventional therapy in pain intensity, disability, quality of life, return to work, and global impression of recovery in different musculoskeletal problems . A systeTo date, no systematic review has provided a complete summary and meta-analysis of the existing literature on the effects of KT in treating knee OA patients, especially focusing on muscle strength improvement, and analyzing muscle strength with isokinetic and isometric measurements separately. Therefore, the aim of this study was to investigate the effect of KT or KT plus conventional therapy on pain, muscle strength, function, and ROM in patients with knee OA or those who had undergone total knee replacement (TKR) due to severe OA. Moreover, collecting and analyzing the data of interventions using KT as the primary treatment or in addition to rehabilitation will provide a deeper understanding of the therapeutic mechanism of KT and help practitioners to make clearer clinical decisions.The existing literature was systematically searched from Jan 1970 to March 2020 using the PubMed, Ovid Medline, CINAHL, Airiti Library, EMBASE, and WOS databases. Search terms related to KT  were used in combination with terms to identify interventions for knee OA or TKR . This systematic review was registered in PROSPERO (CRD42021252313) where the review protocol can be accessed.Since the present study is a systematic review and meta-analysis of the previously published literature, ethical approval or signing of written consent was not required.Studies that met the following criteria were included: 1. the study employed a design for comparative analysis; 2. the participants were adults with a diagnosis of knee OA or post-TKR due to severe osteoarthritic changes in the knee; 3. the interventions of interest were kinesio taping alone or kinesio taping in addition to other conventional therapies, including physical therapy, rehabilitation or medicine; 4. the outcomes of interest were pain, muscle strength, functional performance, and ROM; and 5. there were sufficient data to calculate the standard mean difference (SMD).Articles with any of the following criteria were excluded: 1. non-English-language articles, review articles, meta-analyses, editorials, letters, comments, conference abstracts or case reports; 2. duplicate or non-full-text articles; 3. articles that did not describe an intervention trial; and 5. articles with poor quality according to a Jadad score ≤ 2.Two reviewers, each with more than ten years of experience in physical therapy, screened all articles to identify those that met the study criteria. The methods, evaluations, and results of the articles were collected, and the outcomes of kinesio taping were analyzed. Finally, the Jadad quality score was used to grade the quality of the articles. The Jadad scale contains five items that are graded on a 5-point scale to assess the methodological quality of an article , and an article with a Jadad score ≥ 3 was considered to be of good quality .p < 0.05 or I2 > 50%. A file drawer analysis was used to explore publication bias. A total effect was calculated by a total random-effects model to determine the outcome effects of KT when significant heterogeneity was present; in contrast, a fixed-effects model was used when no significant heterogeneity was present. The SMD and 95% CI of the outcome variables of individual studies and the total effects are presented in forest plots. The effect size was graded as very small (SMD = 0.01~0.2), small (SMD = 0.2~0.5), moderate (SMD = 0.5~0.8), or large (SMD > 0.8), as suggested by Cohen [The extracted data from the included articles were recorded, and a meta-analysis was performed with MedCalc software v18.2.1 . If the outcomes were evaluated at multiple time points during the intervention, only the data at the endpoint of the treatment were used to compare with the baseline data. The means and standard deviations of continuous variables in the articles were analyzed to estimate the SMD and 95% confidence interval (CI). Heterogeneity was measured with the Cochran Q test, and the results were considered statistically significant when The initial database search resulted in the identification of 156 interventions. After the exclusion of 95 duplicates, 61 interventions were left, and the abstracts of these articles were reviewed. In accordance with the exclusion criteria, 44 of the 61 articles were excluded for reasons including study type, study design, non-English articles, diagnosis of participants, or unavailability of full text and left 17 articles. After reviewing the full text of these 17 articles, six more studies were excluded due to low quality (Jadad score ≤ 2), insufficient data, or not including the outcomes of interest. Finally, 11 articles were included in the present meta-analysis. The precise process of the literature search and screening is shown in the flowchart in In total, the included 11 RCTs reflected data from 739 subjects, comprising 564 women (76.32%) and 175 men (23.68%) . Among tp < 0.0001; Q = 78.65; DF = 17; I2 = 78.39%; 95% CI = 66.38 to 86.10). There was a significant small total effect of pain relief for knee OA patients treated with KT  , resting pain, activity pain night pain, and general pain, were measured by the visual analog scale (VAS) or numeric pain rating scale (NPRS) in nine studies with a total number of subjects of 1509 (82%). Significant heterogeneity was found for pain change (o −0.18) . A negatp < 0.0001; Q = 40.97; DF = 8; I2 = 80.47%; 95% CI = 63.77 to 89.48), a significant moderate total effect favoring KT treatment was found . On the other hand, in the HHD subgroup, two studies with six measurements were included and showed heterogeneity  with a non-significant total effect  (Muscle strength was measured by using an isokinetic machine or a handheld dynamometer (HHD) in six studies (55%). An isokinetic machine can assess the concentric or eccentric peak isokinetic torque generated by knee flexors or extensors under different angular speeds or maximal voluntary contraction, whereas an HHD measured the isometric force. According to different assessment methodologies, in the muscle strength analysis, the studies were divided into two subgroups: the isokinetic machine and HHD subgroups. Four studies with nine measurements were included in the meta-analysis of the isokinetic machine subgroup. Although these measurements showed significant heterogeneity (to 0.34) .p < 0.0001; Q = 45.40; DF = 5; I2 = 88.99%; 95% CI = 78.65 to 94.32), and a non-significant total random effect was found  in the four studies that measured six functional tasks, indicating that the participants did not perform the tasks faster than those without KT application  and a non-significant total random effect  (ROM before and after treatment was measured with a goniometer in six studies (55%), providing data of eleven ROMs in the lower extremity. Meta-analysis showed significant heterogeneity (to 0.56) .The present study is the first systematic review and meta-analysis to investigate the effect of KT on isokinetic and isometric muscle strength separately in knee OA populations. The main finding of this study is that KT had a significant small total effect on pain relief and a significant moderate total effect on isokinetic muscle strength improvement in knee OA patients. It was important to include studies that used KT as an adjunct therapy as well as those that used KT as a main treatment. Knee taping combined with exercise provides superior outcomes compared with exercise alone, and a complete rehabilitation program is multifactorial . SeventyFor knee OA patients, pain is the most invasive symptom, which not only affects daily activities but also causes muscle atrophy due to AMI ,29. The Muscle weakness of the lower extremity is common in patients with knee pain and is often observed bilaterally . QuadricUnlike previous studies, we separated the muscle strength data into two subgroups: measurements with an isokinetic dynamometer and measurements with an isometric dynamometer by using an HHD. Interestingly, we found a significant moderate total effect favoring the KT group in the isokinetic subgroup but not in the isometric subgroup. Three possible reasons could have caused this result. First, the diverse properties of the two strength measuring devices could cause this difference, as isometric strength measured by an HHD was less accurate and had greater variation. Although HHD measured strength has been proven to have a moderate to high correlation with isokinetic dynamometry, it is still thought to be greatly affected by rater-related factors, such as the strength and proficiency of the rater, as well as the position and fixation of the subject . In contA non-significant total effect was found in the time to complete functional tasks from the data of four studies ,23. AnanThe reduction in ROM in knee OA may result from joint stiffness, pain, and kinesiophobia, i.e., pain-related fear of movement . KT treaThere are several limitations in this study. First, due to a lack of current literature with clinically pertinent outcomes on the effect of KT treatment for OA patients, only 11 RCTs with a Jadad score higher than 3 were included in the meta-analysis, and they did not evaluate identical outcome variables. There is potential for bias in the validity of our results. Second, if multiple data representing the same outcome of one study were included in the meta-analysis, the weight of that study would increase in proportion. As a result, the total effect would deviate towards the study with more outcome data. Third, there is no specific technique for KT application, and it usually varies according to the symptoms of the patient, therapist’s experience, and intended purpose. This heterogeneity, such as different tensions of the tape or applying KT in different directions and shapes, may have caused the inconsistent results and led to non-significant total effects. Finally, KT is not typically used as a single treatment tool but is instead combined with other treatments, such as physical therapy and exercise therapy. This approach is consistent with Dr. Kase’s theory that KT is mainly meant to assist the patient’s movements via its elastic properties ,7,8; theThe present meta-analysis showed that KT or KT plus conventional therapy has significant effects on pain relief and isokinetic but not on isometric muscle strength improvement for patients with knee OA. No significant effects were found in HHD-measured isometric muscle strength improvement, time to complete functional tasks, or ROM increase. The finding of increased isokinetic muscle strength is particularly valuable as muscle strength is very important for knee stability ; thus, K


We describe an Oropouche orthobunyavirus infection in a women 28 years of age in Colombia. We confirmed the diagnosis by viral isolation, quantitative reverse transcription PCR, and phylogenetic analysis of the small, medium, and large genomic segments. The virus is related to a strain isolated in Ecuador in 2016. Peribunyaviridae, genus Orthobunyavirus). The disease was initially reported in Trinidad and Tobago in 1955; since then, researchers have documented >30 outbreaks in Brazil and Peru and isolated cases in Panama and Ecuador , negative-sense, single-stranded RNA genome  on September 9, 2017. She had a 1-day history of fever, malaise, chills, myalgia, headache, retroocular pain, photophobia, dizziness, sore throat, anorexia, dysgeusia, and nausea. She had conjunctival injection and an axillary temperature of 38.6°C; she had no other pathologic abnormalities and tested negative on a tourniquet test. After receiving informed consent, we collected 12 mL of blood and stored the sample at −80°C.One aliquot of serum was sent to the laboratory of the US Naval Medical Research Unit No. 6  as part of an ongoing collaborative pathogen surveillance effort with the University of Cartagena . This study protocol was approved by the Institutional Ethics Committee in Scientific Research of the University of Cartagena and the US Naval Medical Research Unit No. 6 Institutional Review Board (protocol no. NMRCD.2010.0010) in compliance with all applicable federal regulations governing the protection of human participants. We extracted RNA from the sample; it tested negative for dengue, Zika, and chikungunya viruses by real-time RT-PCR. We inoculated the sample into Vero 76 cells using a previously described technique (https://www.illumina.com) to prepare a library and sequenced the samples with MiSeq Reagent kit version 3 (600-cycle) (Illumina) according to the manufacturer’s instructions.To characterize the virus at the molecular level, we used supernatant from the viral isolation to extract, amplify, and sequence the viral genome. We amplified the complete genome of the virus using a modified protocol of sequence-independent single primer amplification . The phylogenetic analyses of the small, medium, and large segments (GenBank accession nos. MK643115–7) showed that the strain is closely related to a strain isolated in Ecuador in 2016; it also forms a clade with a strain isolated in Peru in 2008 . We cannOur findings support the diagnostic use of OROV-specific RT-PCR for patients with acute febrile illness in this region. The increased use of this diagnostic tool will help clarify levels of circulation of OROV, informing decisions about Force Health Protection of US service members. In conclusion, local transmission of Oropouche orthobunyavirus infection may be occurring in this region.


Arterial stiffness assessed by pulse wave velocity is a major risk factor for cardiovascular diseases. The incidence of cardiovascular events remains high in diabetics. However, a clinical prediction model for elevated arterial stiffness using machine learning to identify subjects consequently at higher risk remains to be developed.n = 760). The model with the best performance was selected and validated in an independent dataset (n = 912) from the Dryad Digital Repository (https://doi.org/10.5061/dryad.m484p). To apply our model to clinical practice, we built a free and user-friendly web online tool.Least absolute shrinkage and selection operator and support vector machine-recursive feature elimination were used for feature selection. Four machine learning algorithms were used to construct a prediction model, and their performance was compared based on the area under the receiver operating characteristic curve metric in a discovery dataset  and sensitivity  trade-off points.The gradient boosting-based prediction system presents a good classification in elevated arterial stiffness prediction. The web online tool makes our gradient boosting-based model easily accessible for further clinical studies and utilization. Cardiovascular disease (CVD) remains the leading cause of death worldwide . ArteriaThe development of a risk scoring system based on simple predictors, i.e., clinical data, is an important step toward the monitoring and diagnosis of elevated arterial stiffness. SAGE based on a multiple logistic regression (LG) was introduced as a method to predict elevated arterial stiffness . HoweverIn this study, to our knowledge, we have developed the first machine learning-based clinical scoring system for elevated arterial stiffness in patients with diabetes, validating the model in an independent dataset from a Japanese cohort. We have also developed a user-friendly web application using this risk scoring system, allowing for further study and application of this system.The discovery dataset included a total of 760 patients recruited from Fujian Medical University Union Hospital  from April 2017 to January 2019. The inclusion criteria were as follows: patients diagnosed with DM , older t1  was used to measure baPWV, blood pressure, and ABI. The patients were divided into two groups: baPWV ≥ 1,400 cm/s as the elevated arterial stiffness (EAS) group and baPWV < 1,400 cm/s as the non-EAS group (non-EAS).2) = weight (kg)/height2 (m2). The estimated glomerular filtration rate (eGFR) was calculated according to the CKD-EPI formula  was based on the height and weight: BMI (kg/m formula . The ascidelines . The intidelines . The smoidelines . Postmenidelines . Coronaridelines . Hyperteidelines . Diabeteidelines . Carotididelines . Carotididelines .Least absolute shrinkage and selection operator (LASSO) is a compression estimation algorithm, which adds a penalty parameter to least squares regression to compress the estimated variables, thereby improving the prediction accuracy and interpretation of a model . Thus, wAccurate prediction of EAS is important for clinical treatment decisions and can avoid excessive medical treatment caused by false-positive prediction. Thus, in this study, we aimed to achieve a simple and high-accuracy predictive model. Machine learning algorithms, including decision tree (DT), support vector machine (SVM), random forest (RF), and gradient boosting (GB), were used to construct the model, and then their performances were compared to determine the best model.Decision tree is a tree structure model that consists of a root node and several internal nodes and leaf nodes. The root node contains all samples, each internal node represents a decision point corresponding to a single attribute, and each leaf represents a single class label . The samp < 0.05 indicates a statistically significant difference.To obtain optimal hyperparameters, the area under the receiver operating characteristic curve (AUROC) was evaluated based on a 10-fold cross-validation with different parameters in the discovery cohort. We tuned the complexity parameter for the DT model, the ntree and mtry parameters for the RF model, and multiple parameters  for the GB model. The SVM, DT, RF, and GB models were constructed using svm (version 1.4.0), rpart (version 4.1−15), randomForest (version 4.6−14), and gbm (version 2.1.5) R packages, respectively. The discovery data were randomly split into two groups 100 times: training data (70%) and testing data (30%). Each time, we first developed the four different machine learning models on the training data based on the previous tuning parameters. We then calculated the AUROC and area under the precision-recall curve (AUPRC) of the four machine learning algorithms on the testing data. Finally, we compared the values of AUROC and AUPRC from the four models to determine which model performed best. After selecting the best-performing model as the final model, we constructed the GB model using the full discovery data. Youden’s index was calculated to determine the best cutoff value of the GB model. To further validate the classification capacity of the GB model, we applied our trained GB model on an independent validation cohort. The ROC and PRC were analyzed using pROC (version 1.16.2) and PRROC (version 1.3.1) R packages, respectively.viahttp://vascularagingpredictor.top/.To develop a web application for EAS assessment that is applicable in daily clinical practice, we designed a web-based tool, an EAS predictor, allowing access to our final trained model. Specifically, we used front-end development technologies, Node.js (v12.14.0), React (v16.13.1), and Ant Design (v4.5.4), to simplify the development process. RestRserve (v0.3.0) back-end development technology was used to load the final trained model. Data required for prediction were received by the model using the TCP/IP method, and then the predictive result was returned. This web tool is hosted on our server, which is freely accessible t-test was used for the comparison of continuous data following a normal distribution, and Mann–Whitney U test was used for the comparison of data with a non-normal distribution. Categorical data are presented as frequency (percentage), and comparisons between two groups were performed using the χ2 test or Fisher’s exact test . The above statistical analysis was performed using R software 3.6.22.The Kolmogorov–Smirnov (K–S) test was used to assess the normality of data. Continuous data with a normal distribution are presented as mean values ± standard deviation (SD), whereas continuous data with non-normal distribution are presented as median values (quartile). Student’s This study enrolled 760 subjects with a mean age of 56 ± 12 years . Based on the dividing value of 1,400 cm/s of baPWV, the subjects were divided into two groups: non-EAS and EAS. The complete data of patients include demographic information, chemistry indicators, diseases, hemodynamic parameters, and echocardiographic and carotid artery ultrasound parameters in each group –3. A totTwo different algorithms, LASSO and SVM-RFE, were applied to select the most significant features for classifying individuals with normal  or abnormally elevated baPWV . First, all features  were included in the LASSO regression analysis and narrowed down to 15 features with non-zero β coefficients in the LASSO regression model . Second,Before the model construction using the full discovery dataset, we first tuned the parameters of the model based on a 10-fold cross-validation. We found that when the complexity parameter of the DT model was set as 0, the model achieved the highest AUC value, whereas when the RF ntree = 1,000 and mtry = 2, the model achieved the best performance. For the GB model, the best performance was obtained when interaction.depth = 2, n.trees = 400, shrinkage = 0.02, and n.minobsinnode = 5 .Next, we randomly divided the discovery dataset into two groups 100 times: training data (70%) and testing data (30%). Each time, four cutting-edge machine learning algorithms with the optimized parameters were used to develop models on the training data. Based on the obtained models, we used the testing data to assess the probability of EAS of the testing population, and ROC and PRC analyses were performed, followed by calculating the AUC values on the testing data. We compared the models and observed that DT was associated with significantly lower AUROC and AUPRC values, whereas the GB approach has higher AUROC and AUPRC values . MoreoveBased on the GB algorithm, we finalized our EAS predictive model by training the GB model on the full discovery data with optimized parameters and calculated GB-based risk scores. In addition, we applied the GB model to the validation data from an independent Japanese cohort. Each predictor and other demographic information for the discovery and validation data are shown in To determine the best cutoff value of the GB model, Youden’s indexes were calculated in both cohorts. The cutoff value (0.75) built on the discovery cohort was higher than that (0.46) of the validation cohort , suggest3). To facilitate further study and use of this GB model for EAS prediction, we built a free and user-friendly online web-based tool  from either the LASSO or SVM-RFE were further selected as the predictors in that they are easily accessible in clinical practice. Evidence suggests that the increase in age, SBP, and DBP are the important risk factors of artery stiffness . ConsistRecently, the SAGE scoring system  was established to predict EAS, which was an important step for the EAS surveillance and identification . HoweverAnother point that needs to be discussed is the cutoff values of the GB model. Compared to the discovery cohort, there was a trend for lower GB scores in the EAS group of the validation cohort , which mCertain limitations of this study should be noted. First, the training sample size was limited. We plan to recruit more subjects from multiple center sites in the future to further increase the robustness of the model. Second, although this study was based on a Chinese cohort and validated using a Japanese cohort, prospective studies in different countries are required to further validate the results. Lastly, limitations in clinical data sharing infrastructure and mechanisms hinder further validation of cutting-edge machine learning methods . We haveIn summary, we applied a cutting-edge machine learning method, GB, to establish an EAS scoring system for the identification of patients with EAS. We also validated the predictive performance of our GB model in an independent cohort from Japan. This GB model may help predict individual EAS risk and help clinicians manage patients with EAS.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Medical Faculty of Fujian Medical University Union Hospital Ethics Committee. The ethics committee waived the requirement of written informed consent for participation.HH and LbL lead the study. QL, WX, and LpL performed the data analysis, implemented the methodology, and generated the web-based tool. LW, QY, LC, and JL collected the data and discussed the results. JF, WX, QL, and LpL prepared the original draft. HH, LL, WX, QL, and LpL reviewed and edited the final 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.


Background: Nanotechnology application has widespread use in many products. Copper nanoparticles (CuNPs) are widely used in industrial applications. The present study was conducted to investigate the effect of the ethanolic saffron extract (ESE) as a natural antioxidant on the hepatotoxicity induced by CuNPs in male mice. Methods: The characterization of CuNPs was determined using ultraviolet–visible absorption spectroscopy, particle size analysis, zeta potential, Fourier-transform infrared spectroscopy, and electron microscope. The effect of saffron on the hepatotoxicity induced by CuNPs in mice was evaluated by evaluating the survival rate of the mice, oxidative stress, antioxidant capacity, DNA evaluation, as well as its effect on the histology and transmission electron microscope of the liver. Results: The results revealed that all parameters were affected in a dose-dependent manner by CuNPs. These effects have been improved when the treatment of CuNPs is combined with ethanolic saffron extract. Conclusions: We can conclude that saffron and its bioactive crocin portion can prevent CuNP-induced oxidative liver damage. This substance should be useful as a new pharmacological tool for oxidative stress prevention. Nanotechnology application is now in widespread use for consumer products and in new pharmaceutical, electronic, and other industries. Metal nanomaterial have become significantly used in biomedical sciences due to their interesting and unique properties ,2. They Copper nanoparticles (CuNPs) are used in industrial applications as an additive in lubricants , for metA collection of toxicological events, such as hepatocirrhosis , lipid pCrocus sativus flower (family Iridaceae) is a flowering plant cultivated in various parts of the world, including Iran, China, Spain, Italy, and Greece [Doudi and Setorki  found thd Greece . It is iCrocus sativus (saffron) has been used in India and other parts of the world for medicinal purposes for many decades. It has been used for nutritional and medical applications, in the food industry , and in the garment industry (dyes). Furthermore, it has a golden yellow-orange color is primarily due to the presence of α-crocin. The medicinal uses of saffron can be attributed to active metabolites, such as crocin, crocetin, picrocrocin, and safranal present within it, which exhibit antihypertensive, anticonvulsant, antidepressant, antitussive, antigenotoxic, anxiolytic, aphrodisiac, antioxidant, anticancer, anti-inflammatory, antinociceptive, and muscle relaxant activity [activity . Moreover, there are more than 150 volatile and aroma-producing elements in saffron, many of which are carotenoids, including zeaxanthin, lycopene, and separate alpha and beta-carotenes . The widSaffron aqueous extract has an important role as a chemotherapeutic application in mice . Patel eSamarghandian et al.  showed tThe UV-visible absorption spectrum showed a typical absorption spectrum of CuNPs . The susThe Zeta potential of the CuNPs was determined to estimate the surface charge of the nanoparticles in solution. The results revealed that the particles were negatively charged with a range of—23.9 ± 6.87 mv .−1, 1651 cm−1, and 1423 cm−1 . The results showed no changes in the general health of mice, where most animals were still active. Additionally, there were no significant increases in the bodyweight of all experimental groups.However, there was a significant decrease in the body weight of mice treated with 250 mg/kg CuNPs, compared to the control group . The morThe serum enzyme markers of the liver as aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) for both control and experimental treated mice are presented in The results showed marked significant increases in concentrations of malondialdehyde (MDA) as an indicator of lipid peroxidation (LPO) in the serum of mice administered with CuNPs, comparing with the control. However, there were no significant differences detected in the MDA levels of mice administered with 60 mg/kg ESE as compared to the control . There wDepending on the dose levels, the results exhibited marked significant decreases in the level of serum TAC of mice that were injected with CuNPs as compared with the control. However, there were observable increases in this parameter in the serum of mice administered with two doses of CuNPs and 60 mg/kg of ESE, as compared to those of the CuNPs groups only .The liver of control mice revealed that the hepatocytes are polygonal in shape and exhibited distinct boundaries, and they have centrally located spherical or ovoid basophilic nuclei and acidophilic cytoplasm. These nuclei showed considerable variations in size from cell to cell. Each nucleus contains one or two prominent nucleoli and dispersed chromatin a. The liSections of liver mice treated with 100 mg/kg CuNPs showed that the hepatocytes were more or less similar to the control. In a few sections, they had lost their characteristic organization, and the cytoplasm was slightly vacuolated. The nuclei were vesicular and displaying their normal shaped structures. Kupffer cells appeared few and showing a marked decrease in their sizes c. HoweveFurthermore, the hepatocytes in sections of liver mice treated with 100 mg/kg CuNPs + 60 mg/kg ESE showed no evidence of damage compared to those treated only with 100 mg/kg CuNPs. However, an observable dilatation in the hepatic sinusoids was seen e. The liUltrathin sections of the liver of control mice revealed that the hepatocytes have a regular oval or spherical shaped nuclei with electron-dense nucleoli and outlined by a well-defined nuclear envelope a. The cyThe electron micrographs of liver mice treated with 100 mg/kg CuNPs revealed injury in the hepatocyte nuclei, and they contain large, dark, and well-developed nucleoli. In the cytoplasm, the mitochondria were rounded and elongated in shape. The rER was greatly dilated and reduced into a few short irregularly placed dilated cisternae through the cytoplasm of hepatocytes, and there were many proliferated smooth endoplasmic reticula, which indicate the toxic effect of CuNPs. Many light electron-dense lipid droplets and small dense lysosomes could be seen c. The liver section of mice treated with 250 mg/kg of CuNPs revealed the deposition of dark electron-dense spherical nanoparticles inside the nucleus of hepatocyte d. In theThe electron micrograph of liver mice treated with 100 mg/kg of CuNPs and 60 mg/kg ESE revealed an improvement in the structures of hepatocytes. Their nuclei were regular in shape and had electron-dense nucleoli. The mitochondria in the cytoplasm were evenly distributed with densely packed structures. The rER was frequently evaluated when short-flattened membranes were present near the nucleus, and if the cytoplasm contained many lipid droplets and many dense lysosomal bodies f.The hepatocytes of liver mice treated with 250 mg/kg of CuNPs and 60 mg/kg ESE showed little improvement in the structure of the nucleus, compared to those of the treated group with 250 mg/kg CuNPs. In the cytoplasm, the mitochondria were characterized by the marked disappearance of their cristae, and the profiles of rER were interrupted g.DNA analysis with the agarose gel electrophoresis, the results showed massive DNA fragmentation, which appears as DNA laddering (smearing) in the liver tissues of mice administered with two doses of CuNPs. However, partial protection against apoptotic and necrotic cells appeared in groups treated with 100 and 250 mg/kg CuNPs and 60 mg/kg ESE, which showed low DNA laddering (DNA fragmentation). Furthermore, no detectable changes were observed in the liver tissue of ESE and control mice . The DNAIn the present study, the toxicity of intraperitoneal injection with CuNPs (100 and 250 mg/Kg body weight) for 30 days on the liver of mice was evaluated. These doses do not necessarily reflect the actual concentrations of CuNPs found in real environments. However, they can be used to assess the health risks from exposure to CuNPs.Concerning the characterization of CuNPs, the present results showed that the crystalline structure morphology of synthesized CuNPs was observed using their optical properties characterized by UV–visible spectroscopy, FT-IR analysis, and TEM. The results revealed that the UV–Vis absorption of the prepared CuNPs in this study showed a typical spectrum. With the TEM, the results showed that CuNPs were spherical, having a smooth surface and the size of the particles was 82.87 nm. FT-IR is an effective method to reveal the functional groups of the prepared CuNPs, at peaks 3426/cm, 1651/cm, and 1423/cm. These peaks correspond to the hydroxyl, oxidized carbonyl group, and conjugated carbonyl groups, respectively. These results are similar to the results of Xiong et al. [The current study revealed that the rate of mortality was increased in mice administered with a high dose of CuNPs (250 mg/kg), and there were significant decreases in the body weights of this group of mice as compared to the control animals. This suggests that exposure exerts a major visible impairment in the health statuses of animals. However, no significant differences in body weight were observed in mice administered with a low dose of CuNPs, as compared to the control. Lei et al.  found thDepending on the dose of CuNPs, the current results revealed a significant elevation in the activity of serum AST, ALT, and ALP of mice administered with 250 mg/kg CuNPs. Serum aminotransferases analyses have become a standard measure of hepatotoxicity because of the significance of these enzymes. AST and ALT are located inside the cell, while the ALP is located on the cell membrane. These transaminases play an important role in protein and amino acid metabolism. In such cases, the serum AST rises and escapes from the damaged hepatic cells into the serum. These enzymes are usually found in the liver and other tissues where they act in the metabolism of energy requiring amino acid transamination. However, in cases of cellular damage, the AST and ALT could leak out into the general circulation, leading to elevated activity . These cThe obtained results are consistent with the previous findings of Doudi and Setorki , who rep2+ [The current results revealed increased levels of MDA and decreased the TAC in the serum of mice administered with 100 and 250 mg/Kg, depending on the dose level. These results follow the results of Al-Salmi et al.  explaine2+ . Knaapen et al.  suggesteThe studies of Fahmy and Cormier  indicate4 in rats. Mansouri et al.  had repoThe present results revealed a marked and significant decrease in serum levels of AST, ALT, and ALP in mice administered with the ESE. These results explained the role of saffron in improving the disruption in the liver function enzymes and its role in alleviating the increased levels of LPO. Additionally, Mohajeri et al.  had repo4 in mice. Additionally, these findings confirm other findings showing the protective effects of ESE on hepatic tissue ischemia-reperfusion-induced oxidative damage in rats [Iranshahi et al.  showed t in rats . Yosry a in rats  suggeste in rats  reportedIn the current study, the cytotoxicity of CuNPs was evidenced by the appearance of morphological changes in liver cells, such as congestion and dilatation of the blood vessels, the presence of much inflammatory infiltration in pre-central veins, as well as the appearance of hepatocellular necrosis. These alterations were prominent in the liver tissues of mice administered with 250 mg/kg of CuNPs. However, the decrease in these degenerative changes in the liver of mice was apparent in the liver tissues of mice treated with ESE. Our present study, parallel with Kim et al. , reporteThe obtained results are consistent with the previous findings of Doudi and Setorki  who founUsing the TEM, the results revealed many ultrastructural abnormalities in the liver tissues of mice administered with 250 mg/kg CuNPs. Most nuclei of the hepatocytes were pyknotic with condensed chromatin. Besides, they contained more than two large, dark, and well-developed nucleoli. These indicate the hypermetabolic activity of the liver, cellular and nuclear degeneration, cellular atrophy or rupture, indicated by the direct toxicities of CuNPs. Moreover, the pyknotic nuclei refer to an irreversibly condensed form of chromatin material in the nucleus, which indicated highly severe and irreversible damage to the liver . This chFurthermore, liver toxicity seen in the current study may be explained by the deposition of CuNPs in the nuclei of certain hepatocytes, leading to the generation of ROS associated with inflammatory, oxidative stress, genotoxicity, and the induction of apoptosis. It had been reported that some NPs, owing to their small size, are capable of reaching the nucleus and might attack DNA . They maThe presence of NPs inside the cell nucleus and lysosomes indicates the important role in the apoptotic process: the lysosomal proteases can be released into the cytosol, where they cause pro-apoptotic proteins to adopt their conformation and to insert into mitochondrial membranes and induce the mitochondria-mediated apoptosis pathway ,74.In the cytoplasm, the results revealed the appearance of fatty deposits, which may be due to LPO, which leads to rough endoplasmic damage and the detachment of the cytoplasmic lipoprotein, which indicates abnormal fat metabolism. The mitochondria showed a marked disappearance of the mitochondrial cristae. This may reflect the disturbances in ox reduction processes taking place in the organelle . MitochoAdditionally, there was an increased proliferation in the number of secondary lysosomes in the cytoplasm of many hepatocytes of the liver of mice administered with 250 mg/kg CuNPs. This indicates an attempt to digest these NPs, and this is considered as a general manifestation of injury. The sequestration of damaged organelles in lysosomes is a mechanism of cellular repair and follows all types of sublethal injury . 2 [Furthermore, the Kupffer cells were found as an indication of the damaging effects of CuNPs in the liver tissues. These cells appeared with marked irregularities in their nuclear counter and having many dense patches of heterochromatin. This indicates their activation and suggests hepatocellular damage. Kupffer cells play a defensive role, protecting against bacterial or viral invasion into the portal blood flow . Other i2 ,82. In the present results, DNA laddering electrophoresis was chosen for the assessment of DNA damage on the liver tissue of mice treated with different doses of CuNPs and/with the ESE. Depending on the dose levels of CuNPs, the present results showed that massive DNA fragmentation was found in the liver tissues of mice. Fahmy and Cormier  explaineApoptosis is associated with a distinct set of biochemical and physical changes involving the cytoplasm, nucleus, and plasma membrane. Early in apoptosis, the cells round up, losing contact with their neighbors, and shrunk. In the cytoplasm, the endoplasmic reticulum dilates and the cisternae swell to form vesicles and vacuoles. In the nucleus, chromatin condenses and aggregates into dense compact masses . MartineAmong the different apoptotic pathways, the intrinsic mitochondrial apoptotic pathway plays a major role in metal NP-induced cell death since mitochondria are one of the major target organelles for NP-induced oxidative stress and apoptosis . Jeng an2/M phase. Furthermore, the administration of saffron resulted in reduced DNA fragmentation which was confirmed by Premkumar et al. . The dec2·2H2O-97%) and L-ascorbic acid (vitamin C-98%) were purchased from Sigma-Aldrich, St. Louis, MO, USA.The copper chloride dehydrates (CuCl2) aqueous solution was prepared by dissolving 0.02 M CuCl2 in 50 mL de-ionized water in a flask. Then, the solution was heated to 80 °C in an oil bath with continuous magnetic stirring. L-ascorbic acid aqueous solution (50 mL of 0.1 M) was added dropwise while stirring. Over time, the color of dispersion was gradually changed from white to yellow to orange to brown and finally to dark brown. The appearance of yellow color followed by orange color indicated the formation of fine nano-scale copper particles from L-ascorbic acid-assisted reduction. The obtained result was centrifuged for 15 min [In a synthetic procedure, copper-nanoparticles were obtained via a wet chemical reduction route. Copper chloride  (Model/CRYODOS-50) at City of Scientific Research and Technological Applications, Borg Al-Arab, Alexandria, Egypt . The obtained solutions were placed in 50 mL falcon tubes, frozen in liquid nitrogen and frozen drying by vacuum Freeze Drying Machine at a pressure of 26.5 pa and 5.0% saccharine that was used as a cytoprotectant. The prepared CuNPs were suspended in saline and dispersed by ultrasonic vibration  for 20 min for all experimental work.One hundred grams of saffron stigmas were macerated and shacked for 3 days in one liter of 80% ethanol at room temperature by using an Environ Shaker . Then, it was filtered, and the filtrate was concentrated under vacuum using the rotatory evaporator (40 °C) till giving dark red residues kentron by using a rotatory evaporator (model/strike 201), at Medical Technology Center, Alexandria University. The obtained ethanol saffron extract (ESE) was chilled in the refrigerator until use .Sixty adult male albino mice (25–29 g) were obtained from the animal house of Medical Research Institute, Alexandria University, Egypt. They were housed (5 mice/cage) in the stainless-steel cages, and they were observed for health status and acclimatized for two weeks before use at 25 ± 2 °C and humidity 55 ± 5% using normal photoperiod day/night. Mice were allowed free access to food and drinking water throughout the study. Mice were cared for following the guidelines of the Care and Use of Laboratory Animals committee, Alexandria University, Egypt. After two weeks of acclimatization, mice were assigned to six groups (10 mice/each) given day after day for 30 days the following treatment. The mice have received 0.5 mL saline solution and presented as group I (control). Group II was injected i.p. with 60 mg/kg ESE. Mice were injected i.p. with 100 or 250 mg/kg CuNPs, respectively, and considered as group III and IV. Groups V and VI were injected i.p. with 100 or 250 mg/kg CuNPs and followed by 60 mg/kg of ESE after each other.The mice were inspected for clinical signs of toxicity by testing their emotion as excitability and aggressiveness. The autonomous functions such as diarrhea, dieresis, salivation, and mortality were evaluated during the time of dosing of 30 days. UV–vis spectroscopy was used to characterize the optical absorption properties of copper nanoparticles. The absorption spectra of samples were recorded in the wavelength range of 250 to 650 nm using a UV-6800 UV\VIS spectrophotometer , at the Medical Biophysics Department, Medical Research Institute, Alexandria University. CuNPs suspension (1 mL) was placed in a quartz cuvette to record its wavelength absorption.The particle size of the prepared particles was determined by Laser Light Scattering on a Nano Zeta sizer particle analyzer . The laser obscuration range was maintained at 15–20%, and the mean particle size was measured after experimenting with triplicate. Using cumulative analysis software and the exponential sampling method, hydrodynamic size distribution, and surface charge  were determined.Fourier-Transform Infrared Spectra of the prepared particles were obtained on a Shimadzu FTIR-8400S . The pellets were prepared by grinding 4–8 mg of samples with 200 mg potassium bromide. Tablets were prepared then fixed on the holder to be examined. The spectra were scanned over the wavenumber range of 4400 to 350/cm.The size and shape of the prepared nanoparticles were determined by transmission electron microscope . For this purpose, the particle suspension was diluted 10-times with distilled water, and a drop of an aqueous suspension containing the biosynthesized CuNPs was placed on 400-mesh copper grids coated with carbon film after allowing the water to evaporate.In one-week intervals over 30 days, all mice were weighed at the end of the experiment, they were euthanized using diethyl ether, and the blood samples were collected by a syringe from the inferior vena cava by heart puncture in EDTA tubes. Serum samples were obtained by centrifugation of the blood samples at 3000 rpm, for 30 min, and were frozen at −20 °C until assayed. The serum levels of malondialdehyde (MDA) , total aThe liver tissues were excised out and preserved at −80 °C for DNA analysis. DNA fragments isolated from cells or tissue that were laddering were determined on 1.2% agarose (15 μg/lane), and were illuminated with 300 nm UV light, and a photographic record was made .Small pieces of the liver tissues were excised carefully, fixed in 10% formalin solution, dehydrated using ascending graded series of ethanol, and cleared by xylem. The specimens were embedded in paraffin wax according to the routine processing protocol of Bancroft and Gamble . Serial 4) at 4 °C for 2 h. Then, the specimens were washed several times with phosphate buffer for 30 min, dehydrated through ascending grades of ethanol concentrations, and at 4 °C they were treated with propylene oxide and embedded in a mixture of 1:1 of Epon-Araldite resin mixture [The small pieces of liver tissue were immediately fixed in 4% formalin and 1% glutaraldehyde, rinsed in 0.1 M phosphate buffer (pH 7.4) at 4 °C for 24 h, and post-fixed using 1% buffered osmium tetroxide .Data were expressed as mean values ± SE, and statistical analysis was performed using one-way ANOVA to assess significant differences among treatment groups. Statistical significance was considered at In conclusion, the present work demonstrates that saffron and its bioactive component, crocin, can prevent oxidative damage of the liver induced by CuNPs. Thus, these substances should be useful as new pharmacological tools for alleviating oxidative stress.


Cancer is one of the leading chronic diseases, which causes premature mortality in Korea. Early detection has been reported to be associated with reduced mortality and morbidity. Consistent evidence reports that lower screening rates are associated with socioeconomic-based disparities. This study aimed to examine income-related disparities in cancer screening services and to analyze the association between utilization of cancer screening and individual characteristics, including income levels.This study utilized the data from the Korea National Health and Nutrition Examination Survey (KNHANES), a population-based survey from 2013 to 2019. The study population included individuals aged 40 years or over. The variables were socioeconomic characteristics and perceived health status. Household income was categorized into quartiles from Q1 (the lowest income group) to Q4 (the highest income group). Multivariate logistic regression analysis was performed to analyze the association between cancer screening and individual characteristics and household income levels.p < 0.001).There were 20,347 individuals included in this study. Among these, 14,741 (72.4%) had undergone cancer screening. There existed a gap in the utilization of cancer screening between the lowest (Q1) and highest (Q4) income quintiles owing to evident income disparities; Q4 thus had a significantly higher likelihood of undergoing cancer screening than other quintiles. Female sex, university and over education, number of chronic diseases, and private insurance coverage were positively associated with cancer screening (Our findings suggest that policymakers should develop and design strategies to increase awareness and efforts to improve the education and promotion of cancer screening among lower-income target groups. Cancer is a global public health challenge. The cancer incidence and mortality rate are rapidly increasing worldwide; also have been reported in developed countries over the last few decades , 2. The Screening is seen by many as a key element in cancer control strategies . Cancer In Korea, the National Cancer Screening Program (NCSP) has conducted population-based screening since 1999 for providing free screening services , 11; it The literature findings revealed that utilization of cancer screening was associated with socioeconomic factors in Korea –20 and oOverall the decades, Korea also experienced rapid socioeconomic growth decline not only in the lifestyle changes but also in the wide of income inequality. Therefore, Korea's homogenous sample population analyzes the association between income disparities and various diseases in Korea –22, 32. Existing studies have been focused on socioeconomic disparity with specific types of cancer screening such as breast , cervicaThis study aimed to investigate the cancer screening rates and trends from 2013 to 2019 by using the KNHANES data among the population aged 40 years or over, we also assessed the contribution of socio-economic factors, including income-based disparities in the utilization of cancer screening.This study used standardized cross-sectional data from the Korea National Health and Nutrition Examination Survey (KNHANES), which is a population-based survey that provides comprehensive data on health status, healthcare utilization, and socioeconomic status of an entire Korean population . It was The dependent variable of this study was whether participants had undergone a cancer screening . The type of cancer screening was classified as (1) free of cost, (2) self-payment, or (3) partial payment screening at comprehensive cancer screening in public, private, or general hospitals.The demographic characteristics included age, sex, education status, marital status, job, income, residence (based on the participant's residence), and types of insurance. The age group was divided into four groups  starting from age 40 years, which is the national cancer screening recommendation standard. Marital status was classified as married, single, and divorced/widowed. The education status had four categories: elementary school, middle school, high school, and university and over. The ccupation was classified as “yes” or “no” according to the participant's answer . Residential areas were divided into urban (city or town) and rural (village) areas. The level of household income was calculated by dividing the household monthly income by the square root of the household size , and classified into four categories: lowest, middle, high, and highest in the quartile . In termLifestyle and health-related variables included participants' perceived health status, stress, smoking, alcohol consumption, physical activity (moderate), cancer, and chronic diseases. Self-reported health status was classified into three categories: fair (very good/good), moderate, and bad (bad/very bad). In self-perceived stress level, "the participants were asked for their perceived stress levels, and four options were given for response: (1) very much, (2) much, (3) a little, and (4) almost none. They were then divided into two categories; the first two responses were considered as the high-level stress (Yes), and the last two were classified as the low-stress (No). Alcohol consumption was categorized into two groups according to the amount and frequency of alcohol consumed monthly included; (1) “Yes” (high-risk drinkers), defined as those who consume more than seven (for men) or five (for women) drinks on a single time at least once per month; and (2) “No” low-risk drinkers, defined as non-drinkers and those who drink less than once per month . Smoking“The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of affiliated University (2021-4-0986). In addition, the KNHANES was approved by the KDCA Institutional Review Board (2018-01-03-P-A) in 2018. All participants provided informed consent to participate in the KNHANES and it was ensured that they remained anonymous.”p < 0.05  and 95% confidence interval (CI) to assess the factors associated with cancer screening. Model 1. age, sex, education, marital status, occupation, residence, smoking, alcohol consumption was assigned as an independent variables, and Model 2. household income, chronic diseases, cancer and types of health insurance focused as an independent variables. Third, a subgroup analysis was performed to analyze the factors associated with cancer screening according to household income, with selected covariates. The differences in the influences of income on cancer screening was analyzed with adjusted odd ratio of covariates were examined by using interaction terms in which income quintiles. Statistical significance was defined as p < 0.05 , 37. Allp < 0.05 , 37.The total number of households participating in the KNHANES for 2013 through 2019 was 55,327. A total 20,347 male and female participants aged 40 years and older were included in this study . The freThe final data consisted of 20,347 participants aged 40 years and over. p < 0.001 level , rarely experienced self-perceived stress (79.9%), were former smokers (75.7%), and had habit of alcohol consumption (68.7%). Those who had regular physical activity (81.4%), and more than two chronic diseases (53%) are underwent cancer screening. Chi-square analysis results of comparison between the cancer screening and no screening with demographic variables showed statistically significant differences at 01 level .p < 0.05 in all models. The p-value of Hosmer and Lemeshow goodness of-fit test logistic regression model showed >0.05, therefore, it can be confirmed that the model was fit to the data well  and ≥3  comorbidity were more likely to undergo cancer screening than individuals with 1 condition. Those who had private health insurance  were more likely to undergo cancer screening than those with no private health insurance. The participants in Q3  and Q4  were more likely to undergo cancer screening than those in Q1. As a result of the Likelihood ratio test, at least one of the independent variables used in the analysis was significant by rejecting the null hypothesis with ata well .p < 0.001) than those of the Q1 household income group. The highest income group of Q4 comprising participants with university and higher education and chronic diseases showed a higher aOR for undergoing cancer screening than those who had low household income, elementary-level education, and one chronic disease  was negatively associated with selected variables. According to the literature, there was no significant association between utilization of cancer screening and age, private insurance, smoking, moderate-intensity physical activity, and the presence or absence of cancer , 27, 32.Previous studies notified that barriers hindering participation in NCSP include less trust in these programs and a lack of awareness of the existence and importance of it , 30, 35,In Korea, NHI enrollment is compulsory for public officials and private school faculty members. An estimated 3–5% of people below the poverty line who cannot afford health insurance premiums are covered by Medicaid (Private insurance) , 33, 34.Furthermore, our findings suggest that socioeconomic status is a very important factor for providing equal access to prevention-oriented primary care. It is necessary to develop awareness-related interventions at the national and regional levels to reduce income disparities in cancer screening utilization. Our findings are similar to previous studies suggesting that income disparity impacts cancer screening positively , 29, 32.The strength of our study lies on the large sample size and the population based self-reported survey data, and this study focused on income disparities with recently available secondary data. There are some policy implications based on the study findings are as follows: the intension of the cancer screening participation to be increased from the middle-aged adults, it could be viewed as a good impact factor of routine screening behavior. The healthcare professionals or policy administrators need to identify and providing the counseling about screening and early detection of cancer according to socio-economic status also important to reduce the income-based disparities in cancer screening. Cancer screening showed differences based on demographic characteristics such as education level, household income, occupation, and perceived health status, it is recommended to expand the scope of free screening for most common cancers and create an environment and individual general characteristics that would make it easier on participation of the people in cancer screening, such as providing paid vacation time, to resolve this income-based disparities. This study recommended to revise the cancer screening duration from “two years to one year” as a benchmark to determine whether the respondents undergone cancer screening.Our results should be interpreted with reasonable limitations. First, cancer screening responses were self-reported and may not be accurate in determining type of cancer screening based on self, partial, and free payment. Therefore, we did not perform logistic regression analysis based on the type of cancer screening. However, literature reporting the association between cancer screening and household income is most likely based on the self-reported responses, which may have influenced the results. Second, Our study included chronic conditions but did not draw conclusions on the severity of the disease or types of cancer. Therefore, it is considered that vulnerabilities in utilizing cancer screening arise as a result of income disparity. Third, this study considered self-perceived stress level by two categories, and it was assessed by the question addressed in KNHANES data. Since the responses are based on respondent's self-report, this may have been affected the recall bias. Therefore, future studies could focus on standardized stress assessment tool such as DAAS-21, which is a set of three scales and more useful to consider even small changes in symptoms, rather than focusing on categorical differences.In the present study, we found an association between the utilization of cancer screening and the household income group. There is a need to develop specific policies for the expansion of public screening programs for the low-income class, to provide more efficient early cancer screening. It was reported that there were also differences in factors associated with the use of cancer screening according to different categorical levels. We also found that the middle-aged group was a vulnerable group that was more likely to not utilize cancer screening than the older adult group. Cancer is widespread among middle-aged individuals >45 years, and it is a serious public health issue. Therefore, it is necessary to make more intention among middle-aged adults to participate in the cancer screening than older adults. Furthermore, attention and effective collaborative efforts by policymakers, health plan administrators, third-party payers, and healthcare providers are needed. In addition, there is a need to develop specific policies for the expansion of public screening programmes for the low-income class to provide more efficiency to encourage regular early cancer screening, especially in the middle-aged group. In the future, research on related factors will be necessary through analysis of the current use of cancer screening programs according to household income level by specific cancer type among middle-aged adults by using the National Health Insurance Service data.To mitigate potential policy implications, we have developed the population-based cancer indicators and monitoring , under tThe recommended policy implications have been divided into population-based screening  and oppohttps://knhanes.kdca.go.kr/knhanes/sub03/sub03_01.do.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The studies involving human participants were reviewed and approved by KNHANES was approved by the KDCA Institutional Review Board (2018-01-03-P-A) in 2018. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.VR, JS, SL, and THK: conceptualization. SL and JS: methodology. VR: data collection and investigation. VR and JS: writing—original draft preparation. SL and THK: writing. All authors read and approved the final manuscript.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.