Introduction: Central obesity appears to play a major role in the pathogenesis of metabolic disorders in polycystic ovary syndrome. Insulin resistance and carbohydrate disorders are associated with dysfunctional secretion of various adipokines by the adipose tissue.de novo with polycystic ovary syndrome (PCOS).Objectives: This study aimed to evaluate leptin, apelin, and visfatin against a background of carbohydrate metabolism parameters in patients diagnosed Material and methods: The study group consisted of 40 patients with PCOS  diagnosed in accordance with the American Society for Reproductive Medicine criteria from 2003. The control group consisted of 37 clinically healthy women . All controls had regular menses and no clinical or biochemical signs of hyperandrogenism. Concentrations of leptin, apelin, visfatin, and insulin were measured by immunoenzymatic methods. Glucose concentrations were determined using spectrophotometry.p < 0.0001) and carbohydrate metabolism, such as insulin , glucose , HOMA-IR , and IRI/glucose . These findings were not observed in the control group.Results: Significantly higher concentrations of leptin, insulin, homeostatic model assessment for insulin resistance (HOMA-IR) index, and the immunoreactive insulin (IRI)/glucose index were found in the PCOS group than in the control group. Notably, the concentration of apelin was over five times lower in the PCOS group than in the control group. In patients with PCOS, a positive correlation was found between the concentrations of insulin and leptin and concentrations of leptin and IRI/glucose. Patients of the PCOS group with body mass index (BMI) ≥  25 had significantly higher values of leptin, insulin, HOMA-IR index, and IRI/glucose index than patients of the PCOS group with normal BMI. In the PCOS group, a positive correlation was found between BMI and leptin concentration  Significantly lower apelin concentration in the PCOS group (>5 fold) than in the control group, associated with a concomitant increase in leptin, may also contribute to carbohydrate metabolism disorders occurring in the course of PCOS.Conclusions: (1) Increased leptin concentration observed in women diagnosed  Currently, two concepts are most often invoked: the neuroendocrine origin theory of PCOS and the epigenetic theory. The first concept indicates that disturbances in the functioning of the pituitary–hypothalamus axis, leading to hyperandrogenism, play a key role.2 The latter concept presents that processes such as histone acetylation, DNA methylation, and post-transcriptional modification of proteins are crucial in the etiology of PCOS. In recent years, a number of mutations related to the etiopathogenesis of PCOS have been identified.3Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of childbearing age, as well as the leading cause of infertility, with the highest occurrence rate between age 20 and 30 years.5 Clinical hyperandrogenism manifests mainly in the form of hirsutism, which is associated with an increased number of hair follicles and greater hair thickness and pigmentation, and affects hormone-dependent zones, such as the upper lip, chin, chest, back, upper abdomen, thighs, and arms. Hirsutism is considered the most important and common manifestation of hyperandrogenism in women with PCOS, occurring in 65%–75% of cases. However, its prevalence differs depending on race and ethnicity.1PCOS is a chronic disease with menstrual disorders occurring in 93% of women.1 The most common phenotype is metabolic: obesity affects 30%–60% of the patients, often accompanied with carbohydrate metabolism disorders, such as impaired glucose tolerance (31%–35%) and type 2 diabetes (7.5%–10.0%).6 Central obesity appears to play a major role in the pathogenesis of metabolic disorders occurring in the course of PCOS. Insulin resistance and carbohydrate disorders are associated with dysfunctional secretion of various adipokines by adipose tissue, in patients with PCOS with and without obesity.5PCOS has three phenotypes, namely, metabolic, hyperandrogenic, and reproductive.ob gene on chromosome 7. It is biosynthesized by the adipose tissue, within the gastric and breast epithelial cells, skeletal muscles, brain, stellate cells in the liver, and placenta. This hormone plays a role in the regulation of appetite and influences glucose metabolism, lipogenesis, lipolysis, thermogenesis, and functions of macrophages and T lymphocytes.8 Previous studies have shown that in individuals with obesity, the mechanism of leptin action is disrupted–despite the presence of a high concentration of this hormone in the circulation, appetite is not suppressed and thus leptin resistance develops.10 Leptin resistance is often associated with hyperinsulinemia and insulin resistance, which may lead to disturbances in energy homeostasis and development of metabolic diseases.11Leptin, discovered in 1994, is a protein encoded by the 12 The most biologically active isoform of apelin is apelin-13, which is present in the mammary gland and hypothalamus. Moreover, the most common isoform (apelin-36) is located in the lungs, uterus, and testicles.13 Studies have documented a significant role of apelin in the course of metabolic diseases, regulation of the appetite center function, adipose tissue growth, and pathogenesis of obesity.15 Apelin reduces blood glucose, increasing its uptake and absorption by muscle cells and adipose tissue. It also increases the sensitivity of cells to insulin. Apelin, through the apelin receptor, affects the glucose transporter type 4 (GLUT4), thus stimulating glucose uptake.16Apelin was first isolated in 1998. The most common isoform consists of 36 amino acids. Apelin is encoded by the gene APLN, located on the X chromosome. Apelin isoforms differ in biological activity depending on the length of the polypeptide chain.17 At present, visfatin is widely known to be produced by hepatocytes, myocytes, and lymphocytes.18 Key functions of visfatin include induction of preadipocyte differentiation into adipocytes and stimulation of the production of cytokines such as tumor necrosis factor alpha, interleukin-1beta, and interleukin-6.Visfatin is a product of the growth factor gene for early B cells, identified in 2005 in visceral adipose tissue.21 It has been postulated that leptin regulates energy, lipid, and carbohydrate metabolisms and potentially may modulate the clinical course of PCOS. According to Altinkaya et al., apelin can serve as a specific biomarker of insulin sensitivity and lipid profile22 and may play a potential role in follicular growth arrest and ovulatory dysfunction.14Despite the great interest in the field of endocrinopathies among women of childbearing age, the exact mechanism of metabolic abnormalities in PCOS has not been completely understood. Studies have reported a potential link between altered type of adipokines produced by adipose tissue and metabolic disorders characterizing PCOS.de novo with PCOS.Therefore, this study aimed to evaluate adipokines, leptin, apelin, and visfatin, with regard to carbohydrate metabolism parameters, in patients diagnosed de novo with PCOS in accordance with the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine criteria from 2003.23 The inclusion criteria were as follows: 1) age >18 years and 2) at least two of three features . Patients with other endocrinopathies such as hormonally active adrenal tumors, hyperprolactinemia, Cushing syndrome, hypothyroidism, and prolactinoma were excluded.The study was conducted in Bydgoszcz, Poland, in two consecutive years (2013–2014). The study group consisted of 40 women, who were patients of the Department of Obstetrics, Women's Diseases and Gynecological Oncology, Collegium Medicum in Bydgoszcz, Copernicus University, Torun′. All patients had been diagnosed The control group consisted of 37 clinically healthy age-matched women presenting to the Clinical Gynecological Outpatient Clinic of the University Hospital No. 2 in Bydgoszcz for routine annual preventive visit. All controls had regular menses and had no clinical or biochemical signs of hyperandrogenism.2). The Ferriman–Gallwey scale was used to assess the severity of hair presence from 0 to 4 in nine body regions (hirsutism).All participants from both the study group and control group underwent detailed physical examination. Participants’ age, height, and weight were estimated. Body mass index (BMI) was calculated as weight divided by the square of height . Written informed consent was obtained from all participants.Blood samples were obtained in the morning (between 7:30 and 9:00), after an overnight fasting (12 h), from an antecubital vein and placed in plastic tubes containing 1) 3.2% sodium citrate  and 2) clotting activator . All samples were centrifuged at 2500 × g for 20 min, and the resulting plasma and serum were stored at − 80°C until analysis but no later than 6 months.The concentrations of leptin [Human Leptin ELISA ], apelin (RayBio Human Apelin C Test–Terminus Enzyme Immunoassay Kit (EIA-APC); RayBiotech Inc., GA, USA), visfatin (RayBio Human Visfatin Enzyme Immunoassay Kit (EIA-VIS-1); RayBiotech Inc.), and insulin (Insulin ELISA Test (ME E-0900); LDN Labor Diagnostika Nord Gmbh & Co. KG, Germany) were determined by the enzyme-linked immunosorbent assay (ELISA).Glucose concentration was determined by a spectrophotometric method (Glucose Colorimetric/Fluorometric Assay Kit (K606-100); BioVision Inc., CA, USA). Homeostatic model assessment for insulin resistance (HOMA-IR) =  [insulin (μU/ml) ×  glucose (mg/dl)]/405 was calculated for the assessment of insulin sensitivity. The immunoreactive insulin (IRI)/glucose index was also determined.Leptin, apelin, visfatin, insulin, and glucose concentrations were determined at the Department of Pathophysiology, Collegium Medicum, Bydgoszcz, Copernicus University, Torun′.p values <  0.05 were considered significant.All statistical analyses were performed using Statistica version 13.3 for Windows . The sample size was calculated using power and sample size calculation program (at a power of 80% and a two-tailed significance level of < 0.05) . The Shapiro–Wilk test was applied to assess the normality of data distribution. To compare proportions of patients between groups, chi-square test was used. Data were distributed nonnormally, and the Mann–Whitney rank-sum test was used, and variables were expressed as median and interquartile range (IQR). The correlations were sought by Spearmann's rank method; The clinical characteristics of women from the study group and control group are presented in As shown in In the PCOS group, a moderate positive correlation was observed between the concentrations of insulin and leptin  and concentrations of leptin and IRI/glucose . A similar finding was observed in the control group . Data from the PCOS group were subdivided based on BMI values, with a threshold of 25 . SignifiIn the PCOS group, a moderate positive correlation was found between BMI and leptin concentrations  and carbohydrate metabolism parameters, such as insulin , glucose , HOMA-IR index  and IRI/glucose . A similar phenomenon was observed in the control group. Among patients with PCOS, the concentrations of selected adipokines and carbohydrate metabolism parameters were analyzed depending on the HOMA-IR value. Women with HOMA-IR ≥  2.5 had significantly higher concentrations of leptin , insulin , and glucose . A significant moderate correlation was found between HOMA-IR and leptin concentration .de novo with PCOS with regard to selected parameters of carbohydrate metabolism.In this study, the concentrations of adipokines, leptin, apelin, and visfatin were assessed in patients diagnosed 2 than in women with normal BMI. Furthermore, the concentration of leptin correlated with the concentrations of insulin, glucose, HOMA-IR index, and IRI/glucose. Moreover, such correlations were not observed within the control group.The concentration of leptin was significantly higher in the PCOS group than in the control group (9.00 ng/ml vs 5.59 ng/ml). Moreover, leptin concentration was nearly threefold higher in women with BMI >25 kg/m19 Jalilian et al., in 2016,20 and Mohaisen et al., in 2019.21 Chakrabarti found positive correlations between leptin levels and both BMI and insulin in 16 women with PCOS. Jalilian et al., also found increased leptin levels in women with PCOS having obesity compared with women with lean body frame. However, they found no correlation between leptin and insulin levels. Jahromi et al., also found significant association of leptin with BMI as well as of leptin with carbohydrate metabolism indices.24These results are consistent with other studies, including that of Chakrabarti in 2013,10 Leptin resistance is often associated with hyperinsulinemia and insulin resistance, which may lead to disturbances in energy homeostasis and development of numerous metabolic diseases.11 These observations became the basis for determining the HOMA-IR index in the PCOS group, which is one of the most frequently used methods of indirect assessment of insulin sensitivity.Previous studies have shown that in individuals with obesity, the mechanism of action of leptin is disrupted–despite the presence of a high concentration of this hormone in the circulation, appetite is not suppressed and thus leptin resistance develops.27In this study, the study group was divided into two subgroups with HOMA-IR ≥ 2.5 and HOMA-IR < .5. Among women with HOMA-IR ≥ 2.5, the leptin concentration was significantly higher. The obtained results are consistent with those of studies, in which increasing insulin resistance was observed among women with PCOS having obesity.30 Altinkaya et al., also found that women with PCOS exhibited lower serum concentrations of apelin than controls. However, they noticed significant positive relation between apelin and BMI and HOMA-IR index.22 Olszanecka-Glinianowicz et al., also found lower isoforms of apelin (apelin-36 and aplein-12) in women with PCOS.30Interestingly, this study reveals a significantly lower level of apelin in the PCOS group than in the control group. In the PCOS group, the concentration of apelin was >5 times lower and was independent of BMI and carbohydrate metabolism parameters. However, studies on apelin have varied and inconclusive results.The results of this study may indicate the predictive value of apelin in the context of metabolic disorders occurring in the course of PCOS, including carbohydrate metabolism. Research on apelin is worth further analysis, as is the verification of the hypothesis on whether adipokine–with significantly lower concentration in patients with PCOS–may be helpful in predicting metabolic disorders in the course of PCOS.As regards visfatin, its concentrations were slightly higher in women with PCOS, but differences were not significant. No difference was found in visfatin levels in subgroups of women with PCOS divided according to BMI or HOMA-IR. Moreover, no significant correlations were found between visfatin and carbohydrate metabolism indices.17 This protein features insulin-mimetic properties, and by binding to the insulin receptor, it leads to an increased glucose uptake. The production of visfatin is a likely compensatory response to insulin resistance to maintain normoglycemia.36 However, in this study, visfatin values in the PCOS group did not correlate with other adipokines, as well as with carbohydrate metabolism parameters and BMI. We speculate that visfatin may play a role in severe metabolic disorders, rather than in early stages of glucose dysregulation.Visfatin also stimulates the accumulation of triglycerides in adipocytes, increasing the expression of fatty acid synthase and adiponectin, and activates the phosphorylation of insulin receptor as well as insulin receptor substrates 1 and 2This study has some limitations. First, the study group was relatively small, and the group of patients with obesity was included on the basis of their BMI–an indicator which features a number of inaccuracies. Second, the exact role of adipokines in the pathogenesis of PCOS is still debated. More detailed analysis including a comprehensive panel of adipokines should be considered for future studies.This study shows significant changes in the concentrations of leptin and apelin. Significantly elevated levels of leptin were accompanied by changes in carbohydrate metabolism toward reduced insulin sensitivity, depending on BMI.de novo with polycystic ovary syndrome, as well as positive correlations between leptin and HOMA-IR, IRI/glucose, and BMI, may indicate a potential role of leptin in the reduction of tissue sensitivity to insulin.Increased leptin concentration observed in women diagnosed Significantly lower apelin concentration in women with PCOS (>5 fold) than in women without PCOS, associated with a concomitant increase in leptin, may also contribute to carbohydrate metabolism disorders occurring in the course of PCOS.The authors stated that there are no conflicts of interest regarding the publication of this article.


The increased serum procalcitonin (PCT) level in cardiac patients is known as a sign of postoperative complications.  Considering the importance of predicting the incidence of both complications and mortality caused by coronary artery bypass graft (CABG) surgery, this study was conducted to determine the serum PCT level and its relationship with one-year morbidity and mortality among CABG patients.  This descriptive-analytical study was performed on 100 patients who underwent CABG surgery in Vali-e-Asr Hospital of Birjand, Iran. They were selected by a census sampling method from March 2014 to March 2015. The Elecsys BRAHMS PCT kit (Roche Company) was then used to measure the patients' serum PCT level. The required data were collected using the patients' medical records and telephone interviews with the patient or his/her relatives by passing one year from their discharge. The outcomes of this study comprised of mortality and morbidity causes . The data were then analyzed in SPSS version 16 by Mann–Whitney, chi-squared, and Fisher exact tests. p=0.001), packed cells (PC) transfusion (p=0.003), and death (p=0.003). In addition, a significant relationship was found between dyslipidemia and hypertension and early mortality rate in patients with high levels of PCT. Of note, risk-adjusted death did not differ significantly between the serum PCT levels after one year .  The postoperative serum PCT level is significantly correlated with sternum wound infection ( Higher PCT serum levels in CABG patients are associated with the increased early mortality rate, sternum wound infection, and PC transfusion. Additionally, the other factors associated with mortality in the patients under study included dyslipidemia and hypertension. High levels of procalcitonin (PCT) are associated with various conditions causing systemic inflammation and their severity, including severe burns, trauma, extensive surgeries, especially cardiac surgery with cardiopulmonary bypass, postresuscitation syndrome, acute pancreatitis, stroke, acute graft rejection, and subarachnoid hemorrhage , 2.The peak level of PCT was observed to be related to various types of surgery such as thoracic, orthopedic, and oncological surgeries –6. MoreoThe PCT algorithm, which is examined to decide on the antibiotic treatment of adult patients admitted to primary care, emergency care, and ICU, suggests that performing the treatment guided by PCT may consequently reduce the exposure to antibiotics without increasing the mortality rate .Therefore, given the importance of predicting the incidence of both complications and mortality caused by CABG surgery, this study was conducted to determine the serum PCT level and its relationship with early morbidity and mortality among CABG patients.This descriptive-analytical study was conducted on 100 patients who were hospitalized in the Heart Department of the Vali-e-Asr Hospital in Birjand, Iran. A census sampling method was utilized for including the cases. The inclusion criteria of this study were patients aged between 30 and 80 years old who underwent CABG surgery and admitted to the cardiac department. In addition, the exclusion criteria included concurrent coronary and valve operation, aortic dissection, and pulmonary embolism. The required data were collected using the patient's medical records and telephone interviews with the patient or his/her relatives by passing one year from his/her discharge. The outcomes under scrutiny involved mortality  and morbidity . For the purpose of the study, the Elecsys BRAHMS PCT kit (Roche Company) was used to measure the serum PCT level. During the study period, a nurse working in the Cardiac Department collected the blood samples from the included patients before intubation, one hour later in the intensive care unit, and 48 h postoperatively. For examining the serum PCT levels, the obtained samples were stored in due observance of the preservation of the cold chain and then transferred in special kits to Shafa Laboratory of Birjand. The serum PCT level was considered within the normal range of less than or equal to 0.8 ng/ml.The protocol of the study was approved by the Institutional Ethics Committee with the ID IR.BUMS.REC.1395.236.Data analysis was performed by SPSS 16 software . The normality of quantitative variables was determined using the Kolmogorov–Smirnov test. Besides, categorical variables were analyzed using the chi-square and Fisher exact tests. The Mann–Whitney test was also used for comparing continuous variables. We calculated the relative risk (RR) with 95% confidence intervals (CI) to compare the death between serum PCT levels. The significance level was considered less than 0.05.n = 67(67%)) were men. The demographic and medical characteristics of these 100 patients are given in p=0.001), PC transfusion (p=0.003), and death (p=0.003). However, no significant association was found between the serum PCT level and the incidence of both dysrhythmia and EF (p > 0.05)  . The res > 0.05) .After the one-year follow-up, of the nine deaths in this study, one case of death occurred during surgery and seven cases occurred in the hospital ward. By passing 30 days from their discharge, one case of death was reported as well. Therefore, mortality is considered as “Early mortality.” These deaths were resulted from all causes of mortality, consisting of three patients (33.33%) due to cardiac causes, one case (11.11%) from brain causes, two cases (22.22%) from renal causes, one case (11.11%) from heart attack, and eventually two cases (22.22%) due to unknown reasons.During this one-year follow-up, except for those listed as early morbidity, no other case was reported. Hence, morbidity is considered as early morbidity.Risk-adjusted death showed a significant relationship with the serum PCT levels after one year .This study aimed to determine how the serum PCT level is associated with both early morbidity and mortality among CABG patients. The results show that serum PCT levels in the patients before, after, and 48 hours after surgery were 0.05 ± 0.06, 0.08 ± 0.11, and 1.44 ± 3.06, respectively, indicating an increase in this inflammatory marker rate after performing the surgery. A study by Arkader et al.  on patieThe results of the present study reveal that those receiving over two units of PC during the treatment and surgery had a significantly higher PCT level compared to those receiving smaller PC quantities. The results of several previous studies have demonstrated that the increased PC transfused during surgery is associated with postoperative complications and higher rates of mortality and morbidity after surgery –12. AddiBased on the results of the present study, there was a significant relationship between the PCT level and some factors such as wound infection. Previously, the results of various studies have shown that inflammation is an arrhythmic stimulant, and the increased PCT levels are associated with the increased inflammation and postoperative complications –17. For The results of the present study show that the increased PCT level is significantly associated with an increase in the early mortality rate. Moreover, Dorge et al.  in theirBesides, the results indicate a significant relationship between early mortality rate and dyslipidemia in the patients with high PCT levels. However, some ambiguities still exist regarding the role of low blood lipids in the outcome of cardiovascular surgery. In the study by Hosseini and Mehrpooya , the meaThe results of the present study show that a significant relationship exists between hypertension and early mortality rate in patients with high levels of PCT. A prospective population-based study has previously reported a positive association between plasma PCT levels and cardiovascular risk factors such as hypertension, in subjects with no history of acute cardiovascular events .According to the results of the present study, the relationship between diabetes and the incidence of outcomes such as CVA, infection, death, and dysrhythmia for different PCT levels was not statistically significant. The results of the study by Santos et al.  showed tAmong the limitations of this study were the small sample size and the one-centered setting of the study. Among the other constraints of this research, types of grafts utilized that were not addressed in this study can be named, which limited the generalizability of the results. Therefore, it is recommended that a similar study be performed with a larger sample size in several therapeutic centers, and by focusing on further variables (such as number and type of grafts).The increased serum PCT levels in patients underwent CABG surgery are associated with the increased early mortality rate, sternum wound infection, and PC transfusion. Moreover, in our patients, the other factors associated with mortality included dyslipidemia and hypertension.


To investigate the risk of mortality associated with sarcopenic obesity (SO), obesity (OB), and sarcopenia in elderlies.2 and muscle strength < 16 Kgf. In men, OB was diagnosed when body fat percentage ≥ 27%, and sarcopenia was diagnosed with ALMI < 7.00 kg/m2 and muscle strength < 27 Kgf. SO was assessed by combining variables used to diagnose obesity and sarcopenia. The probabilistic linkage method was used to obtain deaths in the 2012-January 2017 period from the Brazilian Mortality Registry. Cox regression models were tested, and crude and adjusted hazard ratio calculations were conducted. We analyzed longitudinal data from 270 participants > 65 years of age of Phase III of the Study on Frailty in Brazilian Older People (FIBRA–RJ–2012). Socioeconomic, demographic, lifestyle, morbidity, and functional data were collected by home based interviews. DXA and body composition assessment was conducted in a laboratory. In women, OB was diagnosed when body fat percentage ≥ 38% and sarcopenia by an Appendicular Lean Mass Index (ALMI) < 6.00 kg/m After adjusting for sex, age, race/skin color, walking as an exercise, and hypertension, individuals with sarcopenia were 5.7 times more likely to die (95%CI: 1.17–27.99) than others without sarcopenia and obesity. A high risk of death was observed in individuals with sarcopenia. These results show the need for preventive strategies of early detection and treatment in order to increase survival employing multimodal interventions. There is no consensus in the literature regarding the definition of Sarcopenic Obesity (SO). However, in some studies, it has been characterized as increased fat mass accompanied by reduced muscle mass and muscle strength, i.e., the combination of two body composition phenotypes: sarcopenia and obesity4. However, this association remains unclear due to studies’ diverse designs, cutoff points, assessment methods, and diagnostic criteria6.Studies have emphasized an increasing prevalence of obesity and SO in older adults, with a significant impact on mortality, especially when both these phenotypes are involved3 investigated the association between sarcopenic obesity, sarcopenia, and mortality, and found that only older women with sarcopenia had an increased risk of all-cause mortality, regardless of obesity.In the United States, Batsis et al.6 showed that, compared to eutrophy, sarcopenic obesity entailed a 1.72 relative risk of all-cause mortality. In another review, Tian & Xu.4 analyzed data from prospective cohort studies and showed that individuals with SO have a 24% higher risk of all-cause mortality than those without SO.In a longitudinal study with a sample of 4,252 older adults in England, Atkins et al.7.While different methods have been used to assess body composition, the multiple compartment model is considered the gold standard in scientific practice for assessing the body composition of individuals with obesity. This method employs a combination of several accurate tools to conduct the anthropometric fractionation of body mass. However, Dual Energy X-Ray Absorptiometry (DXA), a non-invasive technique, has adequate validity, reproducibility, accuracy and is less influenced by body water than other methodsIn low and middle-income countries, few studies use accurate methods to assess aged individuals’ body composition and investigate the risk of death. Thus, this study aims to investigate the risk of mortality associated with sarcopenic obesity, obesity, and sarcopenia in an elderly cohort.Data from the Rio de Janeiro section of the Cohort Study Fragilidade em Idosos Brasileiros (FIBRA-RJ – Frailty in Brazilian Older People from the state of Rio de Janeiro) was analyzed. The source population of FIBRA is the registered clientele of a health care plan with broad coverage in the State of Rio de Janeiro. The study included those costumers who, in 2009, had been enrolled for at least one year in the plan, aged 65 years or older, and living in the North region of Rio de Janeiro in the study, totaling 847participants.The sampling was stratified according to sex and age group , with data from the healthcare provider’s registry. All participants 95 years or more were included. An inverse sampling strategy was applied to reach the representative sample size for each stratum, and in this case it was not necessary to increase the calculated sample size to compensate for the nonresponse rate. The estimaded sample was based on the prevalence of frailty syndrome, calculated at 12%.The complete methodology of all phases of the FIBRA study is publicly available (10).Our study analyzed data from the third follow-up wave (FIBRA-RJ - Phase III - 2012/2013), in which body composition was estimated using DXA and mortality data after four years of follow-up in 2017.In phase III, 136 of the 847 enrolled participants died, and 102 were excluded due to Mini-Mental State Examination result ≤ 13; being institutionalized; wheelchair-bound or bedridden; having difficulty walking; severe hearing and visual impairments that prevented them from answering the questionnaire, and presenting an active neurological or psychiatric disorder. Thus, 609 individuals were eligible. Among these, 64 could not be located, and 143 refused to participate, resulting in a sample of 402 participants who were interviewed at their homes.All respondents were invited to attend the Interdisciplinary Nutritional Assessment Laboratory to assess their body composition, and 270 underwent DXA examination. These constituted the study’s final sample .The probabilistic linkage method was used to obtain deaths in the 2012-January 2017 period from the Brazilian Mortality Registry, which led to the identification of 38 post-phase III (2012) deaths. Two variables were ascertained: outcome and date of death (month/day/year). Follow-up time was calculated in months and years from the interview date to the date of death, or from the most recent vital status record. Mortality data were complete in 100% of the sample.The individuals were submitted to nutritional assessment using the FIBRA RJ-III research protocol. During scheduling, all participants received previous guidance on how to prepare for the tests.10. We used a tape measure affixed to the wall to measure height, with individuals standing barefoot. The numbers were recorded in millimeters, without any rounding. Weight was obtained using a portable Plenna/Everest TIN-00110 microelectronic scale with 150kg capacity and 200g accuracy. For weight measurement, the barefoot participants wore light clothes. Weight measurements were recorded in tenths of a kilogram, without rounding.All participants had their anthropometric measurements (weight and height) gauged using the methods described by Lohman et al.To determine bone and tissue mineral density, DXA  was used to assess body composition. Tissues are fractionated into fat mass and fat-free mass. The upper and lower limbs are isolated from the trunk and head by program-generated lines; measurements related to these body parts can then be manually adjusted with a high degree of accuracy. Appendicular muscle mass was characterized using the appendicular lean mass index (ALMI), obtained by calculating the sum of arms’ and legs’ lean masses  divided by height squared (2).2.Muscle strength was measured using a three-replicate protocol with regular time intervals. To this end, a Jamar hydraulic hand dynamometer (NC 701/42 – North Coast) was used to assess strength in the dominant hand. The device’s strap was adjusted to the size of the individual’s hand, using position II as a point of reference. The respondent was asked to exert the highest possible force, and the three measurements were performed. Their mean was subsequently calculated2, and males with muscle strength < 27 Kgf and ALMI < 7.0 kg/m2, were considered to have sarcopenia.Females with muscle strength < 16 Kgf and ALMI < 6.0 kg/m2, and muscle strength < 16 Kgf. Males were considered to have sarcopenic obesity when their body fat percentage was ≥ 27%, their ALMI < 7.0 kg/m2, and muscle strength < 27 Kgf. (2).SO was assessed by combining variables adopted for diagnosing sarcopenia with variables used for diagnosing obesity. Females were considered to have sarcopenic obesity when their body fat percentage was ≥ 38%, their ALMI < 6.0 kg/mSocioeconomic and demographic variables included the following variables: age, sex, race/skin color, and income. Age was measured in full years and separated into two groups . Participants were classified as retirees, pensioners, or as counting on other sources of personal income. Individual income from work, retirement, or pension was assessed in minimum wages (MW) at the time of the interview. Participants were thus categorized as follows: 0 to 2 (MW) - 0 to 668.62 (USD), 2.1 to 5 (MW) -668.63 to 1,671.55 (USD), and > 5 (MW) - > 1,671.56 (USD). Race/skin color was categorized as either black/ brown and white.Lifestyle-related variables analyzed were: tobacco use  and walking as an exercise (yes/no).The following physical morbidities were investigated: diabetes mellitus, hypertension, and heart disease. To this end, the question ‘Has any doctor ever said that you have the following health problems?’  was asked.The descriptive analysis was conducted by frequency distribution for categorical variables and then Pearson’s chi-square test was applied. The body composition phenotypes exposure variable was categorized into four groups: absence of sarcopenia and without obesity, sarcopenia, obesity, and sarcopenic obesity, and the risk of death was estimated using Cox proportional-hazards regression model.p-value < 0.20 in the bivariate analyses were included in the model as covariates. Mortality-related HRs were initially calculated without any adjustment. Model 1 was adjusted for sociodemographic variables ; model 2 for sociodemographic variables + lifestyle ; and model 3 for sociodemographic variables + lifestyle + morbidity (Hypertension). Given the study’s design, statistical analysis was performed using the statistical package SPSS for Windows version 22.The Kaplan–Meier estimator and the log-rank test were used to assess the proportionality of survival curves, which were base for estimation of hazard ratios (HR) by the Cox regression model. For Cox regression, variables with The selected individuals who consented to the home visit only answered the questionnaire after signing an Informed Consent Form. The original research followed the recommendations of Resolution 196/96 of the National Health Council of the Ministry of Health. In the first phase of the FIBRA study, it was approved by the Research Ethics Committee of the Pedro Ernesto University Hospital , and the National Research Ethics Committee (CONEP)  in the third phase.Two hundred seventy (270) individuals with a mean age of 77.5 years (SD = ± 5.92), predominantly females (70%), were analyzed. Thirty-eight participants (14.1%) died during the 4-year follow-up. We identified a higher prevalence of sarcopenic obesity and sarcopenia among males ; paradoxically, the prevalence of obesity in females was higher (59.8%) and statistically significant. The prevalence of sarcopenic obesity in individuals under 75 years of age was lower (12.9%), but higher in obese subjects (69%).The prevalence of diabetes mellitus was higher in obese (55.1%) than sarcopenic obese individuals (20.3%), but without statistical significance. High proportions of obesity (59.8%) and sarcopenic obesity (16%) were observed inindividuals with hypertension, again without statistically significant difference. Regarding lifestyle-related variables, a high prevalence of sarcopenic obesity and obesity was identified in individuals who had stopped smoking . There were also high proportions of sarcopenic obesity (17%) and obesity (51.6%) among individuals who did not practice walking as an exercise.Females had higher mean fat percentage and mean appendicular lean mass index values when compared to males .1, Kim et al.11, Liu et al.12, and Sanada et al.13.In this Brazilian study, sarcopenic obesity and obesity were associated with a higher risk of death, although the difference was not statistically significant. Older adults with sarcopenia were five times more likely to be at risk of mortality than with the absence of sarcopenia and without obesity individuals. These results corroborate international studies, such as those by Batsis and Villareal11 analyzed data from 556 older adults, participants of the Korean Longitudinal Study on Health and Aging (KLoSHA). Sarcopenic men were 5.37 times more likely to be at risk of death. A meta-analysis performed by Liu et al.12 between 2009 and 2017 – which included six prospective cohort studies incorporating 7367 participants – also identified sarcopenia as a predictor of all-cause mortality. Sarcopenic individuals had significantly higher risk ratios than non-sarcopenic ones. In a study by Sanada et al.13 involving 2,309 Japanese older adults in the United States, the authors observed that the risk of death from all causes was higher in seniors with sarcopenic obesity  and sarcopenia  than their peers without obesity and sarcopenia.Kim et al.14. Moreover, regardless of how sarcopenia is diagnostically defined, low muscle mass and low muscle strength are important risk factors for disability and increased mortality16. In this sense, the prevention of sarcopenia should be one of the main objectives of public health professionals.One of the possible reasons for the higher risk of death in sarcopenic older adults is related to adverse outcomes. Sarcopenia has been widely investigated as one of the main risk factors for functional dependence, falls, frailty, institutionalization, and death17 observed that sarcopenic individuals consumed a more significant mean number of routine medicines, had a higher number of comorbidities, respiratory problems, kidney problems, hospitalizations in the year before the visit, and suffered from malnutrition or risk of malnutrition more often. They also had a lower cognitive capacity, worse health-related physical quality of life, higher risk of falls, were more fragile, and got more tired when performing daily activities. Furthermore, seniors with sarcopenia have a lower response rate to treating acute diseases and worse healing of wounds and fractures, leading to worse prognosis19.While comparing sarcopenic and non-sarcopenic individuals, Beaudart et al.20. In this population, obesity can cause changes in body composition and muscle quality and is linked to increased incidence of sarcopenia, increased risk of nutritional deficiencies, lower quality of life, disability, frailty, and shorter lifespan24.Our study found a high prevalence of obesity and SO. Both were associated with a higher risk of death, although the difference was not statistically significant. There were statistically significant higher proportions of obesity in younger (< 75 years) and women. The prevalence of sarcopenic obesity and obesity among older adults in Brazil and worldwide has increased in recent years25. On the other hand, one possible explanation for the higher prevalence of obesity in women may be their higher visceral fat accumulation and longer life expectancy26.The survival bias effect may explain the declining prevalence of obesity in more advanced ages. The negative impact of obesity and its associated morbidities contributes to the higher mortality observed in obese individuals below 80 years of age27. Sarcopenic obesity was at risk of death but without statistical significance. In this sense, some international studies have shown conflicting results with significant associations between sarcopenic obesity and death risk4. Some discrepancies were identified in the proportions and results determined, probably due to the sample size and the different criteria and methods used to assess the risk of death. In a literature review, in a meta-analysis, Tian & Xu4 analyzed data from nine articles with 12 prospective cohort studies and showed that individuals with SO are 24% more likely to be at risk of all-cause mortality than those without SO. However, they observed conflicting results with four studies showing significant associations and four not showing statistical significance.The proportion of participants with SO was high, corroborating other studies28 analyzed longitudinal data from 3,577 participants of the National Health and Nutrition Examination Survey III (1999–2004) aged 50 years or over. They found that SO increased the risk of mortality in people aged 50 to 70 years, but not in people aged 70 years or over. Both obesity and sarcopenia are associated with metabolic disorders and are important causes of disability, morbidity, and mortality29. Studies with conflicting results strengthen consensus building and contribute to the development of more precise methods for the diagnosis of SO. Due to the lack of standardization of criteria and methods for SO diagnosis, its impact on mortality remains unclear18.In the United States, Van Aller et al.30. Health professionals are increasingly able to prevent, delay, treat, and sometimes even reverse sarcopenia through early and effective interventions2.Considering this study’s results, we reinforce the need for interdisciplinary planning of preventive and therapeutic actions targeting sarcopenia and SO. These actions must contemplate multimodal care via the promotion of healthy eating, hyperproteic diets and vitamin D, associated with aerobic physical activityOur study had some limitations. The lack of consensus and cut-off points validated for the Brazilian population is one of them. The small sample size in phase III, losses during follow-up, and the FIBRA study’s closed cohort. Also, representativeness is limited, as our sample consisted of individuals with health insurance and, therefore, with better access to health services and a higher socioeconomic level than those in the population of Rio de Janeiro in general. Another limitation may be related to possible information bias because chronic diseases were self-reported, influencing our estimates. Regarding the strengths of our research, we highlight that, to the best of our knowledge, it is the first Brazilian longitudinal study employing a more accurate method (DXA) to investigate mortality data in older adults with sarcopenia, obesity, and sarcopenic obesity. It can thus be inferred that the associations found are also more robust. Thus, to the best of our knowledge, our study appears to be pioneering the issue in Brazil. In addition, we conduct training sessions, develop protocols for the interviewers before the collection of the study and quality control throughout the collection.In this cohort, a high risk of death was observed in individuals with sarcopenia, reinforcing the need for actions to prevent and treat this muscular disease. A high, albeit not significant risk was also found among participants with SO and obesity. These results show the need for multimodal policies to promote healthy eating and physical activity, increasing these individuals’ survival and preventing sarcopenia. Guidelines to promote healthy aging should be directed maintenance or increased muscle mass to boost survival.


The incidence of thyroid cancer (THCA) continues to increase in recent decades. Accumulating evidence showed that the unbalanced alternative splicing (AS) promotes the occurrence of cancers and leads to poor prognosis of patients. However, the research on alternative splicing events in THCA is lacking, and its underlying mechanism is not fully understood. This study identifies a novel prognostic signature based on AS events to reveal the relationship of AS with tumor immune microenvironment.Based on the AS data, transcriptional data, and clinical information, the differentially expressed alternative splicings (DEASs) were screened out. Least absolute shrinkage and selection operator (LASSO) regression and multi-Cox regression analyses were employed to identify prognostic results related to AS events and establish a prognostic signature. The predictive ability of the signature was assessed by Kaplan-Meier (K-M) survival curve, risk plots, and receiver operating characteristic (ROC) curves. Furthermore, correlations between tumor-infiltrating immune cells, immune checkpoints, immune score and prognostic signature were analyzed.According to the LASSO regression analysis, a total of five AS events were selected to construct the signature. K-M survival curve showed that the higher the risk score, the worse the OS of the patients. Risk plots further confirmed this result. ROC curves indicated the high predictive efficiency of the prognostic signature. As for tumor immune microenvironment, patients in the high-risk group had a higher proportion of immune cells, including plasma cell, CD8+ T cell, macrophages (M0 and M2), and activated dendritic cell. Immune checkpoint proteins, such as PDCD1LG2, HAVCR2, CD274, etc., were significantly higher in the high-risk group. We also found that the ESTIMATE score, stromal score, and immune score were lower in the high-risk group, while the result of tumor purity was the opposite.Collectively, a prognostic signature consisting of five AS events in THCA was established. Furthermore, there was an inextricable correlation between immune cell infiltration, immune checkpoint proteins, and AS events. This study will provide a basis for THCA immunotherapy in the future. The incidence of THCA continues to increase worldwide, mainly due to the progress of imaging technology and the increase of examination methods. The number of thyroid cancer cases detected in the USA each year increased by 240% from 1973 to 2002, eventually reaching 7.7 per 100,000 people. However, the data continues to increase, reaching 15.2 per 100,000 people in 2013  is one of the most important posttranscriptional regulation, which can modify more than 90% of human genes . AccumulIn this research, we established a prediction model including five AS events on the basis of comprehensive bioinformatics analysis. ROC curve and K-M survival curve revealed the prediction capability of the prediction model in THCA. To reveal the underlying mechanism between AS events and 22 types of immune cells, CiberSort algorithm was employed to calculate the proportion of tumor immune cell infiltration between patients in the high- and low-risk groups. Finally, the potential immune checkpoints of patients were analyzed, which may help to break the bottleneck of THCA immunotherapy.https://tcga-data.nci.nih.gov/). AS data of THCA patients were downloaded from the SpliceSeq database (http://bioinformatics.mdanderson.org). Finally, a total of 495 THCA patients with splicing data, transcriptional data, and clinical information were included in this study for analysis.Transcriptional data and clinical information of 506 THCA patients were downloaded from The Cancer Genome Atlas (TCGA) database (p < 0.05 as filter) was selected to identify the differentially expressed alternative splicings (DESAs), and the DEASs related to prognosis were selected for further analysis. The final survival-related AS events was identified by least absolute shrinkage and selection operator (LASSO) regression, which can avoid overfitting of model. Furthermore, multivariate Cox regression was employed to construct the prognostic signature model based on selected AS events. n represented the number of AS events selected by prognostic signature and coefi represented regression coefficient of each selected AS event.For TCGA spliceseq, seven types of AS events were quantified by percent spliced in (PSI), which ranges from 0 to 1 . A PSI vAccording to the results of median risk score, 495 THCA patients were divided into the high- and low-risk groups. For K-M survival curve, the difference of overall survival time (OS) in the high- and low-risk groups was compared. The predictive efficiency of prognostic signature was evaluated by using ROC curve to calculate the survival rate of 1, 3, and 5 years. The hazard ratio (HR) of the risk score and clinical parameter were obtained by univariate and multivariate Cox regression analyses.CiberSort, a tool that can provide specific immune cell types based on RNA profile, was used to analyze the 22 immune cell subtypes in THCA. The vioplot package of R was used to identify different immune cell infiltration between the high- and low-risk groups. At the same time, the immune score was calculated according to the ESTIMATE algorithm. The ggpubr package of R was used to analyze the difference of immune features . Immune status and potential immunotherapy were predicted by comparing the differential expression of immune checkpoints between the high- and low-risk groups. Meanwhile, the correlation of immune checkpoints and the risk score was analyzed.p < 0.001 were set as filtering conditions. Cytoscape (version 3.8.2) was used to visualize networks related to DEASs and splicing genes , HAVCR2, CD70, IDO2, TNFSF4, TNFSF18, CD160, CD80, and CD274 (PD-L1), compared with that in the low-risk group (R ≥ 0.6 and adjusted p < 0.001)  Figure 8Recent studies have focused on the effects of AS events in cancer progression and recurrence. The recurrence of AS events can exert an impact on cancer prognosis . PreviouIn this study, we detected 45,150 AS events in 21,075 genes in 495 THCA patients, suggesting that AS was a ubiquitous biological process in THCA and mainly involved in the regulation of posttranscriptional modification. In addition, 1,089 DEASs were identified from the comparison between THCA and normal tissues. Previous study found that most DEASs were closely related to their corresponding genes, which indicated that AS plays an indispensable role in the posttranscriptional process and can change gene expression . NetworkSRSF5, PDCD10, AKAP8L, FOXRED1, and GALNTL6 were finally identified as integrated prognostic splicing biomarkers in our study. The prognosis of patients with THCA can be predicted accurately predicted by the signature composed with five AS events. According to NCBI, Ensemble, and SMART database, SRSF5 encoded the protein which was an important constituent element of pre-mRNA splicing factors and forms part of the spliceosome . PreviouImmunotherapy targeting immune checkpoints has been proven to improve the prognosis of patients with THCA. Therefore, the difference of immune checkpoint expression between the high- and low-risk groups was analyzed. The results of our study indicated that the patients in the high-risk group had higher expressions of immune checkpoint proteins . An increasing body of evidence showed that CD274 (PD-L1) played a key role in the TME of various tumors. Nikita and Yoo found that high expression of PD-L1 was associated with poor clinical outcomes for THCA patients , 32. HowCancer cells, endothelial cells, and tumor-infiltrating lymphocytes are the main cells that express HARVR2 . It has It has been reported that AS events are widely involved in angiogenesis, invasion, and immune destruction of a variety of tumors . New epiin vivo, which can reduce or eliminate tumor cells and improve the prognosis of patients with cancers.Immunotherapy, which was based on immune cells, can provide a new insight for the treatment of some cancers, including THCA , 49. HowTaken together, a prognostic signature consisting of five AS events in THCA was established, which was helpful for individualized and accurate treatment of patients. Furthermore, there was an inextricable correlation between immune cell infiltration, immune checkpoints, and AS events. This result is of great significance and provides as basis for THCA immunotherapy in the future.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The original draft was prepared and written by JW and YS. JL, MA, and LY were in charge of the data curation. LY reviewed and edited the article. JS and FY were in charge of the project administration. All authors commented and approved the text. All authors contributed to the article and approved the submitted version.This work was supported by the Natural Science Foundation of Guangdong province (No. 2018B0303110013).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.


In addition, it is necessary to be aware of the dangers of exposure to even small amounts of lead in daily life.(1) Objective: Lead, a heavy metal that exists commonly in air, soil and crops may cause chronic disease in the cardiovascular system. The purpose of this study is to investigate how blood lead levels affect cardiovascular disease in adults. (2) Study Design and Participants: It is a cross-sectional, descriptive study using data from the Korean National Health and Nutrition Examination Survey (KNHANES). Data from a total of 1929 participants, derived from the KNHANES, conducted by the Korea Centers for Disease Control and Prevention, in 2017, were analyzed using SPSS version 25.0. (3) Measurement: The cardiovascular disease risk was calculated using the Framingham risk score. There was a strong positive correlation between blood lead levels and the Framingham risk score. Furthermore, of the FRS sub-criteria, systolic blood pressure, HDL cholesterol level and total cholesterol level all also showed a significant correlation. (4) Results: We analyzed the correlation between PbB levels and the FRS sub-criteria, including systolic blood pressure, HDL cholesterol level, total cholesterol level and the FRS total. We found a significant positive correlation between PbB levels and systolic blood pressure, FRS total and total cholesterol level ( The U.N.’s sustainable development goal (SDG) is to minimize the pollution of air, water and soil by chemicals by 2030. Lead (Pb) is a heavy metal that was ranked second among the major toxic substances in 2007 by the United States of America Agency for Toxic Substances and Disease Registry (ATSDR), and a priority heavy metal handled by the Ministry of Food and Drug Safety . Since PAccording to the Toxicological Profile on Lead by the Agency for Toxic Substances and Disease Registry, a blood Pb (PbB) concentration of 10µg/dL is the general standard of risk. However, a number of recent studies have reported that the mortality rate increases even at lower PbB levels ,3,4.Generally, Pb enters the human body via ingestion. However, Pb can also enter the human body via inhalation or skin contact. Pb can adversely affect the respiratory, cardiovascular, musculoskeletal, renal and nervous systems and lead to cancer . Pb has Although it is challenging to establish a clear association between PbB and CVD due to multiple confounding factors such as age, obesity, ethnicity, smoking and drinking, several previous studies have reported the occurrence of CVD-related conditions including hypertension, atherosclerosis and cardiac conduction disorder as well as increased mortality with long-term Pb exposure. Evaluations of bone Pb levels, which build up over a long period of time, have shown that long-term Pb exposure, even at low levels, can cause ventricular myocardial and cardiac conduction problems . It has There are various methods to predict CVD risk. A method that is used widely is the Framingham risk score (FRS). The FRS is a way of calculating and predicting the 10-year CVD risk by quantifying the selected major risk factors of CVD such as sex, age, blood pressure, total cholesterol level, high-density lipoprotein (HDL) level, smoking status, use of antihypertensives and diabetes .In this study, we used the Korean National Health and Nutrition Examination Survey (KNHANES) data to analyze PbB levels and CVD risk using the FRS in the Korean population.This study is a cross-sectional descriptive study using secondary data from KNHANES phase VII-1 (2017) conducted by the Korea Center for Disease Control and Prevention. The KNHANES has been conducted annually by the Korea Disease Control and Prevention Agency (KCDC) since 2007 and includes a health examination and interview in a mobile unit. Twenty-three households in 192 districts are chosen every year as a probabilistic sample, with approximately 10,000 household members aged over 1 year surveyed.Multi-stage, stratified, cluster sampling, which is a complex sample design method, was used to extract samples from KNHANES data for representativeness and improved accuracy of estimation. This is a step-by-step cluster extraction by selecting the first sample based on the cluster, selecting the second sample from the selected cluster, and extracting the third sample, unlike in the case of simple random extraction . A totalWe collected sex, income level, education level, smoking status and body mass index (BMI) information from the participants. Real income per household unit was assessed to estimate the average household income, which was first classified into 30%, and 40% of the total. The upper level of household income was divided into a highest and upper middle group. Lower levels were further subdivided into a lowest and lower middle group. The level of education was classified as ≤6 years, 7–9 years, 10–12 years, and ≥13 years. Smoking status was divided into currently smoking and non-smoking status.For the blood test, samples were collected after at least 8 h of fasting, mostly using the median cubital and cephalic veins. Blood samples were refrigerated and then transported to a clinical laboratory on the same day to perform the analysis within 24 h. Triglyceride, HDL and fasting glucose were measured via enzymatic methods using the automatic analyzer 7600 . Heavy metals were analyzed via Automic Absorption Spectrophotometry using the Perkin Elmer AAnalyst 600.For the CVD risk score, we used the FRS revised in 2008. This calculation divided the participant’s age into nine groups, total cholesterol levels, high-density lipoprotein cholesterol levels, systolic blood pressure and diastolic blood pressure into five groups, and each group was given a unique risk score according to gender. Participants’ current smoking ability and diabetes were divided into two groups according to their presence or absence, and unique risk scores were given according to gender. In this way, the FRS was calculated through the sum of each score estimated in the six processes, and the 10-year coronary heart disease risk was estimated based on the score. We referred to the scoring system used in a previous study and defined a calculated risk of <10%, 10–19% and ≥20% as low, moderate and high risk, respectively .We used SPSS version 25.0  for the statistical analysis. The enumeration of districts of KNHANES included in the analysis were affected using a multi-stage, stratified, cluster sampling method, which is a complex sample design method. A complex sample analysis method of SPSS was used to add sample weights for analysis. The sample weights of KNHANES are a raising multiplier applied so that the estimated value is representative of the entire Korean population and are calculated by reflecting the extraction rate, response rate and distribution of the population. Moreover, if a new variable was created by combining several variables or a statistical model that included several variables for analysis was used, investigation categories, areas and items associated with all the variables were considered. In other words, sample weights that included many categories, areas, and items were referred to as correlation analysis weights in the KNHANES, with weights provided for each year.We performed the Chi-square test and analysis of variance (ANOVA) to analyze differences between groups based on general characteristics and PbB levels. To identify the predictors of CVD risk, we analyzed the FRS sub-criteria, including blood pressure, HDL cholesterol level, total cholesterol level and corresponding PbB level using multinomial logistic regression. The correlation with each variable was verified using Pearson’s correlation coefficient.KNHANES data was used in this study. It was anonymized such that personal information of the participants cannot be identified and was uploaded onto the website of the Korea Disease Control and Prevention Agency. The study was conducted after being reviewed for exemption by the Institutional Review Board (JIRB-2020021701-02-200218).p < 0.001). Regarding the relationship between income and the FRS, the high-income group was the most prevalent for both males and females in the FRS < 10% group (p < 0.001). Regarding education level, individuals with a high level of education ≥ 13 years were the most prevalent in the FRS < 10% group. Contrastingly, in the high-risk group with an FRS ≥ 20%, individuals with an education level < 6 years were the most prevalent. The length of education and FRS displayed significant differences (p < 0.001). There was a significant difference between PbB levels and the FRS sub-criteria, including hypertension, diabetes and systolic blood pressure in both males and females (p < 0.001). However, HDL and total cholesterol levels were significantly different in females only (p < 0.05). Smoking also displayed a significant difference in both males and females (p < 0.05). Regarding the relationship between PbB and FRS, in the PbB < 2 µg/dL group for both males and females, an FRS < 10% was the most prevalent and demonstrated a significant between-group difference (p < 0.005)  and females in their 50 s (22.8%) were the most prevalent. In the FRS ≥ 20% group, males and females in their 70 s or older were the most prevalent, while age and the FRS were significantly different (< 0.005) .p < 0.05) as well as a significant negative correlation with HDL cholesterol level (p < 0.05)  .p < 0.001). In the group with ≥20% CVD risk, the FRS risk predictors were PbB level, systolic blood pressure and total cholesterol level in males and systolic blood pressure and total cholesterol level in females (p < 0.05). In males, the PbB levels were 2.4 times higher with a 10-year CVD risk of 10–20%  and 2.8 times higher with a ≥20% risk , whereas there was no significant difference in females (An analysis of the FRS sub-criteria, including systolic blood pressure, total cholesterol level, HD cholesterol level, and PbB level, revealed that in the group with 10–20% CVD risk, the FRS risk predictors were PbB level and systolic blood pressure in males and systolic blood pressure in females ( females .This is a descriptive study that investigates the association between PbB levels and CVD risk. The results show that a high proportion of those that were younger, had high-income levels and were highly educated belonged to the low-risk group with an FRS of <10%. This is consistent with previous findings that CVD risk increases with age  and thatRegarding the relationship between PbB levels and FRS, the low-risk group with an FRS of ≤10% had low PbB levels below 2 µg/dL in both males and females. Furthermore, of the FRS sub-criteria, systolic blood pressure was significantly low, and HDL was significantly high. This is consistent with previous findings that heavy metals increase blood pressure and blood cholesterol levels . AdditioFurthermore, of the FRS sub-criteria, systolic blood pressure, HDL cholesterol level and total cholesterol level all showed a significant correlation. This supports the previous findings that PbB levels negatively affect systolic blood pressure, diastolic blood pressure and HDL, increase the risk of metabolic syndrome  and is aIn particular, in the moderate-risk group with an FRS of 10–20% and the high-risk group with an FRS of ≥20%, PbB levels and systolic blood pressure were significant predictors of CVD incidence in males. Moreover, with increasing PbB levels, the 10-year CVD risk increased 2.4 times in the FRS 10–20% group and 2.8 times in the FRS ≥20% group. This is similar to the previous finding that risk of death due to CVD increases with long-term Pb exposure  and suppIn the present study, we confirmed a significant correlation between PbB levels and the FRS. This suggests that among the various risk factors of CVD, environmental Pb can be a factor. Therefore, it is necessary to improve the local environmental conditions and increase individual awareness of hazardous substances. We believe that the present findings will serve as a useful indicator of community health.In this study, we demonstrated that PbB levels could be used as a major predictor of CVD incidence. Although Pb use in industrial facilities has rapidly decreased with increasing awareness of its adverse effects, it is still present in some toys, cosmetics, food and accessories. Therefore, it can accumulate in our body without occupational exposure. To prevent this, we need a systematic approach involving dietary and environmental improvements, and cooperation among the industrial, environmental and healthcare sectors to improve the national health status. Therefore, we propose the development of a health care program that can prevent CVD and reduce community exposure to heavy metals.However, the limitation of this study is that the consideration of regional characteristics such as urban and rural, and occupational groups with high and low exposure to lead was not investigated separately.


No significant associations were observed between breakfast quality and physical fitness . However, all the significant associations disappeared after adjusting for physical activity . Our study sheds light on the relevance of adhering to the MDP over physical fitness in school children. However, there is no association between breakfast quality and physical fitness. Furthermore, physical activity seems to explain, at least partially, these findings.Dietary habits have been linked with health in childhood. However, few studies have examined the association between healthy dietary patterns and physical fitness. Therefore, the aim of this study was to examine the associations of adherence to the Mediterranean dietary pattern (MDP) and breakfast quality with physical fitness in children. Further to this, we examined the role of physical activity in these associations. A total of 175 children  participated. Adherence to MDP and breakfast quality were assessed by the KIDMED questionnaire and 24 h recall, respectively. Cardiorespiratory fitness, muscular strength, and speed–agility were assessed. Physical activity was evaluated by wrist-worn accelerometers. Greater adherence to the MDP was related with higher cardiorespiratory fitness, lower-limbs muscular strength, and speed–agility (all β ≥ 0.189, all  Healthy dietary habits are important protective factors of health ,2. The MTogether with dietary habits, physical fitness, particularly cardiorespiratory fitness, has been widely recognised over the last two decades as a powerful marker of health in children and adolescents ,11. CardAt early ages, it seems that combining healthy dietary habits, good physical fitness, and daily practice of physical activity are the cornerstone to present and future healthy lifestyle ,11,12,13Therefore, the aim of this study was to explore the associations of MDP and breakfast quality with physical fitness in school children. Furthermore, we examined whether physical activity modifies these associations among children.This study is under the framework of the High Intensity Interval Training (HIIT) project , a randomized controlled trial that aims to investigate the effects of different doses of 8 weeks of HIIT on body composition, physical fitness, and physical activity in 9–10-year-old children. This work uses baseline data collected prior to randomization. Children were recruited from two different schools in Navarra (Spain). A total of 175 school children  were included in this study (convenience sampling). The inclusion criteria were being 9–10-years-old and not having psychological or physical disorders that could hamper exercising and evaluations. Parents or legal guardians were informed about the aims, design, and protocol of the study. If they agreed, they signed the informed consent in order to participate in the study. The study followed the ethical guidelines of the Declaration of Helsinki , and was approved by the Ethics Committee of the Public University of Navarra. 2 ≤ 0.08) considering a statistical power of 80% and an alpha error of 0.05.We performed statistical power calculations using the G*Power software (version 3.1.9.2) . Our sam2). Weight status  was classified based on the sex- and age-specific BMI cut-off points provided by the World Obesity Federation [Weight (kg), percentage of body fat, and body fat-free mass (kg) of participants were measured by bioimpedance . Height (cm) was measured with a stadiometer . All the body composition assessments were performed in underwear and without shoes. Body mass index (BMI) was calculated as weight divided by height squared  which is a valid and widely used assessment tool in children . The KIDOne 24 h recall of a weekday or weekend day was recorded by trained nutritionists. Children described their intake from the previous day in an interview. To estimate servings and food sizes, food servings pictures were used . SpecifiPhysical fitness was assessed by the Assessing Levels of PHysical Activity (ALPHA) battery, which is known to be feasible, reliable and valid in children .Cardiorespiratory fitness was evaluated by the 20 m shuttle run test . BrieflyUpper-limbs muscular strength was measured by handgrip strength (kg) test which consisted of squeezing the digital dynamometer  as much as possible for 2–3 s. Each hand was measured twice, and the best result of each hand was retained and averaged for the analyses. Lower-limbs muscular strength was measured by standing broad jump test (cm). This test consisted of jumping as far as possible remaining upright. The distance jumped from the start line to the back of the heel (the nearest point of contact when landing) was recorded. The test was performed twice, and the maximum value was used for the analyses.Speed–agility was assessed by the 4 × 10 m shuttle run test (seconds). This test consisted of running back and forth, 10 m apart, as fast as possible. The children had to exchange sponges at each line. This test was performed two times, and the fastest completion time was recorded for analyses.Time spent in physical activity was registered by accelerometers . Children wore an accelerometer placed on the non-dominant wrist during 7 consecutive days 24 h). They were instructed to remove the accelerometers only for water activities . For the analyses, valid data were considered when the children recorded ≥ 600 min/day of waking hours, and a minimum of 3 days (2 weekdays and 1 weekend day) . Non-wea h. They The characteristics of the study sample were examined using descriptive (mean and standard deviations (SD)) or frequencies analyses . Confounders were selected after examining their role in the association of MDP and breakfast quality estimates with physical fitness components. Therefore, sex and age were included as basic confounders. For sensitivity analysis, we additionally included school as a covariate.To investigate relationships between predictors  and outcomes , each outcome was regressed on each predictor, adjusting for the basic confounders of age and sex (Model 1). Additional analyses were adjusted for moderate-to-vigorous physical activity and accelerometer awake wearing time (Model 2). As exploratory analysis, we further observed the relationship between physical fitness and physical activity outcomes.Analyses of covariance were performed using MDP and breakfast quality level (low vs. high) as fixed factors and physical fitness components  as dependent variables. Analyses were adjusted for basic confounders (Model 1). In Model 2, we additionally adjusted for physical activity . Regarding the MDP index, scores ≥ 7 were classified as average to optimal adherence (named as high adherence) to the MDP , and accp < 0.05.All the analyses were performed using SPSS statistics version 22 . The level of significance was set at n = 2), (ii) did not have complete or valid data on MDP (n = 45), and (iii) did not wear the accelerometer or did not have valid data (n = 14).Descriptive characteristics  of the study sample are shown in p ≤ 0.02) after adjusting for age and sex. No significant relationships were observed between any of the examined physical fitness components and breakfast quality index . When the analyses were additionally adjusted for physical activity (Model 2), all the results became statistically non-significant . Relationships between breakfast quality and physical fitness components remained non-significant after adjusting for age, sex, moderate-to-vigorous physical activity and accelerometer wearing time . p < 0.01).p = 0.041), lower-limb muscular strength , and speed–agility  compared to their peers classified as having low adherence to the MDP (p > 0.08). p > 0.05). the MDP . HoweverData are presented adjusted by basic confounders , and additionally adjusted for moderate-to-vigorous physical activity and wearing time . Classification of adherence to the Mediterranean dietary pattern was based on a cut-off score of 7 on the 10 used questions of the KIDMED questionnaire; the high adherence group includes those participants classified as having average to optimal adherence to the Mediterranean dietary pattern. Sample size varied for Model 1  and Model 2 . In the speed–agility test, less time indicated a faster runner; therefore, a lower score indicates better performance.Data are presented adjusted by basic confounders , and additionally adjusted for moderate-to-vigorous physical activity and wearing time . Classification of low and high breakfast quality was based on a cut-off score of 6 on the 10 items; the high breakfast quality group includes those participants classified as medium to high breakfast quality. Sample size varied for Model 1  and Model 2 . In the speed–agility test, less time indicated a faster runner; therefore, a lower score indicates better performance.The main finding of this study is that higher adherence to the MDP was associated with better cardiorespiratory fitness, lower-limbs muscular strength and speed–agility; however, after adjusting for physical activity levels, these results were attenuated, showing the role of moderate-to-vigorous physical activity on these associations. In addition, our results also showed no significant relationship between the breakfast quality index and any of the physical fitness components in children.p < 0.05) [In the last few years, a growing body of studies have reported the influence of dietary patterns on children and adolescents’ health. Yet, less is known about the association between dietary patterns and physical fitness, which is an important marker of cardiovascular health even in childhood. In our study, we observed that children with greater adherence to the MDP showed higher cardiorespiratory fitness, lower-limbs muscular strength, and speed–agility. Moreover, those who were classified into the high adherence MDP group also showed better cardiorespiratory fitness (19%), muscular strength (7%), and speed–agility (3%) levels compared to those who were classified as the low adherence MDP group. Our findings are in accordance with a recent meta-analysis where the authors observed that MDP was positively related to cardiorespiratory fitness, muscular strength, and speed–agility in children and adolescents from 3 to 18 years  . The obsIn regard to breakfast quality, our findings showed no significant association with any of the examined physical fitness components. To the best of our knowledge, there are no previous studies examining the association of these variables in youth, which hampers any comparison. However, our hypothesis on the absence of association is that the breakfast quality index is based on only one meal of the day that could have impacted on children within the first part of the day, but not over the whole day ,26. It ip < 0.05). In line with this assumption, a randomized controlled trial in 8–12-year-old children with overweight/obesity concluded that after a 22-week family-based healthy lifestyle education program, children improved the quality of their diet as well as their cardiometabolic health, and that obesity prevention programs should focus on the avoidance of sugar-sweetened beverages and the promotion of physical activity [In order to examine the role of physical activity on the association of dietary patterns with physical fitness, we further adjusted the analyses for moderate-to-vigorous physical activity. Our findings depicted that physical activity played an important role on the association of MDP and, to a lesser extent, on breakfast quality with physical fitness components . These results suggest that those children who eat properly are also those who are more physically active. This is in line with a recent meta-analysis in youth, where Garcia-Hermoso et al.  observedactivity . TherefoSome practical implications can be derived from this study: (i) improving dietary patterns, mainly through the Mediterranean dietary pattern, could be associated with higher cardiorespiratory fitness, muscular strength, and speed–agility in children; and (ii) schools, parents, and health-related professionals should emphasize the need to promote a healthy lifestyle combining dietary patterns, physical fitness, and physical activity. As an example, a multidisciplinary intervention program focused on improving diet quality, physical fitness and physical activity as well as reducing sedentary time, will contribute to current and future youth health.p = 0.911). The strengths of the present study are: (1) the novelty of the investigation; (2) the use of reliable, valid, and health-related physical fitness measurements; and (3) the use of accelerometers for objectively assessing physical activity.This study presents several limitations: (1) its cross-sectional design does not allow for causal inference; and (2) the limited number of 24 h recall (n = 1) performed either on a weekday or weekend days might have limited the general view of overall breakfast quality. However, we have further examined whether differences exist between weekdays and weekends, and no significant difference was observed in regard to the breakfast quality index (Our study sheds light on the influence of adherence to the MDP on physical fitness in school children. However, there is no association between breakfast quality index and physical fitness. Furthermore, physical activity seems to explain, at least partially, these findings. More studies are needed to examine these relationships in children and adolescents to support or contrast our findings. The public health implications resulting from our results highlight the importance of promoting healthy dietary patterns, specifically the MDP pattern’s role in physical fitness in children.


In this study, multi-walled carbon nanotubes (MWCNTs) were decorated with different types of nanoparticles (NPs) in order to obtain hybrid materials with improved antimicrobial activity. Structural and morphological analysis, such as Fourier transformed infrared spectroscopy, Raman spectroscopy, X-ray diffraction, transmission electron microscopy, environmental scanning electron microscopy/energy-dispersive X-ray spectroscopy and the Brunauer–Emmett–Teller technique were used in order to investigate the decoration of the nanotubes with NPs. Analysis of the decorated nanotubes showed a narrow size distribution of NPs, 7–13 nm for the nanotubes decorated with zinc oxide (ZnO) NPs, 15–33 nm for the nanotubes decorated with silver (Ag) NPs and 20–35 nm for the nanotubes decorated with hydroxyapatite (HAp) NPs, respectively. The dispersion in water of the obtained nanomaterials was improved for all the decorated MWCNTs, as revealed by the relative absorbance variation in time of the water-dispersed nanomaterials. The obtained nanomaterials showed a good antimicrobial activity; however, the presence of the NPs on the surface of MWCNTs improved the nanocomposites’ activity. The presence of ZnO and Ag nanoparticles enhanced the antimicrobial properties of the material, in clinically relevant microbial strains. Our data proves that such composite nanomaterials are efficient antimicrobial agents, suitable for the therapy of severe infection and biofilms. In the last decades, carbon nanotubes (CNTs) received increasing attention due to their unique characteristics , which make them suitable to be used in different areas, including industry, medicine, energy storage and environmental protection ,2,3.CNTs are allotropes of carbon consisting of a hexagonal arrangement of hybridized carbon atoms. They are assembled in cylindrical tubes and can be formed by a single sheet of graphene  or by multiple sheets of graphene linked through van der Waals non-covalent forces  ,5,6. CNTWith the rapid development of industries, more advanced materials are required. A solution regarding this problem was found in designing hybrid materials that will combine the properties of individual components. Surface modification of carbon nanotubes imparts new properties to these materials for various applications, where enhanced CNTs functionality, dispersion and compatibility are required. The most common methods to functionalize CNTs includes oxidation using various acids, when oxygen functional groups  result. Oxygen-containing groups created on nanotubes’ surface promote the exfoliation of CNT bundles, enhance the solubility in polar media and offer the possibility of further modification .Escherichia coli and Staphylococcus aureus bacteria. It was reported that the nanocomposites (MWCNTs_Ag) show a larger inhibition zone, compared with Ag NPs and MWCNTs. These results suggest that the bacterial growth inhibition of the composite sample was a synergetic effect resulting from both the nanoparticles and MWCNTs. Additionally, the interaction and bactericidal mechanism of MWCNTs decorated with Ag NPs was reported to occur due to the physical interaction of the nanomaterials with cell membrane, the faster destructibility of cell membrane and disruption of membrane function, leading to cell death .,33.32,33L) of the MWCNTs was calculated by using the Scherrer’s Formula (1) and the crystallite size for each nanomaterial is presented in K is Scherrer constant (0.91), λ is the X-ray wavelength (1.5406 Å), β is the full-width at half maximum and θ is the Bragg angle (rad).The crystallite size , as comIsotherm absorption/desorption curves for the MWCNTs and MWCNTs decorated with NPs are presented in Dispersion is a process where agglomerated particles are separated from each other and a new interface between an inner surface of the liquid dispersion medium and the surface of the particles to be dispersed is generated. A system is stable when its dispersed phase can exist as separate individual particles for a long time . Carbon In this study, 1.5 mg of MWCNTs and decorated MWCNTs were dispersed in 2 mL of water in a quartz cuvette for 15 min under an ultrasonic bath in water, in order to investigate their dispersion.In Additionally, the nanotubes decorated with ZnO NPs presented the most increased dispersion in time because of the small size of the NPs attached to the MWCNTs surface, approximately 10 nm, while a larger particle size of approximately 30 nm is found on the surface of the MWCNTs_HAp and MWCNTs_Ag. Thus, the spectral changes suggest that smaller particles interact more with water molecules than larger particles ,48.C. albicans strain, the areas of growth inhibition were minimal for all types of nanomaterials tested. These results suggest that the efficiency of the obtained materials is limited against yeasts. This can be related with particularities of their cellular wall (two-layered structure) and eukaryote organization.Qualitative testing of antimicrobial activity demonstrated that MWCNT-based nanomaterials were able to inhibit growth for all tested strains. The length of CNTs is a very important aspect due to the interactions with cell membrane. The shorter tubes exhibit higher antimicrobial performance, compared with longer tubes. This fact is related to the interaction between nanotube and bacteria, leading to more cell membrane damage . The nanS. aureus, B. subtilis and E. coli were 0.25%, while the MIC value for P. aeruginosa was 0.5%. In addition, MWCNTs_Ag presented improved antimicrobial effects that confirmed that the presence of the attached NPs has a great importance; physical interactions between nanocomposites and cell membrane take place, which leads to a faster destructibility of the cell membrane. In the case of MWCNTs and MWCNTs_HAp, the MIC was 1 mg/mL for almost all strains tested, confirming a slightly lower antimicrobial activity.Quantitative tests showed that MWCNTs decorated with ZnO NPs have three times more pronounced antimicrobial effects compared to the pure nanotubes . This reE. coli and P. aeruginosa strains  is different, as compared with bacteria. In C. albicans, is presented. It can be observed that, at higher concentrations, the materials are more efficient in the biofilm eradication. As the nanocomposites concentration decreases significantly (at 0.007% and 0.015%), their efficiency decreases and the yeast pathogen shows a high tolerance to these nanomaterials.F-value determination. According to these results, at the 5% level, the main factors (absorbance and time) have a reasonable effect on stability determination. No insignificant factors were obtained, thus, the stability of the MWCNTs and decorated MWCNTs can be measured by UV analysis. According to p-values, the decorated nanomaterials are more stable in time, compared with MWCNTs.The analysis of variance (ANOVA: single factor) for stability of water dispersion of MWCNTs, MWCNTs_ZnO, MWCNTs_HAp and MWCNTs_Ag by measuring the relative absorbance in time is presented in S. aureus, B. subtilis, P. aeruginosa, E. coli and C. albicans. The importance of the main factors, such as nanomaterials’ concentration and absorbance for each strain after biofilm eradication, are considered for predicting the antimicrobial activity of MWCNTs, MWCNTs_ZnO, MWCNTs_HAp and MWCNTs_Ag against Gram-positive and Gram-negative strains and fungal pathogens. The degrees of freedom (df) for concentration and absorbance were 7 and 4, respectively. The SS can be applied to investigate the adequacy of the proposed models, with the smallest values being obtained for the MWCNTs_ZnO and MWCNTs_Ag. According to these results, at the 5% level of probability, the main factors, such as concentration of the nanocomposites and the type of strain used for analysis, have a reasonable effect on the biofilm eradication of the strains. Additionally, there were no insignificant factors and the SS and df of lack of fit were zero for all the nanocomposites. Based on the F-values of the main factors, the best antimicrobial activity was obtained for MWCNTs_ZnO and MWCNT_Ag. All the p-values, for all concentrations, strains’ absorbance and materials, were less than 0.05, so the proposed model was adequate, and the nanomaterials’ antimicrobial activity was highlighted.S. aureus, B. subtilis, P. aeruginosa, E. coli and C. albicans. The higher antimicrobial activity was observed for MWCNTs_ZnO and MWCNTs_Ag, with the largest diameter of inhibition zone being obtained for these nanocomposites (13–6 mm for MWCNTs_ZnO and 6–7 mm for MWCNTs_Ag). The biofilm formation test demonstrated that MWCNTs_ZnO and MWCNTs_Ag presented the highest antimicrobial activity, with the inhibition occurring even at lower concentrations, such as 0.015% and 0.007%. These results were supported by the statistical analysis. The SS was applied in order to investigate the adequacy of the proposed models, with the smallest values being obtained for the MWCNTs_ZnO and MWCNTs_Ag. In addition, based on the F-values of the main factors, the best antimicrobial activity was obtained for MWCNTs_ZnO and MWCNT_Ag. Thus, the obtained materials could be considered as competitive candidates for the development of efficient antimicrobial systems to fight against resistant pathogens and biofilm infections.In this study, we reported the decoration of MWCNTs with different types of nanoparticles, such as ZnO, Ag and HAp, in order to obtain hybrid materials with improved antimicrobial activity. The decoration of MWCNTs with NPs was confirmed by structural and morphological analyses, such as Fourier transformed infrared spectroscopy, Raman spectroscopy, X-ray diffraction, transmission electron microscopy, environmental scanning electron microscopy/energy-dispersive X-ray spectroscopy and Brunauer–Emmett–Teller surface area analysis. The nanoparticles attached on the MWCNTs surface presented variable diameters, from 7 to 13 nm for ZnO NPs, 15–33 nm for Ag NPs and about 35 nm for HAp. In all the cases, the NPs were attached and aggregated to the surface of MWCNTs, as demonstrated by SEM analysis. The agglomeration of the NPs indicates the supporting role of the MWCNTs, as a center for the deposition of the clusters. Additionally, the dispersion in aqueous medium of the obtained nanomaterials was investigated and all the decorated MWCNTs presented a better dispersion in water, demonstrating a proper dispersion of the nanomaterials that retain their properties. The in vitro results demonstrated that the obtained nanocomposites have a significant antimicrobial activity and reduce biofilm formation in many relevant microbial strains, such as