This study aims to evaluate the value of machine learning-based dynamic contrast-enhanced MRI (DCE-MRI) radiomics nomogram in prediction treatment response of neoadjuvant chemotherapy (NAC) in patients with osteosarcoma.A total of 102 patients with osteosarcoma and who underwent NAC were enrolled in this study. All patients received a DCE-MRI scan before NAC. The Response Evaluation Criteria in Solid Tumors was used as the standard to evaluate the NAC response with complete remission and partial remission in the effective group, stable disease, and progressive disease in the ineffective group. The following semi-quantitative parameters of DCE-MRI were calculated: early dynamic enhancement wash-in slope (Slope), time to peak (TTP), and enhancement rate (R). The acquired data is randomly divided into 70% for training and 30% for testing. Variance threshold, univariate feature selection, and least absolute shrinkage and selection operator were used to select the optimal features. Three classifiers  were implemented for model establishment. The performance of different classifiers and conventional semi-quantitative parameters was evaluated by confusion matrix and receiver operating characteristic curves. Furthermore, clinically relevant risk factors including age, tumor size and site, pathological fracture, and surgical staging were collected to evaluate their predictive values for the efficacy of NAC. The selected clinical features and imaging features were combined to establish the model and the nomogram, and then the predictive efficacy was evaluated.The clinical relevance risk factor analysis demonstrates that only surgical stage was an independent predictor of NAC. A total of seven radiomic features were selected, and three machine learning models  were established based on such features. The prediction accuracy (ACC) of these three models was 0.89, 0.84, and 0.84, respectively. The area under the subject curve (AUC) of these three models was 0.86, 0.92, and 0.93, respectively. As for Slope, TTP, and R parameters, the prediction ACC was 0.91, 0.89, and 0.81, respectively, while the AUC was 0.87, 0.85, and 0.83, respectively. In both the training and testing sets, the ACC and AUC of the combined model were higher than those of the radiomics models (ACC = 0.91 and AUC = 0.95), which indicate an outstanding performance of our proposed model.The radiomics nomogram demonstrates satisfactory predictive results for the treatment response of patients with osteosarcoma before NAC. This finding may provide a new decision basis to improve the treatment plan. Osteosarcoma is the most common primary malignant bone tumor, accounting for approximately 12% of primary bone tumors and mostly occurring in adolescents with a high degree of malignancy. However, a natural prognosis of osteosarcoma is extremely difficult. In the past, the 5-year survival rate of patients undergoing surgery alone was only 20–30% .Currently, tumor necrosis rate after chemotherapy, calculated using postoperative pathological sampling, is used as the “gold standard” for evaluating NAC response. However, this method was invasive and involves a complicated operation. Random sampling or biopsy only examines part of the tumor tissues obtained, which cannot comprehensively assess the intra-tumor heterogeneity before operation. Therefore, it cannot be used for real-time monitoring or application of non-operative patients. As a non-invasive alternative, medical imaging has shown great potential in osteosarcoma (OS) diagnosis and in NAC efficacy evaluation. For the efficacy evaluation of NAC for osteosarcoma, previous reports mainly focused on routine scanning to determine tumor volume changes, diffusion-weighted imaging (DWI) signal characteristics, and MRI dynamic enhancement mode . HoweverMore recently, with the advent of “radiomics”, there has been a growing focus on the discovery and usage of quantitative radiomics features of MRI images. Radiomics builds a relevant statistical model from a large number of high-dimensional extractable features from medical imaging data  to assist in diagnosis, prognosis, and therapy monitoring. Machine learning is an important step in radiomics that involves building data-based computational models and methods to improve the accuracy, performance, or predictive power of the model. As a result, machine learning strategies have a strong prognostic and predictive performance, as well as excellent stability, which is required for radiomic-based analysis. In recent years, radiomics-based machine learning has been utilized in the diagnosis and prognostic assessment of liver, prostate, lung, and breast cancers , 7.In particular, the radiomics characteristics of primary tumors have been proved to be closely related to how tumor responds to chemotherapy, and it has been reported that the radiological characteristics of primary colorectal cancer can successfully predict the efficacy of NAC , but theIn this study, machine learning-based radiomics nomogram was applied to identify poor histologic response to chemotherapy patients, which helps avoid ineffective multi-cycle chemotherapy in patients who do not respond well to chemotherapy. The aim is to provide guidance to clinicians with different therapeutic schemes, such as surgical tumor removal suggestion and chemotherapy regimen modification, to reduce the risk of disease progression and metastasis.2, cisplatin (DDP)—100 mg/m2, methotrexate (MTX)—10–12 g/m2, and ifosfamide (IFO)—10 g/m2. A chemotherapy cycle includes four rounds: the first ADM (D1–D3) and DDP (D4), the second MTX (D1), the third MTX (D1), and the fourth IFO (D1–D5). The disease development of patients should be observed after each round, and the effect of NAC is generally evaluated after the end of one chemotherapy cycle.This study was retrospective and has been approved by the institutional review board of our hospital, with informed consent of the patient being waived. A retrospective analysis of patients with osteosarcoma, as confirmed by surgery and pathology, between January 2016 and May 2020 was performed. The patient inclusion criteria were as follows: (1) osteosarcoma confirmed by histopathology, (2) MRI scans performed at two timepoints (within 1 week before the NAC implementation and at the end of the two cycles of NAC), and (3) more than two cycles of NAC treatment were performed in the local hospital. The exclusion criteria were as follows: (1) patients who did not undergo multiple-sequence MRI before or after NAC, (2) patients undergoing direct surgery without NAC, (3) patients who failed to complete the two cycles of NAC or discontinued the treatment, and (4) patients that were unable to provide complete MRI data. The specific diagnosis and treatment process of all patients were conducted under the consensus of experts of Clinical Diagnosis and Treatment of Typical Osteosarcoma . The speA total of 172 patients with osteosarcoma who underwent NAC and surgical treatment were collected, and 35 patients with imperfect MRI and pathological data were excluded. Twenty patients had direct surgery but had not undergone NAC treatment; 15 patients failed to complete two cycles of chemotherapy or terminated chemotherapy. As a result, a total of 102 patients were included in the study Figure 1Clinical information was collected from the medical record data, including age, tumor size, tumor site, pathological fracture, and surgical stage. Surgical staging was performed according to the surgical staging criteria for osteosarcoma .All MRI scans were acquired at a local hospital on a Siemens Skyra 3.0 T MR scanner with (1) axial fat-suppressed T2WI: TR = 4,200 ms, TE = 100 ms, FOV = 260 mm × 350 mm, flip angle = 15°, slice thickness = 4.0 mm; (2) axial T1WI: TR = 500 ms, TE = 20 ms, FOV = 260 mm × 350 mm, flip angle = 15°, slice thickness = 4.0 mm; and (3) coronal fat-suppressed T2WI: TR = 4,200 ms, TE = 10 ms, FOV = 360 mm × 380 mm, flip angle = 15°, slice thickness = 4.0mm. Joint coil or body coil was selected based on the range and location of the tumor.First of all, a fat-suppressed T1WI  scan was acquired before injecting the contrast agent. Then, 0.1 mmol/kg of body weight of the gadolinium-based agent  was injected using a Medrad high-pressure syringe (rate = 2 ml/s), followed by injecting 20 ml normal saline into the tube. DCE images were acquired as six post-injection scans during the intravenous injection of Magnevist. The dynamic scanning time was approximately 360 s, with a temporal resolution of 3s.2. The ROI was obtained from the layer with the best enhancement, avoiding necrotic tissue and blood vessels. Time–intensity curve (TIC) was automatically generated by the software. A gradual increase in the signal of solid tissue, without a well-defined shoulder, was defined as “curve type I”. A moderate initial rise in the signal, followed by a plateau, was defined as “curve type II”. An initial rise rapidly to a peak in the signal, followed by a decline, was defined as “curve type III”. Conventional semi-quantitative parameters of enhancement wash-in slope (Slope), time to peak (TTP), and enhancement rate (R) were obtained by calculating the TIC curve.The scanned images are fed into the post-processing workstation and processed through GE AW Volume Share 4.0. Regions of interests (ROIs) were manually delineated after having been discussed by two senior-level radiologists in musculoskeletal MRI diagnosis. The area of the ROI was about 10–20 mmDCE-MRI sequence was used for radiomics analysis. The radiomics analysis method includes the following steps: image collection and lesion segmentation, feature extraction, feature selection, model construction, and prediction evaluation of the models Figure 2To minimize MRI intensity variations, the image was normalized by centering at the mean with standard deviation using the following formula:x indicates the original intensity, f(x) indicates the normalized intensity, xμ refers to the mean value of the image intensity, xσ indicates the standard deviation of the image intensity, and s represents optional scaling, set to 1 by default. Normalization is based on the intensity of the entire image instead of just within the segmentation region.where http://www.itksnap.org). All the lesions (VOI) were manually delineated by one radiologist. The radiologist has 6 years of experience in musculoskeletal imaging diagnosis and was blinded to the clinical information of the patient. All delineations are then reviewed by a senior radiologist, and discrepancies are corrected based on tumor borders. The VOI should cover the entire lesion area, including the bone of the lesion, with its surrounding soft tissue mass, as well as the cystic necrosis area inside the lesion. The edema area and blood vessels around the lesion should be excluded. In this study, 102 VOIs delineated on scans from 102 patients were used for subject analysis (The volume of interest (VOI) was accurately delineated on the strongest enhanced phase using ITK-SNAP . These features were divided into four groups. Group 1 (first-order statistics) consists of 18 descriptors that quantitatively describe the distribution of voxel intensities within the MR image through commonly used basic metrics. Group 2 (shape- and size-based features) contains 14 three-dimensional features that reflect the shape and size of the region. Group 3 (second-order texture features) contains 75 texture features that quantify region heterogeneity differences, calculated from gray-level run length and gray-level co-occurrence texture matrices. Group 4 (higher-order filter features) contains 1,302 first-order statistics and texture features after applying Laplacian, logarithmic, exponential, and wavelet filters on the image.A total of 1,409 quantitative imaging features were extracted from MR images with the Radcloud platform , were used to reduce redundant features. For variance threshold, features with eigenvalues of the variance smaller than 0.8 were removed. The SelectKBest belongs to a univariant feature selection method, and Based on the selected features, three supervised classifiers were constructed for the radiomics-based models in this study: K-nearest neighbor, KNN; support vector machine, SVM; and logistic regression, LR. KNN calculates the distance between each sample point and all other sample points, keeps the k nearest neighbor points of the sample point, and assigns a class to the sample point by majority vote of the class of its k nearest neighbors. SVM combined the precision and function complexity of a given data to find the best proportion and to obtain the best generalization ability. LR includes classification, function establishment, solving optimal model parameters through optimization iteration, and verifying the model performance. To train the model, Gridsearch algorithm (Python scikit-learn library) was used for parameters that optimize the performance.To test whether the combined clinical indicators and radiomics signatures improve the predictive performance, a multivariate logistic regression model was used to integrate the established radiomics labels and the clinical indicators in the training set to build a predictive model for the combined efficacy. Stepwise regression analysis and Akaikes information criterion (AIC) test are used to determine the best clinical information to be included from the candidate clinical indicators . A low AIC score indicates that the statistical model takes both complexity and accuracy into consideration. The model with the lowest AIC score provides the most effective independent factors, which optimizes the construction of a multi-factor regression model with the least parameters while avoiding over-fitting and ensuring desirable data fitting. Based on the combined model, the nomogram diagram transforms it into a visual therapeutic prediction model, providing a practical tool to predict the likely probability of individual chemotherapy effectiveness. The nomogram sets the corresponding score value according to the regression coefficient of each variable in the multivariate logistic regression equation (the contribution of each influencing factor to the efficacy) and then sums the score of each influencing factor to calculate the total score. The conversion function between the total score and the efficacy of chemotherapy (endpoint event) was then used to obtain the prediction probability of efficacy for each patient.t-test . Mann–Whitney U-test was applied to compare the difference in tumor surgical staging, tumor site, pathological fracture, and the semi-quantitative parameters , with P <0.05 defining the difference as statistically significant. To assess the predictive performance of the classifiers, the receiver operating characteristic (ROC) curve, namely, area under the curve (AUC), was used in both training and testing datasets. Four indicators, including P [precision = true positives/], R [recall = true positives/], f1-score [f1-score = P*R*2/(P + R)], and support , were selected to evaluate the performance of the classifiers in this study.We used Radcloud  to manage imaging data, clinical data, and subsequent radiomics statistics analysis. Another statistical analysis was performed with SPSS 20.0 and MedCalc15.2.2. Differences of onset age and tumor size between the effective group and the ineffective group were compared by means of independent-sample P > 0.05), except for surgical staging (P = 0.013). The effective or ineffective rate of chemotherapy was consistent between the training dataset and the testing dataset, and no significant difference was found in age, longest diameter of tumor, tumor location, and pathological fracture. The ratio of patients in each surgical stage was similar between the two sets , where 71 cases belong to the effective group and 31 cases belong to the ineffective group. Most clinical risk factors of the patients, including age, tumor size, pathological fracture, and pathological type, show no statistically significant difference between the effective group and the ineffective group (two sets Table 1.P = 0.013). There is no statistically significant difference in Slope and R (P = 0.350) before NAC; while after NAC, the differences in Slope, TTP, and R between the two groups becomes statistically significant (P = 0.023). There was a difference in TIC distribution before and after NAC in the effective group (P = 0.002). There was no significant difference in TIC distribution before and after NAC in the effective group (P = 0.570) (P = 0.103). The ROC curve was used to predict the importance of each semi-quantitative parameter on the efficacy of NAC in osteosarcoma. Taking the RECIST standard as the curative effect classification standard, the sensitivity and specificity of the three parameters  to predict a desirable response to osteosarcoma after chemotherapy were 0.83, 0.92, and 0.91 and 0.69, 0.85, and 0.75, respectively. The AUC was 0.87, 0.85, and 0.83, respectively.After NAC, the Slope and R of the effective group decreased, and the TTP increased. The difference of each semi-quantitative parameter before and after NAC was statistically significant (= 0.570) Figure 4In the first step, the reproducibility ICC score of each feature was used to evaluate feature stability, and features with ICC >0.85 were selected. According to this criterion, 863 (61.2%) stable features were reserved for further screening. Then, we selected 446 features from 863 features using the variance threshold method. Furthermore, 74 features are selected with the select K best method. Finally, LASSO regression was performed to select 74 radiomics features for dimensionality reduction and 10-fold cross-test to obtain an optimal -log value of 1.45 Figure 5via AUC, sensitivity, and specificity  are separately built by learning feature values extracted from DCE-MRI to evaluate the training set and the testing set of the model. The performance of KNN, SVM, and LR classifiers are compared cificity Table 3.After constructing the radiomics labels, the combined prediction model was formed by combining the labels with clinical indicators. After AIC stepwise regression, surgical staging was determined as the optimal clinical index. The combined model was successfully constructed using a multivariate logistic regression model to integrate surgical staging and radiomics labels and then demonstrated using a visual nomogram Figure 7Although the introduction of NAC in OS treatment has improved the survival rate of patients, local recurrence or metastasis still occurs in approximately 30 to 40% of the patients due to tumor heterogeneity, and there are significant differences in tumor biological behavior and response to NAC in different patients . In receOur research demonstrates that, besides surgical staging, other clinical characteristics, including age, tumor size, whether pathological fracture occurs, and tumor site, are not adequate as independent risk factors to predict the effectiveness of NAC for osteosarcoma, which is similar to the result of a previous study using traditional methods . For staIn this study, we analyze the data from 102 patients with osteosarcoma, and we used machine learning to validate that MR radiomics features before NAC therapy are closely related to tumor heterogeneity and the efficacy of NAC. Seven high-level statistical features were selected from the DCE-MRI images that highly relate to the NAC efficacy. Such features are indicators of strength and texture, which effectively reveal the heterogeneity and subtle changes in tissue morphology within the tumor , 21. FivWe aim to establish the best artificial intelligence model to predict the efficacy of NAC for osteosarcoma treatment. In our study, SVM and LR performs better than KNN, possibly because the manual delineation of lesions adopted in this study was affected by human factors. Osteosarcoma is often mixed with the formation of tumor bone, leading to the inclusion of undesired tumor bone components in manual segmentation. The feature parameters extracted from the images of these tissues are less capable of differentiating subtle differences between groups, resulting in the low diagnostic efficiency of KNN. LR is a classical classifier which provides not only the results but also the corresponding probabilities, so the fitted parameters can clearly display the impact of each feature on the result. However, it is essentially a linear classifier, which is not applicable when the correlation between features is high. It is also not robust to outliers. In this study, the SVM classifier also has a high predictive performance, with the sensitivity, specificity, and AUC of the testing set being 0.79, 0.79, and 0.93, respectively. Thus, the appropriate classifier should be selected based on the specific situation. LR is suitable for the case whose number of features is large and is similar to the number of samples. SVM is suitable for a small number of features with general samples that are neither too large nor too small. Our results suggest that a classifier based on radiomics features extracted from the best-enhanced DCE-MRI can be used as a new method to predict the efficacy of NAC. This method can help determine the efficacy of NAC before surgery. Therefore, it is capable of assisting clinicians to determine appropriate treatment plans for patients. Previously, several reports have demonstrated that predictive models based on radiomics features can be used to predict the efficacy of colorectal, lung, and liver cancers , 7, 25.The semi-quantitative parameters of DCE-MRI effectively reveal the characteristics of tumor angiogenesis: the level of Slope and TTP represents the amount of new angiogenesis in tumor tissue, and R reflects the overall vascular density and permeability of the tumor. We adopt ROC curve analysis in this study and found that Slope, TTP, and R also exhibit notable predictive efficacy in predicting the NAC response of OS, and Slope receives the highest value. However, a nomogram based on radiomics offers better predictive performance. The reason may be that traditional semi-quantitative parameters are based only on imaging, but a nomogram combines a large amount of high-throughput imaging information and clinically valuable indicators to form a more comprehensive evaluation model. It customizes the treatment for patients more accurately and improves the prognosis. The combined model, nomogram, has high predictive accuracy and is convenient and practical, and it has broad clinical application prospects in the treatment of OS. This model is helpful to optimize the treatment strategy of locally advanced cervical cancer. Currently, there is a lack of effective markers to predict the efficacy of chemotherapy in clinical practice, and it is uncertain whether patients should receive preoperative NAC. A nomogram enables doctors to identify chemotherapy-sensitive or chemotherapy-insensitive patients before the initial treatment to develop appropriate regimens. For insensitive patients with large tumor foci, simultaneous radiotherapy and chemotherapy should be selected immediately, and for young patients with chemotherapy-sensitive patients, NAC combined surgery is recommended. In addition, due to the deficiency of radiotherapy facilities in some developing countries, NAC has been explored as an advanced treatment for tumor control before concurrent radiotherapy and chemotherapy. The combined radiomics model can also assist in identifying patients who are suitable for NAC prior to concurrent radiotherapy and chemotherapy. Furthermore, the nomogram combined model may be able to predict the response of patients with recurrent or metastatic cervical cancer to systemic chemotherapy using preoperative MRI images. If the nomogram combined radiomics model can be utilized in clinical practice, it will be beneficial to promote personalized precision medicine for OS.In conclusion, our study demonstrates the feasibility of combining artificial intelligence with MRI radiomics to predict the efficacy of NAC for osteosarcoma by depicting VOI during the most intense period of enhancement. This is a noninvasive and highly accurate method that can predict the efficacy of NAC for osteosarcoma before surgery. It helps avoid ineffective multi-cycle chemotherapy in patients who do not respond well to chemotherapy as well as guide the clinical doctors with a different therapeutic schedule.Due to sample size limitation, the number of cases used in the testing set of this study is small. It is necessary to further increase the sample size of the testing set in the future to compare the effectiveness and practicability of these classifiers. Furthermore, this study only used radiomics and clinical features to construct the NAC efficacy prediction model, without the pathological information of the patients. Further research is needed to construct a more comprehensive prediction model combining clinical, pathological, and imaging features. In addition, VOI in this study is manually delineated. Since the delineation process is time-consuming, this study adopted the sketching scheme of the review of young doctors and senior doctors, without repeated sketching of lesion areas. In subsequent studies, the accuracy and repeatability of VOI should be further evaluated. For research with a larger sample size in the future, semi-automatic or automatic segmentation can be adopted to reduce time cost.The original contributions presented in the study are included in the article/This study was retrospective and was approved by the Institutional Review Board of People’s Hospital of Zhengzhou University, and informed consent of the patients was waived.YG was the general responsible person of the project, responsible for the design of the project, writing and checking the article, and responsible for the reliability of the article. YG also formulated the overarching research goals and aims. HL participated in the development of the whole experiment, planned the main parts of the experiment, and analyzed the results. HL was also responsible for the detailed analysis and delineation of patients’ MRI images. YG and HL are also responsible for the coordination and review of this study. TC participated in the planning and execution of the experiment, and assisted in the specific analysis, delineation, and verification of patients’ MRI images. LZ was responsible for the design of the experiment, the exploration and implementation of the radiomics methodology, the analysis of the results, and the writing of the main part of the manuscript. FZ was responsible for the collection, sorting, classification, and statistics of clinical information of patients. YX was responsible for software design, computer programming, and data analysis related to the radiomics portion of the study. QG was responsible for patient enrollment, imaging and clinical information collection, and data collation. All authors contributed to the article and approved the submitted version.YX was employed by the company Huiying Medical Technology Co., Ltd.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This meta-analysis aimed to assess the efficacy and safety of transcutaneous acupoint electrical stimulation (TEAS) for postoperative pain in laparoscopy. The review has been registered on the “INPLASY” website and the registration number is INPLASY202150101.  Relevant randomized controlled trials are selected from seven electronic databases  from their inception up to November 30, 2020. Twenty-eight studies were included in this meta-analysis, and the statistical analyses and the exploration of heterogeneity sources were conducted by Stata 15.0 software. Besides, the bias assessment of the included studies was evaluated using the Cochrane risk of bias tool.  In total, 28 RCTs covering 2787 participants were included. The meta-analysis suggested that TEAS can effectively relieve pain in the short term after laparoscopy, reduce the postoperative consumption of rescue analgesics, improve the quality of life of patients, and shorten the length of hospitalization. And no serious adverse events are related to TEAS. Therefore, TEAS is relatively safe and efficacy for clinical application. The most used acupoints were Hegu (LI14), Neiguan (PC6), and Zusanli (ST36).  TEAS can be recommended as a complementary and alternative therapy for the treatment of postoperative pain after laparoscopy. However, the included RCTs had some methodological limitations. Therefore, larger-size, more rigorous, and higher-quality RCTs are needed in the future to further explore the efficacy and safety of TEAS for postoperative pain after laparoscopy. For the literature to be difficult to obtain the full text, we checked and identified the ongoing or unpublished studies through the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), Clinical Trials.gov, Chinese Clinical Trial Registry (Chi CTR), and the reference list of eligible RCTs. Two reviewers (Meng and Mao) independently screened the titles and abstracts for eligibility and examined the full text of the articles. Any discrepancies were resolved by consensus or after consulting a third party (Song).A comprehensive search was carried out in PubMed, the Cochrane Library (CENTRAL), Embase, and four Chinese databases  from their inception up to November 30, 2020. Because of the language restriction of our researchers, only studies published in English and Chinese were included. The search strategy consisted of Medical Subject Heading (Mesh) terms and free-text terms with logical operators. Asterisks are truncation symbols that can help us search for all designs with asterisks. We performed an initial search of PubMed as follows : #1 “traParticipants: they were adults over 18 years old and underwent any kind of laparoscopy under general anesthesia. There are no restrictions on gender, race, occupation, location, malignancy of the disease, and many other aspects. When these patients underwent surgery other than laparoscopy, we only analyzed the pain indicators related to laparoscopy.Type of study: randomized controlled trials (RCTs) in English or Chinese with no limitation of the blinding method.Type of interventions: the intervention groups were treated with TEAS or TEAS combined with other therapy, such as patient-controlled intravenous analgesia (PCIA) or other anesthesia methods. The intervention time, frequency, waveform, acupoints, and course of treatment of TEAS are not limited. The control group were treated with sham-TEAS or blank control or combined with other treatment methods which are the same as the intervention group or combination of the above several methods.Study outcomes: primary measures: (a) pain intensity: relevant overall postoperative pain using any scale, such as Visual Analogue Scale (VAS); (b) consumption of postoperative analgesics. Secondary measures: (a) quality of life after the surgery: assessed using validated scales, such as the pain score in QoL-40; (b) duration of hospitalization; (c) adverse events such as postoperative nausea, vomiting, pruritus, etc. Safety evaluation was assessed using the adverse event reported in the studiesNon-RCTs, crossover trials, quasi-randomized trials, protocols, reviews, case reports, animal experimental research studies, ongoing trials, literature without full text, duplicate publications, and irrelative interventions and outcomes were excluded.We excluded trials in which the controls underwent different frequency, waveform, intervention time, and other forms of TEAS compared with the intervention group.Data extraction was independently conducted by two investigators (Meng and Mao) according to the criteria above. Disagreements were resolved through discussion and consensus was reached with a third investigator (Yan). The two authors made a final judgment by reading the full text of the remaining articles. All available information related to our research was extracted from the included studies. The following data was extracted from the studies using a predesigned form: first author name, publication year, types of surgery, sample size, intervention, intervention measures and time, acupoints, waveform, electrical stimulation frequency, outcome measures, and adverse events. If the information was incomplete, we tried to acquire it by contacting the correspondent authors via e-mail or telephone.The Cochrane risk of bias tool  was usedP < 0.05 was considered statistically significant. For continuous variables, so the mean difference (MD) or standard mean difference (SWD) with 95% confidence interval (CI) was used for analysis. For dichotomous data, such as the rates of responders and adverse events, the relative risk (RR) with 95% confidence intervals (CIs) was utilized for analysis. In the multiarm RCTs, we only extracted the data related to our study. For studies that satisfied the predefined inclusion criteria with multiple intervention groups, which used different intervention duration or different acupoints, meta-analysis will be conducted carefully when merged the data into a unified intervention group data. The magnitude of heterogeneity was measured using heterogeneity index I2 statistic: when I2 < 50%, a fixed-effects model will be used for pooled data; when I2 ≥ 50%, a random-effects model was used. For each merged analysis, a heterogeneity test was performed using the chi-squared statistic. If I2 ≥ 50%, the synthesized studies were considered an indicator of a substantial level of heterogeneity. Subgroup or sensitivity analysis was performed to identify the cause. Subgroup analyses identified the possible factors that contributed to the heterogeneity, such as different intervention duration, interventions, types of surgery, and waveform. Funnel plots were introduced to detect the existence of potential publication bias within RCTs (n ≥ 10). If meta-analysis is not feasible, narrative descriptions are provided. If heterogeneity of significance found in the included studies cannot be explained by subgroup analysis, we will not conduct a meta-analysis.Statistical analysis was performed with the Stata 15.0 software. A total of 238 articles were identified during the initial study selection, 82 duplicates were removed, and 121 articles were excluded after reviewing abstracts and titles. Seven articles were excluded after reading the full text. For articles in which the data were repeatedly published, we choose the one with the higher quality and more related outcomes. Finally, 28 RCTs  met the In the included 28 trials –48, 4 2, 34, 47 n ≥ 5 RCTs) reported VAS scores were analyzed to explore the analgesic effect of TEAS after laparoscopy.Among the included studies, 8 studies were reported only in the form of graphs, without mean and standard deviation. However, our contact with the author is often unsuccessful. Therefore, the data are often unavailable and can only be excluded. One study  recordedP = 0.248, I2 = 26.1%). The combined data showed that the TEAS group was effective in reducing pain at this time compared with the control group . Six studies reported postoperative VAS scores at 6 h , a random-effects model was used and showed no statistical difference between the two groups. The combined data extracted from 9 studies related to postoperative VAS score 12 h showed obvious heterogeneity , and a random-effects model was used. Based on the types of surgery, gastrointestinal surgery showed good intergroup homogeneity . The subgroup analysis in favor of the TEAS group was effective in reducing pain at this time compared with the control group in the gastrointestinal surgery and gynecological surgery  . Based on the waveform, we conducted a subgroup analysis. The homogeneity between continuous waveform groups is good . The results showed significant pain reduction in favor of the TEAS group versus the control group at this time when applied continuous wave and dilatational wave .Five studies reported a postoperative VAS score at 4 h . The fixs at 6 h . Due to < 0.001] . Fifteen< 0.001]  providedP = 0.943, I2 = 0%). The combined data indicated that the postoperative consumption of analgesics was significantly lower in the TEAS group than that in the control group .In our study, the consumption of postoperative analgesics after laparoscopy was used as another important indicator to evaluate the analgesic effect of TEAS. Six studies , 41, 42 Five studies , 34, 43 P = 0.018, I2 = 75.2%). According to different types of surgery, the subgroup analysis was performed. It showed good homogeneity  and significant improvement  within the TEAS group who underwent gynecological surgery.Three studies , 22, 43 P = 0.16, I2 = 39.1%). Meta-analysis results indicated that the duration of hospitalization in the TEAS group was shorter than that in the control group .Five studies , 47, 48 P < 0.05), but there was no significant difference at 24 h and 48 h after surgery. The results of Chen et al. [Adverse events are the main evidence of safety evaluation. The adverse events in our study refer to a series of complications after the operation . In the 28 included studies, 6 , 38, 44 n et al. , 36, 44 n ≥ 10 RCTs) (P = 0.261 > 0.05).To assess the stability of the study results, our study performed a sensitivity analysis on the meta-analysis one by one. It showed that the results of each meta-analysis were stable. A funnel plot was used to assess publication bias based on the VAS score at 24 hours after the surgery 10 RCTs) . It show10 RCTs)  suggesteEnhanced recovery after surgery (ERAS) advocates optimizing multiple approaches to perioperative pain management . PostopeTo systematically assess the efficacy and safety of TEAS for postoperative pain after laparoscopy, our study conducted a systematic review and meta-analysis of 28 RCTs involving 2787 patients. Our meta-analysis suggests that TEAS can effectively relieve pain in the short term after laparoscopy, reduce the postoperative consumption of rescue analgesics, improve the quality of life of patients, and shorten the length of hospitalization. Therefore, TEAS can be recommended as a complementary and alternative therapy for the treatment of postoperative pain after laparoscopy. Besides, no serious adverse events related to TEAS and the occurrence of treatment-related safety problems were reported in the included studies. Therefore, we could think cautiously that TEAS is relatively safe and efficacy for clinical application.A previous study suggested that epidural anesthesia can reduce postoperative pain scores in abdominal surgery , so it iBesides, we did not categorize different types of pain, which may affect the results. Therefore, a more rigorous experimental design is needed to confirm the results of our study. We found that TEAS was effective in alleviating pain intensity at 4h, 12h, and 24h after laparoscopy, although this may depend on the type of surgery and waveform of the electrical stimulation device. TEAS can also effectively reduce the consumption of analgesics 12 h after surgery, but the sample size included in this study was small, and the pharmacological mechanism of different analgesics was not fully considered. This indicates that TEAS can effectively relieve postoperative pain in the short term. However, in the process of future studies, more objective large-scale RCTs are still needed to provide more evidence support, and more attention should be paid to the standardized research program of TEAS and the follow-up of long-term efficacy.At present, the analgesic mechanism of TEAS is not clear. Some studies –60 belieFor patients who have experienced laparoscopy, the body function is in a relatively weak state, resulting in patients with insufficient strength, blood stasis, and reduced meridians, resulting in postoperative pain symptoms. According to the traditional meridian theory of traditional Chinese medicine, the regulating effect of acupuncture and moxibustion is reflected not only in regulating the movement of Qi and blood, making the meridians and collaterals smooth, but also in regulating the ups and downs of Qi and blood, so that the organs and collaterals are supported by Qi and blood, and correcting the partial decline of the body. Acupoints are special parts of the viscera by draining Qi into the body surface. Electrical stimulation on the acupoints can play the role of regulating Qi and regulating blood, draining meridians, and dredging collaterals. Hegu (LI14), Neiguan (PC6), and Zusanli (ST36) are important acupoints for analgesia in meridian theory. Both ancient literature and modern studies show that Hegu (LI14) is good at relieving pain . The expI2 = 32%, REM). Although this study has found that TEAS can improve postoperative quality of life and shorten the duration of hospitalization, more large RCTs with objective results are needed to confirm these findings.The QoR-40 scale is designed to evaluate the quality of postoperative recovery. Its effectiveness has been verified clinically, and it is widely used to evaluate the quality of postoperative recovery . The durFor the aspects of the waveform and electrical stimulation frequency, the included studies mostly adopted dilatational waveform with 2/100 Hz. In terms of analgesia, a previous study  has suggIt must be acknowledged that our meta-analysis has several limitations. (1) The intervention time, waveform, and frequency of electrical stimulation, acupoints, and other aspects of TEAS treatment are not uniform due to the different clinical experiences. At the same time, the treatment regimens in the control group were not uniform, which may affect the accuracy of the effectiveness assessment. (2) Our review may be affected by a high degree of heterogeneity, and it is difficult to find out the main reason that affects the efficacy of TEAS. (3) We did not distinguish between different types of pain and did not summarize the optimal TEAS treatment for postoperative laparoscopic pain. (4) Most RCTs were conducted in China, which may lead to publication bias and affect the validity and reliability of the system evaluation. (5) The methodological deficiencies and small sample size of the included trials may overestimate the efficacy to some extent. (6) No long-term follow-up information has been reported, so long-term efficacy remains to be confirmed.In this systematic review and meta-analysis, TEAS can be cautiously considered as a treatment for postoperative pain after laparoscopy, which is effective in alleviating pain in the short term, reducing the use of remedial analgesics, and improving postoperative quality of life and length of hospital stay. TEAS is a noninvasive and easy-to-operate treatment, which can be operated after simple training, low application price, and good treatment compliance. It is worthy of clinical promotion and application. Although this study has limitations, it provides a direction and basis for future research. Due to the methodological deficiencies of the included RCTs, larger-size, more rigorous, and higher-quality RCTs are needed in the future to further explore the efficacy of TEAS in the treatment of postoperative pain after laparoscopy. Therefore, it is necessary to further optimize the treatment plan in terms of intervention time, electrical stimulation frequency and waveform, and acupoint selection. The long-term therapeutic effect of TEAS needs further studies determined by the observation of prolonged follow-up time. Besides, more attention should be paid to the economic impact of TEAS in the health care system.


N = 102), who participated in martial arts or team sports or were sedentary children. Executive functions were measured with the tests: Attenzione e Concentrazione, Digit Span test, Tower of London, IOWA Gambling task BVN 5-11, and BVN 12-18. Results demonstrated that children practicing martial arts showed better executive functioning and higher school marks than those involved in team sports or not involved in any sports. Furthermore, participants aged 12 to 15 years old outperformed in cool and hot executive functions tasks and had a better academic performance. Thus, the present findings supported the view that regular practice of extracurricular sports enhances executive functions development and consequently influences academic performance.It is well known that curricular physical activity benefits children’s executive functions and academic performance. Therefore, this study aimed to determine whether there is an influence of extracurricular sports on executive functions and academic performance. However, it is less known which specific types of the sport better enhance executive functions in children; to investigate this issue, this study compared the performance on executive functions tasks and academic performance in one hundred and two boys and girls with an average age of 11.84 years recruited from Italian schools and gyms ( The World Health Organization (WHO) has identified the school as a key setting for the promotion of physical activity (PA) in children . The schHaapala  carried EFs are a collective term under which a broad spectrum of cognitive abilities is summarized. These abilities are needed for goal-directed, purposeful thoughts and behaviors ,20,21. WEvidence suggests that different types of sport may influence EFs in various ways: movement, motivational and emotional enhancement, social interaction, and cooperation ,29,30. CDespite the increasing occurrence of studies that demonstrate the positive effects of PA on the cognitive domain, results concerning the influence of PA on school achievement are variegated ,40,41, aBecker and colleagues  found a Moreover, tennis play was associated with better working memory, cognitive flexibility, and inhibition . Dyer anDespite these results from the studies mentioned earlier, little is known about AP as influenced by specific sport categories. For example, research has supported team sports ; on the In conclusion, specific sports require different demands related to varying cognitive loading .The purpose of this study is to compare the performance of Cool EF and Hot EF tasks and school achievement, among participants involved in martial arts, team sports, and sedentary children with ages ranging from 7 to 15 years.Difference among the two sports groups was hypothesized; in particular, that participants involved in martial arts would show better performance on tasks measuring EFs when compared with peers practicing team sports. Moreover, all sports groups would show better performance on EF tasks compared with sedentary peers. Lastly, it was hypothesized that better performance on EFs tasks reflects better school marks on mathematical and linguistic school subjects. As concerning age, the 12-to-15-years-old group was hypothesized to outperform on EF tasks.A total of 102 Italian school children  with an average chronological age of 11.84 (2.41) years were involved in this study.Participants were classified into two age groups 7–11 (43.1%), 12–15 (56.9%). In addition, 40.2% did martial arts, 18.6% were sedentary, and 41.2% practiced team sports. As concerning gender, 56.9% were male and 43.1% were female. Inclusion criteria were the absence of intellectual disability, visual or neurological impairment, and/or neurodevelopmental disorders; and to correctly understand and speak the Italian language.Participants practiced martial arts or team sports in their leisure time three times per week at least in the 2 years prior to the research. Sedentary children did not participate in any sport at least in the 2 years prior to the research.The medium socio-economic level was predominant (51.7%), based on parents’ education and employment parameters. Participants were recruited in public schools or gyms, all located in an urban area, based on voluntary participation in the research project. After the headmaster of each school or gym approval, parents were contacted through flyers announcing the research project with aims, procedures, and a guarantee of anonymity and confidentiality for participants. Then parents were invited to allow their children to participate in the study and provide their written consent. This study was carried out following the recommendations of the Declaration of Helsinki (2013) and the Ethical Code of the Italian Association of Psychology (AIP).Firstly, a Socio-Demographic Schedule was administered to collect participants’ age, education, school marks, and SES. The criteria for SES evaluation were the family size, parents’ education, and job. The medium-high status was given by the parental qualification of high school or graduation and job requiring a diploma or high qualification. The medium status was given by parental qualification or middle school and high qualified job as a teacher, employee, shop assistant, or similar. The medium-low status was given from the parental qualification of primary school and qualified to require as housekeeper or student.A battery of multiple standardized tasks was used to measure executive functioning and multiple standardized tasks were used. This consisted of the following tests: The Stroop test and The Distributed Attention test derived by the CD-ROM from Attenzione e Concentrazione ; The TowThe Digit Span Test was composed of two tasks: the Forward Digit Span, which required participants to repeat a sequence of digits in the same order of the instructions, and the Backward Digit Span, which required participants to repeat the digits in the reverse order of the instructions. Forward Digit Span consisted of 27 sequences ranging from two to nine digits, while Backward Digit Span contained 24 sequences ranging from two to eight digits. The experimenter verbally presented each sequence at the rate of one digit per second. Two trials were administered for each sequence length; if participants were correct on either trial, then they advanced to the following sequence with the number of digits increasing by one. The test was ended when participants failed on two trials of the same length. Scores were computed by counting the total number of digits successfully remembered Forward Digit Span and Backward Digit Span were analyzed as separate dependent variables, and two scores were obtained .The Stroop test assessed the ability to inhibit cognitive interference of word meaning on the ability to name the color of the words appearing on the screen . There were two categories of stimuli fallen into two categories: congruent trials including words in which color word and the color print matched ; incongruent trials including words in which color word and color print were different . Scores resulted in reaction time and accuracy for congruent and incongruent trials.The Tower of London (ToL) measured planning strategies. Participants were showed on the laptop screen a wooden set with three pegs and three balls , and participants were asked to move balls to reach the configuration, following specific rules . The ToL was composed of 12 trials with an increasing level of difficulty. Scores were computed by counting the correct configuration from 0 to 12 points.The Iowa Gambling Task (IGT) is a computerized card game to assess decision-making abilities by simulating real-life situations with rewards and punishments. It is composed of four card decks: A, B, C, and D. The A and B decks are “disadvantageous,” short-term, and risky card desks. Each participant chooses a card, and s/he immediately gains money, but a high penalty follows the choice. The C and D are “advantageous”, long-term, and safe card decks. A smaller gain and lower penalty followed participant’s choice. The task is unknown to the participant, consisting of 100 trials . Long-term decision-making is reflected in the IGT score calculated as the number of cards selected from the advantageous, safe decks minus those selected from the disadvantageous, risky decks. The net score of the first 40 trials reflected uncertainty decision-making; the net score of the last 40 trials reflected risk decision-making. A high net score was given by selecting fewer cards from the disadvantageous but immediate reward decks (A and B) and drawing more cards from the advantageous reward decks (C and D). Two singles scores were obtained: 1. “good play,” given by the choice from advantageous, good, decks outweigh those from disadvantageous, bad one; 2. “bad play” given by choices from risky, bad decks exceed those from safe, good ones.The Attenzione e Concentrazione test was used to test distributed attention through a dual-task test. Participants were instructed to push a button whenever a target appeared, simultaneously a list of words, and the child was asked to push another button when he heard the word target. Thus, attention was distributed on two parallel tasks, the visual one and the auditory one. Two scores were entered: correct answers and errors.The Verbal Fluency Test derived consisted of category fluency and phonemic fluency to test the speed of access to the lexicon. Participants were given a minute to produce as many words as possible within a specific category  or starting with a given letter . Scores were computed for each category (or given letter) and a total as a summary by adding all the scores together.Tasks were administered to each participant by a researcher in a quiet room of the school/gym and required one session of 30 to 40 min. Tasks were presented in a balanced order to avoid the effect of sequence. For example, the initial order was: 1. The Digit Span; 2. The Distributed Attention, 3. The ToL; 4. The Stroop test; 5. The IOWA Gambling Task; 6. The Verbal fluency. Then, the order was 1. The Distributed Attention; 2. The ToL; 3. The Stroop test; 4. The IOWA Gambling Task; 5. The Verbal fluency; 6. The Digit Span, and so on.School achievement was measured through the final school marks in linguistic and mathematical subjects reported by each participant at the end of the first four months of the school year. School marks ranged from 1 to 10, with higher scores indicating better school achievement. The researcher verified the matching between the self-reported school marks and school report cards.p ≤ 0.05.SPSS software  was used to run statistical analyses. Multivariate ANOVA was computed to compare cognitive outcomes in children involved in martial arts, team sports, and sedentary children. The independent variables were sport and age, and the dependent variables were the scores on Hot EFs and Cool EFs tasks, such as working memory, inhibition, planning, attention, and decision making. The significance level was set at p = 0.000, η2p = 0.123], inhibition , verbal fluency , and in auditory distributed attention . Moreover, significant differences were found on the IOWA test in the criterion of differences between good and bad play . Results are showed in p = 0.029, η2p = 0.073], inhibition , distributed attention , visual distributed attention , and auditory distributed attention . Regarding Hot EFs, a significant difference on IOWA test in good play  was found. Results are showed in Data analysis showed significant differences between the three groups for the following cognitive abilities. As concerns the age main effect, 12-to-15-year-old participants had higher scores in working memory [F (1102) = 13.137, No interaction effects of factors were found.School marks in linguistic and mathematics were higher in children involved in martial arts than their peers involved in team sport and sedentary children. The martial arts group outperformed in linguistic, both at the ages of 7-to-11-years-old (M = 8.56) and 12-to-15-years-old (M = 7.59). In mathematics, only 7-to-11-years-old children practicing martial arts reported higher scores (M = 8.56) compared to other groups. The means and standard deviations are summarized in This study aimed to compare performance on EFs and AP of children practicing martial arts, team sports, and sedentary children with an average age of 11.84 years. Our findings show that the 12-to-15-years-old group would perform better in EF tasks, both Cool and Hot. Higher performances were found in working memory, inhibition, verbal fluency, distributed attention, and decision-making tasks. This is coherent with developmental trajectories showing how a gradual linear maturation defines EFs from preschool throughout adolescence .The gradual growth of EF is widely due to the involvement of the prefrontal cortex (PFC), particularly in the dorsolateral region. Structurally, this region develops slowly across age; from the age of six years, an activation of PFC, although less specialized, is evident when children perform EFs tasks, but this development carries on with the age until reaching the complete maturation in early adulthood age ,26Moreover, participants practicing martial arts displayed a better performance on EF tasks and AP than those who attended team sports or were sedentary. In addition, they performed better in inhibition, working memory, distributed attention, verbal and auditory, verbal fluency tasks, and decision making.Historically, martial arts have highlighted the importance of self-regulation abilities, and for this reason, the terms self-control and discipline are strongly connected to them . The abiIn the study, a significant benefit was observed for AP, and it consisted in higher marks on linguistic and mathematic areas for children regularly practicing extra-school sports; these results are in line with previous researches and reinforce the beneficial effects of PA on EFs and as a consequence on AP ,47,57,58To sum up, based on our results, PA as martial arts would be helpful to improve school abilities, not only as AP but also as school readiness. As proof of this, Pinto-Escalona et colleagues  implemenInteresting implications on the educational fields are supported. Firstly, coherently, it is imperative to encourage sport participation at a young age. Specific parent or teacher education programs would be necessary to share good practices deriving from the awareness of sports benefits. Too often, these benefits are linked only to physical health, as the limitation of overweight and obesity for an increasingly inactive lifestyle on childhood. Teachers and families need to understand how sports activities can contribute to child cognitive development by enhancing planning, sustained and divided attention, working memory, inhibition abilities by enjoying activities. In a complementary way, researchers and practitioners need to understand what sports and exercise interventions are suitable for cognitive development to create the perfect matching between one sports task and one executive function. In particular, as concern the martial arts, it would be remarkable to study the cognitive profiles of children practicing different components such as kumitè and kata characterized by different levels of open or closed skill activities, different goals, and different exercises training programs.To sum up, the findings of this study suggest how sport participation and the practice of martial arts, in particular, contribute to improving school abilities. This study’s strength is highlighting the influence of participation in after-school sports activities on the development of EFs and on academic performance. With the recognized benefits of physical fitness for health since childhood, most studies have focused on the benefits of school physical activities.Furthermore, future research is needed to remedy the shortcomings of this study. A significant limitation lies in methodological concerns as the measurement of children’s AP through school grades at the end of the term. Even if the grades were reliable, direct measurements of academic skills such as reading, writing, and arithmetic should be made. This is because EFs directly influence the acquisition of the school-skills as mentioned above, which, together with other contextual and social factors, ultimately result in school grades.More future research is needed to fully understand the link between sport, EFs, and AP. Results from this study further our understanding of martial arts, which can enhance cognitive development, in particular EFs. Martial arts represent an exercise program supporting life-long physical and psychological positive effects, with significant consequences on EFs and AP.From the psycho-educational point of view, it is essential promoting participation in sports. It has been shown to significantly increase opportunities for children to be physically active, both in curriculum physical activity and extracurricular sports ,63.


We aimed to investigate whether the relationship between fat mass and bone mineral content (BMC) is mediated by insulin, leptin, adiponectin, dehydroepiandrosterone sulphate, testosterone and estradiol in children aged 9-11 years.We utilised cross-sectional data from the Physical Activity and Nutrition in Children study . Fat mass and BMC were assessed with dual-energy X-ray absorptiometry. Endocrine factors were assessed from fasted blood samples. We applied the novel 4-way decomposition method to analyse associations between fat mass, endocrine factors, and BMC.Fat mass was positively associated with BMC in girls  0.005 to 0.020) and boys . The relationship between fat mass and BMC was mediated by free leptin index in girls  and boys . The relationship between fat mass and BMC was partially explained by mediated interaction between fat mass and free leptin index in boys  and by interaction between fat mass and adiponectin in girls .At greater levels of adiponectin and free leptin index, the fat mass and BMC relationship becomes less positive in girls and boys respectively. The positive association between fat mass with BMC was largely not explained by the endocrine factors we assessed.https://clinicaltrials.gov/ct2/show/NCT01803776], identifier NCT01803776.[ Increased fat mass may increase bone mass through greater mechanical load on bones . As bonevia the sympathetic nervous system  BMC in a population sample of girls and boys aged 9 to 11 years, and to assess the extent to which this relationship is mediated by insulin, leptin (free leptin index), adiponectin, DHEAS, testosterone and estradiol using the 4-way decomposition method. We hypothesized that fat mass would be positively associated with TBLH BMC, and that this association would be partially mediated by insulin, free leptin index, adiponectin, DHEAS, testosterone and estradiol.This study utilized cross-sectional data from the two-year follow-up of the Physical Activity and Nutrition in Children (PANIC) Study, an 8-year controlled lifestyle intervention study in a population sample of Finnish children  with ongoing follow-up assessments. BMC data were taken from baseline to include as a covariate. Of the 736 children invited to participate, 512 attended the baseline examinations and 438 attended 2-year follow-up examinations. For the present analyses, we excluded children who were currently taking or had previously taken oral corticosteroids, as this could influence BMC . CompletThe study protocol was approved by the Research Ethics Committee of the Hospital District of Northern Savo . and conducted according to the ethical guidelines of the Declaration of Helsinki. The parents or caregivers of the children provided their written informed consent, and the children provided their assent to participation.General health was assessed by a questionnaire completed by parents or caregivers. The questionnaire included items on children’s history of chronic diseases and allergies diagnosed by the child’s physician, and detailed information on children’s medications, prescribed to be used regularly or on demand. Pubertal status was assessed by a research physician. Central puberty was determined as breast development at Tanner stage ≥2 for girls and testicular volume ≥ 4 mL assessed by an orchidometer for boys .2) was calculated, and the BMI cut-offs of the International Obesity Task Force were applied to classify children as underweight, normal weight, overweight, or obese weight status  to an accuracy of 0.1 kg. For stature and body weight, the mean of the values was used in analyses. Anthropometric measurements were conducted following the standard protocol used in Finnish health care, outlined by Saari et al. . Body mat status .2), fat mass (kg) and lean mass (kg) were measured by a trained and experienced research nurse using the Lunar Prodigy Advance dual-energy x-ray absorptiometry (DXA) device  and the Encore software, Version 10.51.006 . These measurements were made in accordance with the instructions outlined by manufacturers using standardized protocols. The same DXA device and software were used for all measurements. DXA provides valid and reliable data on BMC and body composition in children (coefficient of variation = 0.01 – 4.37%) (TBLH BMC (g), aBMD (g/cm– 4.37%) . A quali– 4.37%) .Venous blood samples were taken following a 12-hour overnight fast. Blood was immediately centrifuged and stored at –75°C until biochemical analyses. Serum insulin concentration was measured by electrochemiluminescence immunoassay with the sandwich principle . Plasma leptin concentration was analysed using a competitive radioimmunoassay  and plasma soluble leptin receptor concentration was analysed using an enzyme linked immunosorbent assay (ELISA) kit . Free leptin index was calculated by dividing leptin with leptin receptor and multiplying by 100 and was used instead of leptin and leptin receptor in statistical analyses, as it has been suggested that free leptin index better reflects the physiological actions of leptin . Serum hAnalyses were performed with Stata/SE for Mac software, Version 16.1 . Differences in age, stature, BMI categories and pubertal status based on stages described by Tanner  between Med4Way command in Stata/SE, which allows the total relationship between fat mass and BMC to be separated into four components: a controlled direct association (association due to neither mediation or interaction), a reference interaction (association explained by interaction only), a mediated interaction (association explained by mediation and interaction), and a pure indirect association (association due to mediation only)  see Figure 2nly) see , 29. Twonly) see . The alpModels were confirmed to meet assumptions of linearity, normality, and homoscedasticity of residuals. In 96% of boys, estradiol levels were under the lowest limit of quantitation, and therefore the analysis of estradiol could not be performed for boys. As 73% of girls had measurable levels of estradiol, the 27% of the samples with estradiol levels below the lowest limit of quantitation were included in analyses with the estradiol level coded as the lowest limit of quantitation. Given the nature of mediation analysis, multicollinearity is expected. In all models, all variance inflation factor (VIF) values were less than 10, and most were less than 5, indicating acceptable levels of multicollinearity . InfluenChildren included in this study did not differ from the children excluded from this study for age, stature, pubertal status and body weight status Table 1.p < 0.001) and boys  when adjusting for either insulin, free leptin index, adiponectin, DHEAS, testosterone or estradiol  and boys  in all models with either insulin, free leptin index, adiponectin, DHEAS, testosterone or estradiol  and boys   Table 2.p < 0.001) and boys  (p < 0.001) and boys  (p < 0.001). When fat mass changed from the median to the 75th percentile, the difference in TBLH BMC explained by the mediated interaction was negative in boys  (p = 0.001) and boys   Table 2.p = 0.036), and there was an interaction between fat mass and adiponectin on TBLH BMC in girls only   (Fat mass was not associated with adiponectin in girls or boys (= 0.031) Table 2.Fat mass was not associated with DHEAS in girls or boys Table 2.p = 0.048)  Table 2.Fat mass was not associated with estradiol in girls Table 2.A summary of the significant mediation and moderation effects is presented in Our study is the first to formally test the mediation and interaction of insulin, free leptin index, adiponectin, DHEAS, testosterone and estradiol in the relationship between fat mass and TBLH BMC in a population sample of predominantly normal weight pre- and early-pubertal children. The positive relationship between fat mass and TBLH BMC was suppressed by mediation through free leptin index in girls and boys, and moderated by adiponectin and free leptin index in girls and boys respectively. Our findings indicate that the association between fat mass with TBLH BMC was largely not explained by the endocrine factors we assessed. Greater fat mass provides additional loading on bones, which may explain the positive association between fat mass with TBLH BMC. This proposed mechanism of mechanical loading due to increased fat mass is further supported by associations of a greater magnitude observed between lower-limb fat mass and BMC compared to upper-limb fat and BMC (unpublished observations), indicating the relationship between fat mass and BMC is more pronounced in load-bearing bones. However, as highlighted in a 2020 review article, the complex relationship between mechanical loading, due to lean mass, fat mass or weight-bearing activity, with bone metabolism, and the moderating role of associated endocrine and paracrine factors in this association is not yet fully understood .The positive association between fat mass and TBLH BMC is in line with previous research in pre- and early-pubertal children , 5. The In vivo evidence indicates that insulin acts as an anabolic agent for bone , Foundation for Paediatric Research, Doctoral Programs in Public Health, Paavo Nurmi Foundation, Paulo Foundation, Diabetes Research Foundation, The Finnish Medical Society Duodecim, Orion Research Foundation sr, Research Committee of the Kuopio University Hospital Catchment Area (State Research Funding), Kuopio University Hospital (previous state research funding (EVO), funding number 5031343) and the city of Kuopio. The UEF LC-MS Metabolomics laboratory is supported by Biocenter Finland and Biocenter Kuopio. The open access publication fees were supported by the University of Exeter.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.


As a powerful antioxidant in the human body, uric acid (UA) has been the subject of increasing research that focused on its influence on Alzheimer's disease (AD) in recent years. The latest literature was gathered to describe the influence of serum uric acid (SUA) level on the onset and progression of AD and to analyze the possibility that SUA is a biomarker of Alzheimer's disease. A large number of existing studies suggested that the SUA level was lower or tended to decrease in patients with AD, and increased SUA level may have a protective effect in AD, which could reduce the risk of onset and slowing the course of the disease. However, some Mendelian randomization analyses suggested that genetically determined uric acid was not associated with AD risk. Existing research results are contradictory due to the high inconsistency of the studies, the selection of subjects, and other factors. UA also showed a strong association with cognitive function, and there appeared to be a gender-selective neuroprotective action. Due to its potent antioxidant properties, the low uric acid level may contribute to oxidative stress to accelerate disease progression. But some preclinical data showed a possibility that in some special cases, UA had a prooxidant properties. The possibility was raised in the discussion of the underlying mechanism that both the low uric acid level and the rapidly progressive course of the disease were the consequence of malnutrition. This paper reviews recent advances in the study of SUA and AD which offers the possibility of new biomarker, new prevention, and treatment strategies for Alzheimer's disease. Uric acid (UA) is a product of purine metabolism, which is a natural and powerful antioxidant that helps remove superoxide by blocking the degradation of superoxide dismutase, the enzyme responsible for purine removal . The SUACurrent trends indicate that early detection of AD by noninvasive approaches is a popular area of research. A growing number of studies have demonstrated that UA was linked with the risk, progress, and prognosis of AD, through its neuroprotective effect, antioxidant capacity, metal complexation, and other mechanisms . HoweverOn December 04, 2020, we performed a search of PubMed and Web of Science. Language and regional restrictions were not imposed. We searched the database above using search terms including “Alzheimer” AND “uric acid”, “dementia” AND “uric acid”, and “cognitive” AND “uric acid”. The reference lists of included studies and relevant reviews were studied manually to minimize the omission of potentially eligible articles. We mainly selected literature from 2016 to 2020 and included older literature that was commonly cited and highly valued .In recent years, there has been an increasing interest in studying the risk of developing AD in populations with different concentrations of SUA. However, the relationship between level of SUA and the risk of AD has been conflicting in different types of studies, and the evidence is weak in elderly subjects.n = 320; hazard ratio (HR) 0.81; confidence interval (CI) 0.72–0.91) and both AD  and vascular dementia  [In recent years, several prospective cohort studies with large sample size and long follow-up period have been published. A prospective cohort study in Sweden enrolled a population-based sample of 1462 females who were followed for up to 44 years. During the follow-up period, serum uric acid levels were measured twice. They found that a higher SUA concentration (per standard deviation of 76.5 mmol/L) was related to a lower risk for incident dementia  age 72.4 (4.1) years, 61.7% female). The result showed that 110 participants developed dementia. After multivariate adjustment, the multivariate HR of the highest versus lowest SUA levels was 1.79. The correlation was stronger with other subtypes compared to AD, including VD and mixed dementia (MD) [z-score difference, -0.149; 95% CI, -0.246, -0.052) [Because of the difficulty of follow-up and other factors, only a few studies have considered the subtype classification in the cohort study of dementia. Alam et al. studied 11,169 participants in communities (ARIC) cohort with 24.1-year median follow-up period. As the study progressed, a total of 2005 cases of incident dementia were detected. They conducted adjustments including cardiovascular risk factors. After that, SUA and incident dementia showed an uncorrelated outcome . Elevated baseline levels of SUA were relevant to faster decline of cognition  . These sTwo population-based cohort studies , 9 indicn = 65, 95, and 72, respectively). SUA levels were significantly lower in the AD group (4.84 ± 1.30 mg/mL) than in the healthy control group . After adjusting for age, sex, body mass index, and creatinine levels, the correlation that existed between SUA and AD showed that the level of SUA was independently relevant to the diagnosis of AD [μmol/L) were elevated compared to the control group  [In addition to the cohort study, there were more retrospective and cross-sectional analysis. Boccardi et al. did a retrospective study of UA and late-onset AD. A total of 232 subjects were divided into three groups, including healthy controls (HC), mild cognitive impairment (MCI) group, and AD group (is of AD . The resis of AD . The samis of AD –16. Howe < 0.01) . They co < 0.01) –20. Obseμmol/L  compared to the control group [Scholefield et al. systematically analyzed the results of various biochemical pathways in AD. The analysis showed the decrease of uric acid in biological fluids of AD cases and suggested that the decline in serum UA could be used as part of a generic biomarker for dementia . In a meol group . The metol group . Paradoxol group . The abool group .n = 17,008) and controls  [Over the past few years, four two-sample Mendelian randomized analyses have been performed to investigate the relationship between genetically determined circulating UA levels and risk of AD. Mendelian randomization is a statistical method that uses genetic variants like single nucleotide polymorphisms as genetic tools to make causal inferences about the nature of exposure-outcome relationships . William 37,154) . The res 37,154)  and Yuan 37,154) . This anAmong the related studies on SUA and the risk of AD, existing cohort studies and an animal experiment suggested that high SUA level indicated a low risk of AD, and the evidence was stronger in women. Consistent with this, a large number of retrospective studies, cross-sectional analyses, and systematic meta-analyses showed that AD patients had lower SUA level than healthy controls. Conflicting conclusions of other studies may be due to the selection of subjects and the absence of subgroup analysis of dementia. Some Mendelian-random analysis indicated that gene-determined UA was not related to the risk of AD, suggesting the importance of the influence of acquired confounders.n = 1064, including 271 HC, 596 MCI, and 197 AD). SUA and AD biomarkers in cerebrospinal fluid (CSF) were recorded once for baseline. Cognitive assessment scales were assessed continuously. The result showed that higher SUA level was related to slower cognitive decline, particularly in MCI and AD subgroups, and this association was more significant among female participants (P < 0.001). Cerebrospinal fluid biomarker models showed that high concentrations of UA attenuated the adverse effects of Aβ1-42 and tau on cognitive decline in female subjects. However, it was noteworthy that in male subjects, the interaction was limited to resistance to the adverse effects of Aβ1-42 only, and there was no significant interaction with tau [β and tau. Higher level of SUA may indicate slower progression of AD. The results also showed sex-related differences in uric acid's protective effects on cognition, which may partially explain the conflicting results and conclusions of the two cohort studies mentioned above.With the progression of AD, cognitive impairment becomes more and more serious. In recent years, only one cohort has observed cognitive decline in patients with AD at different baseline uric acid levels. Ye et al. used the AD Neuroimaging Initiative database to evaluate the cognitive decline of MCI and AD patients  compared to HC . Markedly positive correlations were shown between the Mini-mental State Examination (MMSE) scores and levels of SUA (P < 0.05). UA was a protective factor for MCI  [There were some studies on the influence of SUA on cognitive function, which were not AD targeted. In a cross-sectional analysis, Xue et al. found that levels of SUA were markedly decreased in MCI patients (292.28 ± 63.71 7-0.999) . Similar7-0.999) .Wang et al. enrolled 12798 middle-aged and elderly people over 45 years old in the follow-up study of health and pension in China. They measured the baseline plasma UA level, and the cognitive function was evaluated by a variety of methods. The results showed that middle-aged and older Chinese with high UA levels at baseline had better cognitive function, but not with rates of cognitive decline . Xu et aIn contrast, in a case-control study, higher levels of circulating UA were considered to be relevant to impairment of cognition in pharmacologically untreated elderly subjects . In a twβ1-42 and tau on decline of cognition in female subjects. This gender-related effect has also been observed in some other studies, which may be due to the fact that the standard SUA level of men and women is different. A large number of cross-sectional studies found that the elderly with high UA level had better cognitive function and SUA was considered to be a protective factor of MCI. The decreased level of SUA was relevant to AD-related cerebral hypometabolism, but it is still uncertain whether there is a causal relationship. Still, some studies have shown that UA had an adverse influence on cognition , inflammation, endothelial dysfunction, and vascular damage [Based on former research, UA had a dual effect on cognition including neuroprotective action and neurotoxic action. The dual effect of UA is reflected in a variety of hypotheses, including oxidative stress (OS), interaction with r damage .β, neurofibrillary tangles (NFT), and inflammation. In turn, pathological changes of AD could promote oxidative stress, which has been experimentally demonstrated in postmortem brain tissues in AD patients and AD transgenic mouse models [Current research indicates that OS has a crucial part to play in these mechanisms. The influence of OS is particularly important in neurodegenerative diseases. The brain is especially vulnerable to reactive oxygen species (ROS). Lipids, proteins, and nucleic acids of neurons can be attacked by ROS, causing inevitable neuronal dysfunction . Evidence models . Therefoe models .UA is a natural and powerful antioxidant of humans. The antioxidant effect of UA is attributed to its capacity to chelate transition metal ions to make stable complexes , 49 and κB pathway and led to dysfunction of cognition. They also found that hyperuricemia in rats and people was relevant to gliosis in the hippocampus by using magnetic resonance imaging [An in vivo experiment conducted by Shao et al. showed that UA induced hippocampal inflammation through the TLR4/NF- imaging . Another imaging . Mazumde imaging  pointed  imaging .Other potential links between uric acid and cognitive impairment can be suggested from the perspective of genetic syndromes and malnutrition. Some genetic syndromes are characterized by congenital uric acid disorders and neurological deficits, for example, primary renal hypouricemia , 61 and Hypouricemia is recognized as a sign of poor nutritional status, and some studies showed that poor nutritional status can cause faster cognitive decline in people with dementia . There iThe relationship between SUA and AD remains controversial, while current evidence supports the hypothesis that elevated UA levels could reduce the risk of AD, slow down the decline of cognition, and delay the progression of AD, and high SUA level may related to lower risk and progression of AD. But findings of some studies contradicted it. The main reasons for contradiction between the results are study inconsistency, the difference in subject selection (sex and age), and the lack of subtype analysis of incident dementia.The current studies have some shortcomings, such as only recorded the UA level at baseline, one-time record could not reflect long-term uric acid levels, the small number of large-sample, AD-targeted cohort studies, and inadequate adjustment of confounding factors like nutritional status and comorbidity.Whether the dual effect of UA can be selectively controlled, whether it has different effects on men or women, and whether there is a causal relationship between low SUA and AD-related cerebral hypometabolism are questions that need to be considered in the design of future studies. Future epidemiological studies should measure the SUA level several times to record dynamic changes and analyze the actual increase of SUA in different genders, carry out the assessment of nutrition, frailty, and comorbidity to fully exclude the influence of confounding factors, and combine imaging examinations in the study design.


This study aims to fill the gaps in ethnomycological knowledge in Serbia by identifying various fungal species that have been used due to their medicinal or nutritional properties. Ethnomycological information was gathered using semi-structured interviews with participants from different mycological associations in Serbia. A total of 62 participants were involved in this study. Eighty-five species belonging to 28 families were identified. All of the reported fungal species were pointed out as edible, and only 15 of them were declared as medicinal. The family Boletaceae was represented by the highest number of species, followed by Russulaceae, Agaricaceae and Polyporaceae. We also performed detailed analysis of the literature in order to provide scientific evidence for the recorded medicinal use of fungi in Serbia. The male participants reported a higher level of ethnomycological knowledge compared to women, whereas the highest number of used fungi species was mentioned by participants within the age group of 61–80 years. In addition to preserving ethnomycological knowledge in Serbia, this study can present a good starting point for further pharmacological investigations of fungi. Ethnomycology represents an area of ethnobiology that investigates traditional knowledge, as well as cultural and environmental effects, of the association between fungi and man through time and space . Fungi aMycology has a strong and long tradition in Europe and the knowledge of European species, their distribution, ecology and status is the most extensive in the world . On the As part of Europe, the Balkan peninsula, despite its immense biological and cultural diversity, has begun to attract the attention of ethnobiologists only in the last decades . ThereafThis study aims to fill the gaps in the ethnomycological knowledge of the Balkan Peninsula, in particular in Serbia. The primary objective was to document fungal taxa that are traditionally used in Serbia. We collected data related to the identification of various fungus species and their edibility, medicinal and food properties, as well as their modes of preparation. Detailed analysis of the literature was also performed in order to provide scientific evidence related to the recorded medicinal use of fungi in Serbia.The ethnomycological survey was carried out during 2016, with participants from different mycological associations in Serbia . Data were collected randomly using semi-structured interviews. A total of 62 participants were interviewed. The age of participants was between 18 and 80, with an average value of 59 years  and the Interviews were performed orally by researchers from the Laboratory of Mycology, Department of Plant Physiology at the Institute for Biological Research “Sinisa Stankovic”. Clarifications of the context and the aim of the investigation were presented to the potential participants at the beginning of the surveys. The participants were asked to list all the fungi species they used. In particular, the interview included the following questions: respondent name, sex, age, residence, nationality, profession, local names of the fungi they use, preparation/administration and type of use. For the identification, researchers were equipped with dried fungi samples, photos and literature ,18,19,20www.indexfungorum.org; the access date 2 March 2021). The acquired data gathered were grouped in Microsoft Excel and further assessed by quantifying the use reports. Each time a fungus was indicated as “used” this was considered as one “use-report” (UR). Statistical analysis was performed using the Chi-squared test of independence, with Yates’s correction for continuity.All fungi cited by participants were taken into account for subsequent analysis. After collecting data, fungal species were ranked based on the number of times that they were mentioned by the participants. Species names and authors’ abbreviations were annotated according to the Index Fungorum site , followed by Russulaceae (11), Agaricaceae (8) and Polyporaceae (8). The male participants reported the use of the higher number of fungus species compared to women. The Chi-squared test of the number of species reported by various age categories yielded significance. It was observed that the highest number of species was mentioned by participants within the age group of 61–80 years. Older generations had a good knowledge of fungi as compared to the groups below 40 years of age.In our study, a total of 85 species belonging to 28 families were identified. On average, each interviewed person mentioned nine edible species, with the lowest number of mentioned species at three and the largest at 50. Species with the highest number of use reports were Fomes fomentarius, Ganoderma applantatum, G. atkinsonii and G. lucidum, the reported fungus species were pointed out as edible, but only 15 of them were declared as medicinal. In Serbia, fungi are commonly utilized as prominent components of traditional foods and recipes (Tricholoma terreum and Verpa bohemica). Namely, they are used cooked, although the water in which they were boiled should be removed after processing. The reason for this is the possible presence of thermolabile toxins.With the exception of  recipes . AccordiToday, it is not unusual for urban people, particularly from the middle class, to collect fungi for their own consumption. Furthermore, the commercial harvesting of wild edible fungi also occurs . AccordiEthnomedicinal applications are one of the most important features of fungi, meaning that they are of nutraceutical value. Nowadays, numerous dietary supplements, in the form of extracts, tinctures and capsules, are made from medicinal fungi . These aCalvatia gigantea) was utilized both internally and externally.In our study, about 30% of the participants confirmed that they used fungi as medicine, whereas 15 fungal species  were utilized due to their positive effects on health. In the following, we evaluate the status of scientific research and application for each of these species. Most of these species were consumed internally (90%), whereas only one species  and Gentiana macrophylla (herb), increases levels of VEGF and TGFβ1 in rats, leading to wound healing [gigantea among the Serbian population  mushroom. It has been commonly applied in the folk medicine of Russia, Poland and other Baltic countries, primarily as an antiparasitic and antimicrobial agent and to stop wound bleeding. For these purposes, it is used orally as a tea or snuffed as a powder or ash [F. betulina in Russia [F. betulina as an immune booster.r or ash . In addir or ash . Its usen Russia . Howevern Russia , this spGanoderma applanatum, artist’s bracket, is found throughout the world, mainly on the bases of tree stumps. It has been used in Chinese herbal medicine, along with G. lucidum, in order to treat or prevent a range of chronic diseases [diseases .G. applanatum were able to regenerate NK cell activity and the IL2 and IFNγ production of the spleen cells in sarcoma 180 transplanted mice [The exo-biopolymer from this fungus, mainly containing carbohydrates, is able to increase the activity of natural killer cells . Polysacted mice , altogetGanoderma atkinsonii is found in Europe and in the Euro-Asian region. Some records [ records  indicate records , so thisGanoderma lucidum is one of the most widely recognized medicinal mushrooms. Some of the indications for its usage are bronchitis, asthma, hypercholesterolemia, hepatopathy, hypertension, arthritis, neurasthenia, hypertension and immunological diseases, all due to numerous bioactive molecules present in this fungus—phenolic compounds, polysaccharides and terpenes [terpenes .G. lucidum stimulates innate immunity through the activation of NF-kappaB [G. lucidum can act on different components of immune defense, including antigen-presenting cells, NK cells and T and B lymphocytes [G. lucidum [Extracts from this fungus regulated the expression levels of serum immune cytokines and enhanced the anti-tumor immunostimulatory activity in a Hepa1-6-bearing C57 BL/6 mouse model . The mycF-kappaB  and variphocytes . Even a  lucidum , highligG. lucidum described by Lu et al. [G. lucidum for the treatment of cardiovascular risk factors in people with diabetes mellitus or metabolic syndrome.A bioactive mixture containing u et al.  exhibiteu et al. . This stLentnula edodes, shiitake mushroom, has been cultivated throughout Asia for many years, and according to traditional Chinese medicine it exhibits beneficial effects on heart health, lung diseases and many other indications. The spectrum of its biological activities is associated with its nutritional profile and the presence of biologically active molecules such as dietary fiber; provitamin D2; and vitamins B1, B2, B12 and niacin [d niacin .β-glucan-enriched extract of this mushroom was able to profoundly reduce the levels of cholesterol in a mouse model [Its role in the prevention of high cholesterol blood levels  could bese model . Previouse model .Meripilus giganteus is a tree parasite with an edible fruiting body. It is rich in carbohydrates and proteins, whereas it presents a low fat content [ content .M. giganteus (The immunity enhancing activity recorded in this study for iganteus  has not Pleurotus ostreatus, oyster mushroom, is the second most cultivated edible mushroom worldwide, after Agaricus bisporus. It is rich in β-glucans and dietary fibers, with a range of biological roles [al roles .P. ostreatus intake on glucose metabolism, mainly the reduction in fasting and/or 2 h postprandial glucose [Agaricus bisponus and Pleurotus ostreatus eliminated the negative effects of diabetes in experimental animals by reducing the serum glucose level after 28 days of application [P. ostreatus were linked to molecules such as ergosterol [Clinical trials have demonstrated the beneficial effects of  glucose , giving lication . The antgosterol  and polygosterol .P. ostreatus has been used among the studied population in order to enhance immunity (P. ostreatus increased levels of interleukin-2, immunoglobulin G and immunoglobulin M; tumor necrosis factor-α; as well as immunoglobulin A in piglets [P. ostreatus to the diet of malnourished mice enhanced their humoral immunity and activated macrophage cells [immunity . In prev piglets . The addge cells . The immge cells  and pleuge cells .Trametes versicolor, turkey tail, is a medicinal mushroom that is widely used due to its medicinal value, with characteristic morphological features—concentric multicolored zones on the upper side of the cap [ the cap .T. versicolor modulate immunity by reducing levels of TLR4, MyD88, CD14, IL-1β and TNF-α expression [β-glucans from T. versicolor can also protect mice from Salmonella typhimurium infection by enhancing the activity of innate immune cells [C. versicolor and its components has been reviewed by Chu et al. [Polysaccharopeptides from pression , whereaspression . Glucan pression , and β-gne cells . The curu et al. , Saleh eu et al.  and Habtu et al. , and theThe Balkan Peninsula, which is very rich in mushroom genetic resources, deserves more intensive ethnomycological studies. The current study provides useful documentation, which can contribute to preserving ethnomycological knowledge in Serbia. Interest in mycology is on the rise, as evidenced by the high number of species used by amateur mycologists. This interest contributes to the development of more detailed knowledge on mycomedicinces and mycofood. There is a need for further ethnomycological studies in order to preserve the current knowledge, since the use of fungi as food and medicine was mainly recorded among the elderly population.