Conclusions: The use of hydrotherapy during the first stage of labour is safe and is associated with increased breastfeeding rates compared to conventional delivery.Background: Hydrotherapy is a technique used for pain management during labour, but its safety for both the mother and foetus remains uncertain. Objective: The main aim of this study is to determine whether the use of hydrotherapy in the first stage of labour is safe for both the mother and newborn. Methods: A retrospective observational study was conducted to collect data from the partogram, maternal and neonatal history. Results: A total of 377 women who gave birth at the Costa del Sol Hospital in Malaga between January 2010 and December 2020 were randomly selected. They were divided into a control group (253 women) and an intervention group (124 women) that used hydrotherapy in the first stage of labour. There were no significant differences between the groups in terms of age, history of previous miscarriages, type of delivery, or newborn weight. The results showed that most women who opted for hydrotherapy were nulliparous, and the use of hydrotherapy during labour was safe for both the mother and foetus. There were no significant differences in the variables of maternal arterial hypotension, postpartum haemorrhage, postpartum maternal fever, foetal complications, neonatal admission, 1 and 5 min Apgar scores, umbilical arterial or venous pH, or foetal cardiotocographic recording. However, there was a significant difference ( The use of water as a therapeutic medium is not new, although its exact origins are not known. However, there is evidence of ancient cultures such as China, Egypt, Japan, Greece, and Rome using water as a treatment for physical and psychological ailments. In addition, there are bibliographic references  to cliniHydrotherapy is a method that focuses on pregnant women, especially during childbirth, which is why many women find it comfortable and useful . In factThe benefits of water, such as buoyancy, hydrostatic pressure, and temperature, are relevant and beneficial to women during the birth process, as numerous studies have shown. These benefits include positive effects on the maternal experience of labour, such as reduced use of epidurals, improved ability to cope with pain, shorter labour, greater sense of control during the process, and increased comfort and ability to adopt comfortable positions . A CochrHowever, there is controversy about neonatal outcomes and baby safety. Associations such as the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) argue that the potential risks to the newborn outweigh the benefits for the woman.The American College of Nurse-Midwives (ACNM) position statement on hydrotherapy in labour and birth recommends that women be provided with evidence-based information about water birth and that it be available to those with uncomplicated pregnancies who desire this option .In response to the positions of the associations, current studies present data analyses that report on various neonatal clinical outcomes when comparing births without the use of hydrotherapy and births with the use of hydrotherapy. These studies do not suggest that outcomes are worse for babies born by water birth .These findings are echoed in studies such as that by Davies et al. (2015), which concludes that water birth does not appear to be associated with adverse neonatal outcomes in a sample of low-risk women .Another study by Bailey et al. (2020) concludes that water birth is not associated with an increased neonatal risk, nor is there a higher incidence of extensive perineal lacerations or postpartum haemorrhage .Other specific adverse neonatal outcomes, such as respiratory distress, anaemia, sepsis, hypoxic-ischemic encephalopathy, asphyxia, or death, did not show significant differences between the groups that used water immersion and those that did not .The Clinical Practice Guideline on Normal Childbirth Care in Spain, which is currently in force, recommends warm water immersion as an effective method of pain relief in the late stages of the first stage of labour . This guThe hypothesis of this study is that the use of hydrotherapy during childbirth is safe for both mother and newborn and does not show significant differences in the variables analysed, including maternal arterial hypotension, postpartum haemorrhage, postpartum maternal fever, foetal complications, neonatal admissions, Apgar scores at 1 and 5 min, arterial or venous pH of the umbilical cord, and foetal cardiotocographic record. In addition, it is hypothesised that the use of hydrotherapy during childbirth may increase breastfeeding rates compared to conventional childbirth.The main aim of this study was to determine whether the use of hydrotherapy in the first stage of labour is safe for both the mother and newborn.-To study maternal perinatal outcomes.-To study foetal outcomes of the use of hydrotherapy during labour.Secondary objectives are:This is a retrospective observational study. The study was conducted in accordance with the Declaration of Helsinki for research on human subjects and was approved by the Ethics Committee of Costa del Sol Hospital (002_oct18_PI-hydrotherapy labour) in November 2018.Women who gave birth at Costa del Sol Hospital between January 2010 and December 2020 were randomly selected from an anonymous database and retrospectively included in our observational study. The randomisation of the database was performed by the hospital’s IT department using computer software.Data collection took place between September 2021 and May 2022 in the hospital’s clinical documentation unit, with data collected from the partogram, including clinical data on the mother, newborn, and delivery. For this purpose, a password-protected database was designed with various logical mechanisms to prevent the introduction of erroneous data.Data analysis was performed from June 2022 to September 2022.The inclusion criteria for the study were low-risk pregnant women, at term, with a singleton pregnancy, cephalic presentation, and need for hospital admission for delivery, with induction or spontaneous onset of labour.The study was carried out on patients who gave birth at the Costa del Sol Hospital in Málaga.Two groups were formed: the intervention group, consisting of women who used hydrotherapy during the first stage of labour, and a second control group who did not use hydrotherapy during labour.Exclusion criteria were pregnant women with a twin pregnancy, pregnancies that began prematurely (<37 weeks), or post-term (>42 weeks).Age: the age of participants was recorded in years.Parity: The GAPV formula (pregnancy-miscarriage-live birth) was used to record the parity of the pregnant women who participated in the study. For data analysis, it was classified as Nulliparous (no previous births) and Multiparous (one or more previous births).Type of delivery: the categories considered for the end of the second stage of labour were spontaneous vaginal delivery, vacuum-assisted delivery, forceps-assisted delivery, and caesarean section.The duration of the use of hydrotherapy during the first and/or second stage of labour was defined in minutes.Postpartum perineal: classified as intact, first-degree tear, second-degree tear, third-degree tear, fourth-degree tear , and epiMaternal hypotension: recorded in millimetres of mercury (<90/60 mmHg).Fever: for analysis, fever was recorded if the temperature was >38 °C; no fever if the temperature was <38 °C.Postpartum haemorrhage: yes/no.Breastfeeding: yes/no.Foetal cardiotocographic recording during dilation and expulsion, data collected according to the clinical practice guidelines of the National Health System : reassurNeonatal weight: measured in grams.Apgar score  at 1 andVenous and arterial pH.Admission to neonatal unit: yes/no.In order to avoid bias in the collection of data related to the variables to be considered, a database (Db) was designed, protected by a key, and equipped with various logical mechanisms to prevent the introduction of false data. Only the researchers involved in this project could access the database. It should be noted that the identifying data of the patients were separated in a second Db with a different access key. In this latter Db, only the principal investigator had access, and all researchers were committed to respecting the confidentiality of the data in accordance with the Personal Data Protection Law of 8 November 2018, and Law 41/2002 of 14 November, which is fundamental and regulates the autonomy of patients and their rights and obligations in terms of clinical information and documentation.The sample size calculated for this study was 248 pregnant women, with 124 in the control group and 124 in the hydrotherapy group . The sample was later increased to 377 women as it was considered necessary to subdivide the main groups in order to extend and improve the study.t-test  was used for quantitative variables. Multivariate logistic regressions were performed between the following variables: postpartum haemorrhage, postpartum perineal status , foetal complications, neonatal admission, abnormal RCTGF signs, maternal arterial hypotension, and maternal fever. Each model was adjusted for age and number of pregnancies .Descriptive analysis was performed using measures of central tendency, dispersion, and position (median and interquartile range (P75–P25)) for quantitative variables and frequency distribution for qualitative variables. To assess differences between study groups (absence vs. presence of hydrotherapy), the chi-squared test (or Fisher’s exact test if expected frequencies were less than 5) was used for qualitative variables, while Student’s p < 0.05. The analysis was performed using SPSS vs. 28.0 program for Windows  statistical software.For all analyses, the level of statistical significance was set at The intervention consisted of collecting data from patients who used hydrotherapy in the first stage of labour to compare with data of patients who did not use hydrotherapy.The data were directly collected from the paper partogram in the pregnant woman’s medical record. The clinical documentation unit allowed personal access to the data. Once the data were obtained, statistical analysis was performed.After analysing the collected data in this study, we observed notable characteristics in the sample, particularly differences in previous pregnancies and childbirths of the women under analysis that showed statistically significant variations. These data are shown in On the other hand, a descriptive analysis was conducted regarding the time spent using hydrotherapy among women who chose this technique during the first stage and/or second stage of labour. The results are presented in p-value of the Fisher exact test is 0.22, indicating that the differences are not significant.Among the maternal outcome data regarding postpartum haemorrhage, it was observed that 2.4% of pregnant women who did not receive hydrotherapy experienced postpartum haemorrhage, compared to 4.8% of women who received hydrotherapy. The p = 0.651), and no statistically significant differences were found , suggesting that there is no significant relationship between maternal hypotension and the use of hydrotherapy. In the group that did not use hydrotherapy, 5.1% had maternal hypotension, whereas in the group that used hydrotherapy, 5.6% had maternal hypotension.It was investigated whether the use of hydrotherapy affected maternal hypotension. No significant differences were found between the groups (p = 0.550) were found between the groups.The presence of maternal fever in the postpartum period was analysed, and no statistically significant differences (p = 0.540). There were no complications in 96% of newborns from mothers who chose to use water therapy during labour, and in 97.2% of cases where water therapy was not used. There were no differences in neonatal admissions (p = 0.846); however, the hydrotherapy group had a lower percentage of newborns admitted to the neonatal unit (4.8% vs. 5.9% in the non-hydrotherapy group).Analysis of neonatal outcomes showed no statistically significant differences between the groups in terms of neonatal complications or neonatal admissions (p = 0.782). In the group that did not receive hydrotherapy, one newborn had an Apgar score of two, indicating severe neonatal depression at birth, and two newborns had Apgar scores between four and six, indicating moderate depression. The neonates in this group had normal Apgar scores between seven and ten in 98.8% of cases. In the hydrotherapy group, one newborn had an Apgar score between four and six, indicating moderate depression, and 99.2% of this group had scores between seven and ten, indicating normal newborn status.In both groups, Apgar scores were analysed at 1 min and 5 min after birth. Apgar scores analysed at 1 min after birth showed no significant differences between the groups  observed in 98.4% of cases in the group that used hydrotherapy and in 96.4% of cases in the group that did not use hydrotherapy during delivery. No significant differences were found in the analysis, indicating good health of the newborns in the group that used hydrotherapy.p = 0.234). Calming RCTGF were present in 90.1% of the hydrotherapy group and 94.4% of the hydrotherapy group. In the group that did not use hydrotherapy, three RCTGF were abnormal and 22 were not sedative. These numbers decreased in the group that used hydrotherapy, where there were no abnormal RCTGF and seven non-sedating RCTGF.No statistically significant differences were found in the results of the foetal cardiotocographic recording (RCTGF) (p = 0.490), with values of pH = 7.35 ± 0.071 in the group of women who received hydrotherapy and pH = 7.353 ± 0.064 in the group of women who received conventional treatment. The arterial pH values were also not significant (p = 0.400), with values of pH = 7.291 ± 0.086 in women in the hydrotherapy group compared to pH = 7.287 ± 0.088 in women who did not receive hydrotherapy.The neonates’ venous and arterial pH levels were recorded. There were no statistically significant differences in venous pH between the groups (p = 0.005) were found in favour of the hydrotherapy group who decided to breastfeed (96% vs. 85.7%). The comparison between the two groups showed that more women in the hydrotherapy group breastfed their newborns.Significant differences (p = 0.135). The same is true for postpartum perineal status, which has an odds ratio (Exp(B)) of 1.039 (95%CI 0.64–1.68), which is not significant (p = 0.876). For the presence of foetal complications, these patients had an odds ratio (Exp(B)) of 1.533 (95%CI 0.46–5.10), not significant (p = 0.486). For increased neonatal attendance in the neonatal unit, hydrotherapy patients had an odds ratio (Exp(B)) of 0.796 (95%CI 0.29–2.16), not significant (p = 0.655). For the presence of foetal cardiotocographic record (FCRCF) in hydrotherapy patients, the odds ratio (Exp(B)) was 0.561 (95%CI 0.23–1.37), not significant (p = 0.486). The presence of maternal hypotension in hydrotherapy patients was also not significant (p = 0.655) and its odds ratio (Exp(B)) was 1.217 (95%CI 0.46–3.21). Finally, the presence of maternal fever in hydrotherapy patients was also not significant (p = 0.203) and its odds ratio (Exp(B)) was 2.940 (95%CI 0.177–49.01).In the multivariate logistic regression model related to the presence of postpartum haemorrhage, hydrotherapy patients have an odds ratio (Exp(B)) of 2.487 (95%CI 0.75–8.22), although not significant . However, this finding contrasts with other studies, such as Lewis et al. , who fouOur results include information on the effects that the use of hydrotherapy in childbirth can have on maternal health. These findings are supported by other studies in which no adverse effects were observed for the mother ,15,16,17According to the results of two meta-analyses, one conducted by Taliento et al. , includiFurthermore, we found that the use of hydrotherapy is not related to a higher risk of tears, and there is also a lower number of episiotomies in women who use hydrotherapy. These results are supported by our study and other recent studies ,3,20,22.In this study, our results are consistent with previous research on the use of hydrotherapy in relation to maternal outcomes, such as perineal status and maternal infection. In 2014, the American Academy of Pediatrics (AAP) and The American College of Obstetricians and Gynecologists (ACOG) published a clinical report indicating the possible maternal benefits of hydrotherapy during the first stage of labour. However, there was controversy regarding neonatal outcomes in births with the use of hydrotherapy.We can state that, with respect to neonatal outcomes and current scientific evidence, multiple comparative studies between births with hydrotherapy and traditional births have concluded and ensured that water birth is not associated with a higher incidence of adverse neonatal outcomes. Various types of studies from different sources ,18,23,24In our study, we did not find significant differences in Apgar scores between newborns in both groups. This result is consistent with several previous studies ,23,25,26Multivariate analysis was performed due to the large number of variables used in the study, to avoid confounding bias in this type of design. None of the models showed statistical significance for the presence of hydrotherapy. This is highly significant in our study as it indicates that the use of hydrotherapy during labour does not present a greater risk than labour without the use of hydrotherapy for experiencing any of the complications expressed in the study variables.It is important to note that this study was conducted in a specific hospital and its results may not be generalisable to other settings. However, the findings are promising and suggest that hydrotherapy during labour can be a safe and effective option during labour and delivery. Additionally, the use of hydrotherapy during labour may also have additional benefits, such as increasing rates of breastfeeding.In conclusion, the study suggests that the use of hydrotherapy during the first stage of labour is safe and may have additional benefits, such as increased breastfeeding rates.In summary, research on hydrotherapy during labour is ongoing, and more studies are needed to fully understand its safety and effectiveness.


Serum lipids have been proven to influence periodontitis. The atherogenic index of plasma (AIP) is an important marker of lipid levels. The purpose of this study was to investigate the association between periodontitis and AIP in adults.10 (triglycerides/high-density lipoprotein cholesterol). Periodontitis can be classified into four categories based on attachment loss and probing depth . Multivariable logistic regression after adjusting and hierarchical analysis were conducted to investigate the relationship between periodontitis and AIP in adults.The study included participants from the 2009–2014 National Health and Nutrition Examination Survey who received a complete periodontal exam and a complete record of AIP. AIP was calculated as logP < 0.05). Univariate analysis showed that AIP was associated with the incidence of periodontitis (P < 0.05), but not with the severity of periodontitis (P > 0.05) in participants. Multifactorial logistic regression analysis showed no correlation between the incidence of periodontitis and AIP among all participants , but a significant association with AIP in the non-smoking participants .The final sample included 4,371 participants, representing approximately 60 million people in the United States. Periodontitis among the AIP groups  was statistically significant (There was a significant correlation between periodontitis and AIP in the non-smoking population.The online version contains supplementary material available at 10.1186/s12903-023-02853-y. Periodontitis is recognized as a chronic, multifactorial, inflammatory disease caused by the interaction of bacterial biofilms and host response . The disBoth periodontitis and dyslipidemia are major risk factors for cardiovascular disease . High trSerum lipids have been proven to influence the severity of periodontitis, with lipid-mediated inflammatory responses playing an important role , 13. TreTherefore, in the present study, our primary objective was to elucidate the relationship between the presence and severity of periodontitis and AIP in a large nationally representative sample of adults.https://www.cdc.gov/nchs/nhanes.The NHANES, National Health and Nutrition Examination Survey, is a major program of the National Center for Health Statistics that began in the early 1960s, to assess the health and nutritional status of adults and children in the United States. The survey combines household interviews and health screenings to provide comprehensive biological, psychosocial, behavioral, and demographic information free of charge. This cross-sectional analysis was conducted using data from the 2009–2014 cycle of the NHANES. The data were sourced from a database of household interviews and physical examinations. This manuscript followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for human observational studies. Data are de-identified, can be publicly accessed at https://www.cdc.gov/nchs/nhanes/irba98.htm).The study involving human participants were reviewed and approved by the NCHS. The Research Ethics Review Committee approved the NHANES survey protocol. Institutional Review Board approval and documented consent was obtained from participants , periodontitis according to the Centers for Disease Control and Prevention-American Academy of Periodontology (CDC-AAP) periodontitis case definitions  (n = 452Participants were categorized based on the CDC-AAP periodontitis definitions . Based o10 (triglycerides/HDL-C) and represented as a classification variable according to the quartile method.AIP was assessed from a blood sample and calculated as log2) ratio. Participants were categorized into three groups: “never” (lifetime use of < 100 cigarettes), “former” (lifetime use of ≥ 100 cigarettes and no longer smoking), or “now” (lifetime use of ≥ 100 cigarettes and smoking every day or someday)[The basic information of the participants was selected as the covariable for this study. Participants were divided into Non-Hispanic White, Non-Hispanic Black, Mexican American, and other race according to their ethnicity. Participants were divided into two groups, Married/Living with partner and Divorced/Never married/Widowed/Separated, based on whether they currently lived with their spouse. The Annual family income is divided into groups greater than $20,000 and groups less than or equal to $20,000. According to the level of education, participants were divided into three categories, respectively, less than high school level, high school level, and more than high school level. BMI was calculated as the weight (kg) to height squared (m someday). Partici someday).± standard error. Baseline data for study participants were grouped using the AIP quartile. The chi-square test or Student’s t-test was used to determine the P-value of the distribution. Univariate logistic regression was performed to evaluate the correlation between the presence and severity of periodontitis and AIP with other covariates. Furthermore, stratified analysis was used to assess the relationship between the presence and severity of periodontitis and AIP according to age, sex, BMI, smoking, and alcohol consumption. Multinomial regression analyses were conducted to investigate the correlation between the presence of periodontitis and AIP. Models were adjusted for age, sex, BMI, ethnicity, annual family income, education, smoking, and drinking. All statistical analyses in this study were carried out using the R version 4.1.2 (NHANESR package). P = 0.05 was used to determine the statistical significance.The primary objective was to investigate whether the presence and severity of periodontitis were associated with AIP in a large-scale population survey in the United States. All participants were divided into four groups according to the previous classification method of periodontitis: no, moderate, mild, and severe. AIP (continuous variables) was represented by quartiles in the study. Complex data were calculated using descriptive statistics. Categorical variables among covariates were calculated as unweighted frequencies and weighted estimates of overall proportions, and continuous variables were presented as mean P ≤ 0.05) were detected between periodontitis and AIP. Covariates with significant differences included age, sex, BMI, race, marriage, education, smoking, and alcohol consumption.The weighted characteristics of the analyzed samples are shown in Table P > 0.05) but was positively associated with the risk of periodontitis. In addition, the severity of periodontitis was found to be significantly associated with smoking, alcohol consumption, and education level . Groups with low AIP values Q1) were less likely to develop periodontitis than Q2, Q3, and Q4  in the unadjusted model (model 1). While age and gender were adjusted in model 2. The trend P-value in both models was consistent with that in the unadjusted model group, indicating that participants with low AIP values were less likely to develop periodontitis. Notably, after adjusting all covariates in Table  were lesFurther, stratified analyses were performed based on age, sex, BMI, smoking, and drinking Table . In the The most significant differences were found in the 40–50 years age group  in the age-stratified analysis, and the non-smoking patients  in the smoking-stratified analysis. Subsequently, we analyzed the relationship between periodontitis and AIP using multifactorial logistic regression in the non-smoking (Table Periodontitis is the most common oral disease and the sixth most prevalent human disease . TherefoAIP has been used to quantify comprehensive lipid levels as a reliable biomarker of dyslipidemia . StudiesBased on the above information, we concluded that there may be a possible link between periodontitis and AIP. The traditional single-center, small-sample population approach to evaluate the relationship between periodontitis and lipid levels is still controversial and has low predictive value. In contrast, our study could obtain relatively reliable results using data from a national population survey.In our study, AIP was used as four categorical variables. The results of the univariate logistic analysis showed a significant association between the presence of periodontitis and AIP, but not between the severity of periodontitis and AIP. The results of our multifactorial logistic analysis, controlling all covariates, showed no significant relationship between the presence of periodontitis and AIP. To investigate whether this correlation exists in a specific population, we used the stratified analyses and found significant differences in periodontal disease prevalence between different AIP groups among the non-smoking patient group and the 40–50 age group, respectively. After controlling all covariates, multivariate logistic regression showed a significant association between the presence of periodontitis and AIP in the non-smoking population.Our results are similar to the previously reported association between periodontitis and dyslipidemia. A meta-analysis also showed that periodontal disease was associated with hyperlipidemia . Gomes-FWe speculate that in patients with periodontitis, the release of inflammatory mediators from periodontal tissues into the bloodstream may cause systemic low-intensity inflammation, which can adversely affect health . This syAs a result, the findings of the present study provide a theoretical basis for offering information on periodontitis and body lipid levels. The main advantage of this study is that we were able to obtain relatively reliable data and reduce bias by analyzing a large sample of the population. Another advantage of this study is that we obtained more reliable results by determining the relationship between discriminating AIP and periodontitis in different populations through stratified analyses.Despite the study’s novel findings from a large US population sample, it has several limitations. First, because the study used a cross-sectional design, we were unable to determine the complex causal relationship between periodontitis and AIP. Second, it was unable to exclude all confounding factors that could impact the results, such as diabetes, hypertension, arrhythmia, fatty liver, and other diseases that can affect lipid abnormalities. Because retrospective studies are very difficult to accurately diagnose related diseases, this study did not include relevant contents. Third, the reason for the significant correlation between periodontitis and AIP in the non-smoking population needs to be investigated further.The present study found a significant correlation between periodontitis and AIP in the non-smoking population.Below is the link to the electronic supplementary material.Supplementary Table 1. Periodontitis is classified according to the US CDC-AAPSupplementary Table 2. Adjusted multinomial logistic regression of AIP with periodontitisSupplementary Table 3. Adjusted multinomial logistic regression of AIP with periodontitis in a population aged 40-50 years


Current guidelines for obesity prevention and control focus on body mass index (BMI) and rarely address central obesity. Few studies have been conducted on the association between normal-weight central obesity and the risk of diabetes mellitus (DM).26,825 participants from the National Health and Nutrition Examination Survey (NHANES) were included in our study. A weighted multivariate logistic regression model was used to analyze the relationship between different obesity patterns and the risk of DM.Our results suggest that normal-weight central obesity is associated with an increased risk of DM  compared with normal-weight participants without central obesity. When stratified by sex, men with normal-weight central obesity, obesity and central obesity were found to have a similar risk of DM  and a higher risk than all other types of obesity, including men who were overweight with no central obesity  and obese with no central obesity .Our results highlight the need for more attention in people with central obesity, even if they have a normal BMI. Witinal fat . People inal fat . In addiThe aim of this study was to evaluate the association between different combinations of BMI and WC and the risk of DM, and to obtain quantitative data on the risk of normal-weight central obesity by using normal-weight without central obesity as a reference. Our hypothesis was that normal-weight central obesity increases the risk of developing DM compared to normal-weight without central obesity.2.2.1.The study design of the National Health and Nutrition Examination Survey (NHANES) has been reported in detail in previous literature , 23. In 2; (3) Participants had available BMI and WC data; (4) The participants’ diabetes status was clear (yes or no). Finally, a total of 26,825 participants were included in the study.The study included participants from NHANES over five periods from 2009 to 2018. The criteria for inclusion are: (1) Age ≥ 18 years; (2) BMI ≥ 18.5 kg/m2.2.2. The weight and height were measured by trained NHANES personnel. The weight was measured using a portable electronic scale with an accuracy of 100 g and the height was measured using a tape measure with an accuracy of 0.1 cm. WC was measured in a standing position. The operator first palpated and located the bilateral iliac crest, placed the tape measure horizontally on the iliac crest, and gently attached it to the skin surface without compressing the skin. When the participant is in the minimum breathing stage, the data recorded by the tape measure is WC. Measurements of BMI and WC were recorded to the nearest 0.1 unit. BMI was divided into 3 categories: (1) normal weight (BMI: 18.5–24.9), overweight (BMI: 25–29.9), and obese (BMI ≥ 30.0) , smoking history, drinking history, hypertension status, and hyperlipidemia status. Smoking history included current smokers, never-smokers, and former smokers. Drinking history included never/mild drinkers, moderate drinkers, and heavy drinkers. Participants were considered to have hyperlipidemia if: Self-reported hyperlipidemia, taking lipid-lowering medications, total cholesterol ≥ 200 mg/mL, triglycerides ≥ 150 mg/mL, LDL ≥ 130 mg/mL, or HDL ≤ 40 mg/mL in male and ≤ 50 mg/mL in female . Partici2.5.The overall goal of the study was to assess the effects of different categories of BMI and central obesity on the risk of DM. Therefore, a weighted logistic regression analysis was performed on 26,825 participants to obtain quantitative data on the risk of DM for different types of obesity. Since NHANES is a study with a complex stratified sampling design, corresponding weights were used for statistical analysis. For categorical data, weighted percentage (%) was used, whereas for continuous variables, weighted mean and 95% confidence interval (CI) were used. To investigate the relationship between different patterns of obesity and DM risk, we created a multivariate logistic regression model and adjusted for potential confounders, which included age, sex, race/ethnicity, etc.We assessed whether these relationships varied by age (<50 vs. ≥50), race (nonwhite vs. white), education (under college vs. college or above), smoking status (never vs. ever), alcohol status (mild or never vs. heavy or moderate), hypertension status (yes vs. no), and hyperlipidemia status (yes vs. no). The association between BMI and WC is different in men and women  . Therefop < 0.05 was statistically significant.All statistics were performed using Stata, version 15.1 . All tests were bilateral, and 3.p < 0.001). Most of the participants were non-Hispanic white (65.1%), with education above high school (85.1%). The prevalence of hypertension and hyperlipidemia was 37.2 and 70.5%, respectively. In general, central obesity was associated with an increased prevalence of hypertension and hyperlipidemia compared with non-central obesity across the BMI categories. Baseline characteristics of participants in different combinations of BMI and WC can be obtained in The average age of the 26,825 participants included in the study was 47 years old, and 690 (2.6%) of them were normal-weight central obese. Of the 26,825 participants, 7,740 (28.9%) had normal BMI, 8,786 (32.8%) were overweight and 10,299 (38.4%) were obese. According to the World Health Organization’s criteria for defining central obesity, 15,251 (56.9%) participants had central obesity. In contrast, when BMI was used as a measure of overweight or obesity, the detection rate of overweight and obesity was 71.1%, higher than the prevalence of central obesity (56.9%). Correlation analysis showed that WC was significantly correlated with BMI  have a decreased risk of diabetes , while obese non central obesity women (n = 24) have an increased risk of diabetes .4.The results of this large cross-sectional study, which included 26,825 participants from 2009 to 2018, showed that participants with normal-weight central obesity were at an increased risk of developing DM. When stratified by gender, it was found that men with normal-weight central obesity and obesity and central obesity had a similar risk of DM, and the risk was higher than that of men with any combination of BMI and WC, including men with overweight and no central obesity and men with obesity and no central obesity. In addition, the results of the receiver’s operator curve suggest that WC may be a better predictor of DM than BMI.Some previous literature has reported the association between WC and BMI and the risk of DM, but few studies have investigated the risk of DM in normal-weight central obesity. A cohort study of 3,001 previously diabetic-free participants reported that both WC and BMI were related to an increased risk of type 2 diabetes (T2D) after a median follow-up of 4.7 years, and that BMI was more effective than WC in predicting the occurrence of T2D . This isThe following reasons may explain why participants with normal-weight central obesity have an increased risk of DM. Firstly, the accumulation of visceral adipose tissue may be an explanation. The accumulation of visceral adipose tissue may have implications for the development of obesity-related diseases, such as diabetes, cardiovascular disease, and some cancers . And visOur conclusions have important public health and clinical value. First, in the current guidelines, BMI is still the standard index to measure obesity clinically, and individuals with normal BMI are classified as normal in practice regardless of their WC. In the recent joint guidelines for obesity management from the American College of Cardiology, the American Heart Association, and the Obesity Society, waist measurement is recommended for individuals who are overweight or class I obesity to assess the risk of obesity-related comorbidities, and not for individuals with a normal BMI because there is insufficient evidence that such individuals increase the risk of obesity . The gui4.1.To the best of our knowledge, this is the first cross-sectional study to comprehensively assess the association between different types of obesity and the risk of DM. We used nationally representative standardized data from the NHANES database, which increased the stability of our results. In addition, WC is a simple and reliable measure of visceral fat accumulation, which increases the general applicability of our results. However, our study has the following limitations: First, due to the cross-sectional design of this study, a causal link between obesity and DM cannot be inferred. Second, some of the participants’ diabetes diagnoses were based on self-reporting, which may lead to recall bias. Third, the sample size of obese women with no central obesity is small, which may affect the stability of our results to some extent. In general, a larger BMI is often associated with a larger WC, so obesity without central obesity is not common in the population. The number of obese women with no central obesity included in the analysis was only 24, so the results have a relatively wide 95% CI and must be interpreted with caution. In future studies, more attention can be paid to the obese without central obesity population to investigate their risk of developing metabolic diseases.5.The results of our cross-sectional study showed that participants with central obesity of normal weight had a higher risk of developing DM. When stratified by sex, men with normal-weight central obesity, obesity and central obesity were found to have a similar risk of DM and an increased risk than men with any combination of BMI and WC, including men who were overweight with no central obesity and obese with no central obesity. Our results highlight that BMI alone cannot distinguish the distribution of adipose tissue, and that even in people with normal BMI, the risk of DM may be increased due to excessive accumulation of abdominal fat. The exact mechanism between different types of obesity and a higher risk of DM needs to be clarified with larger sample sizes and more well-designed prospective studies.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Research involving human participants were approved by the National Center for Health Statistics (NCHS) Research Ethics Review Board. The participants provided written informed consent to participate in this study.XSJ designed the study, analyzed the feasibility of the study, and wrote the manuscript of the paper. QYC, JHL, GFW, and LHL extracted the data. SJ, XZ, and ZQL collated and merged the data. JJL conducted the statistical analysis, drew figures and tables. ACY reviewed the manuscript, provided critical scientific input, and checked the whole process of the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Mastitis is an important disease that can reduce milk production and farmer income as well as negatively affect human health. This study aimed to summarize dairy mastitis in Indonesia, both subclinical mastitis (SCM) and clinical mastitis (CM), and its prevalence in different provinces, the diagnostic methods, and the animal species.Relevant studies on mastitis in dairy animals in Indonesia were obtained from PubMed, Scopus, ProQuest, Google Scholar, and Garuda. The title and abstract were screened for the eligibility of the studies. The full text of the selected studies was assessed and the data were extracted for analysis. To determine the pooled estimate of the prevalence of mastitis, a random-effects model was performed using the “Meta” and “Metaphor” packages in the R software version 4.2.2. The heterogeneity of several characteristics  was evaluated through subgroup meta-analysis. Meta-regression analysis was conducted to assess the trend of mastitis prevalence reports over time. Publication bias was evaluated using Egger’s test and a funnel plot.A total of 735 studies were retrieved for the title and abstract screening, which resulted in the final selection of 37 studies with a total of 6050 samples for meta-analysis. The pooled estimate of mastitis prevalence in dairy animals in Indonesia was 59.44% . Based on mastitis type, SCM had a significantly higher prevalence than CM . No significant difference was observed in the analysis of other subgroups. Among provinces, Central Java had the highest prevalence , whereas Yogyakarta had the lowest . Based on animal species, cow and goat had a prevalence of 63.42%  and 44.96% , respectively. Based on the diagnostic method, the California mastitis test resulted in 60.08%  and the Institut Pertanian Bogor test, 56.00% . No significant change in the prevalence of mastitis in Indonesia was observed from 2003 to 2022.This study demonstrates that the pooled estimate of mastitis prevalence in dairy animals in Indonesia is >50%. Based on subgroup analysis, SCM had a higher prevalence than CM; however, the prevalence between provinces, detection methods, and animal species in the 2003–2022 periods was not significantly different. A mastitis control strategy needs to be developed to reduce the prevalence of mastitis and further loss in milk production. In developing countries such as Indonesia, mastitis is one of the most prevalent and costly diseases in the dairy industry; it reduces milk production, alters milk quality, and eventually reduces farmers’ income , 2. MastStaphylococcus spp., Escherichia coli, Campylobacter, Yersinia, and Salmonella [The milk production in Indonesia cannot fulfill the national demand. It provides only approximately 22.7% of the national consumption, causing Indonesia to rely on >75% of imported milk . On the lmonella . Thus, met al. [Sudarwanto et al.  reportedThis study used data from previous reports. No animal or animal product was used in this study, so ethical clearance was not required.The literature search and analysis were conducted from December 2022 to January 2023. The study was conducted using selected articles reporting dairy mastitis in Indonesia published between January 2003 and December 2022 . IndonesBefore the study, a protocol was prepared as per the guideline of Open Science Framework (OSF) (https://osf.io/u9egh/) and Systematic Reviews for Animals and Food (SYREAF) (https://syreaf.org/protocols/). PubMed, Scopus, ProQuest, Google Scholar, and Garuda were systematically searched for the literature using medical subject headings terms “mastitis,” “subclinical mastitis,” “clinical mastitis,” “dairy,” “cattle,” “goat,” “buffalo,” “ruminant,” and “Indonesia” that were combined or separated using “AND”/”OR.” The selection was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Guidelines . Figure-The selection of articles for the meta-analysis was based on the following criteria: (1) cross-sectional study; (2) peer-reviewed original articles or conference proceedings; (3) clearly stating the prevalence of dairy cattle, goat, or buffalo mastitis; (4) having a minimum of 30 samples; (5) published in English or Bahasa Indonesia; and (6) providing data of mastitis in dairy animals in Indonesia. Reports regarding the investigation of the antimicrobial resistance of mastitis-causing bacteria, knowledge of farmers on mastitis, duplicate publication or extension of the analysis from the original studies, and incomplete studies were excluded from the review process. The screening of the title and abstract in Rayyan–Intelligent Systematic Review (https://www.rayyan.ai/) included 45 reports published from 2003 to 2022 in the second eligibility screening using full text articles. A total of 37 studies met the inclusion criteria after the second screening. Most of the studies (n = 23) provide the prevalence of an animal basis, whereas the others (n = 14) present a quarter-basis.Conflicts in the screening process were solved through discussion between the two reviewers until reaching an agreement. The extracted data consisted of author name, year, location of the study, detection method, animal type, sample size, and total prevalence of mastitis , and all data were collated into predesigned Microsoft Excel sheets .et al. [Study quality was evaluated using a checklist with a scoring based on a simple scale system following Ding et al. . The risThe meta-analysis was conducted using the R software version 4.2.2  using the “Meta” and “Metaphor” R packages . The obtSubgroup analysis was conducted by identifying the heterogeneity of mastitis prevalence in four predefined groups: Province, mastitis type (SCM or CM), animal type (cow or goat), and diagnostic method. For the diagnostic method subgroup meta-analysis, only the California mastitis test (CMT) and the Institut Pertanian Bogor 1 (IPB-1) test were included in the analysis. Due to their high sensitivity and specificity, these are the most commonly used methods in mastitis detection , 16. If et al. [Meta-regression was conducted to assess the secular trend in the publication year of the study of mastitis prevalence in Indonesia following Loiklung et al. . The pubThe robustness of the pooled estimate of mastitis prevalence was verified through mixed-model calculations to compare the result of a fixed-effect model with that of a random-effects model (a model of choice). Leave-one-out meta-analysis was also conducted to determine if each study disproportionately influenced the study results.The risk of publication bias was assessed using Egger’s test with p < 0.1 as an indicator of publication bias . A funneA total of 735 studies were retrieved and subjected to the screening process, including 37 studies with 6050 samples, ranging from 30 to 592 in the selected articles. The scoring rate of the study quality assessment is presented in 2) index value was 98%. The forest plot . This study found a significant heterogeneity  between 37 studies. The heterogeneity  and Riau (26.67%), were excluded due to the limited number of studies; thus, only data from four provinces, all in Java Island, were analyzed. The prevalence of SCM was significantly higher than that of CM  . The preBased on the meta-regression analysis, the mastitis prevalence was not significantly different in terms of the publication year (p = 0.48), with a positive increase trend of the equation: Y = −10.39 + 0.005*Year. It revealed that publications between 2003 and 2022 had similar prevalence.et al. [et al. [The calculation using the fixed-effect and random-effects models showed similar results . As the results indicated the robustness of both models, we chose the random-effects to be used in our study. The results of the leave-one-out meta-analysis indicated slight changes in the overall pooled estimate of mastitis prevalence in Indonesia. The prevalence was the lowest at 58.65%  if the study by Nisa et al.  was remo [et al.  was exclThe result of Egger’s test showed p = 0.74, which does not indicate severe publication bias.The results of this study provide baseline information on mastitis prevalence in dairy animals in Indonesia. The pooled estimate of mastitis prevalence was 59.44% , dominated by reports from Java Island with more SCM than CM cases. Our pooled estimate of prevalence was higher than that in China (37.7%)  and EthiThe high prevalence of SCM in Indonesia indicates that more than half of dairy milk distributed in Indonesia contains high SCC or microorganisms that could alter milk quality. This could be attributed to intrinsic  or extrinsic  factors . In IndoIn our analysis, most of the studies of mastitis in dairy animals were conducted in four provinces on Java Island, where 97% of dairy farms are located . Among tAlthough the farm management of dairy cows and goats is similar, cows had a higher mastitis prevalence (66.42%) than goats (44.96%). The difference was not statistically significant (p = 0.05). The insignificant difference in statistics could be altered by the small number of study on goats compared with cows , increasing the standard error in the study on goats. If more studies of goat mastitis are included, their difference will become significant. A similar pattern has been reported in the study by Hasan , which sIn Indonesia, mastitis in dairy animals is commonly detected using the CMT and IPB-1 test, which provide easy and fast results. Based on these methods, mastitis prevalence was not significantly different. This implies that both methods equally provide a good representation of mastitis condition. The CMT and IPB-1 test have similar principles in mastitis detection; both detect SCC within the milk by implementing viscosity changes after the cell reacts with the reagent , 16. ComThis study has some limitations. First, most of the studies were conducted in only four of the 36 provinces in Indonesia. Although there were reports from other provinces, two provinces in Sumatra Island were excluded from the subgroup province meta-analysis due to the limited number of mastitis studies. Considering these four provinces represent >90% of the dairy population, our result may represent the national condition. The results of this study should be used to improve dairy farm management practices and develop a mastitis control strategy to eventually alleviate the economic loss. However, only dairy cows and goats were included in the animal species subgroup analysis, as studies on dairy buffalo were lacking. Furthermore, we only used the CMT and IPB-1 test for the diagnosis because they are the most common methods for indirectly detecting mastitis. Other diagnostic methods, such as mastitis paper, detergent, and breed tests were excluded due to lack of reports.This study shows the pooled estimate of mastitis prevalence in dairy animals in Indonesia. Based on the subgroup analysis, SCM had a higher prevalence than CM, but the prevalence based on provinces, animal species, and detection methods is not different. The prevalence had a similar trend from 2003 to 2022. A mastitis control strategy needs to be developed to reduce mastitis prevalence and further loss in production.All authors participated in the study design. DMN and MA: Collected, selected, and analyzed the articles. PS: Rechecked the meta-analysis and result. DMN, MA, PS, and PP: Drafted the manuscript. All authors have read, reviewed, and approved the final manuscript.


Frequency distributions, prevalence and statistical differences were analyzed using Pearson’s chi-square test. of the 8,716 notifications, most occurred in the state capital (48.2%) and related to female victims (82.2%) aged between 10 and 14 years (38.1%). There was a higher prevalence  and relative frequency of rape (84.5%), sexual exploitation (5.8%) and neglect/abandonment (4.6%) among victims of Black race/skin color . Only 4.6% of notifications occurred in primary health care services. notifications were more frequent among female pre-adolescents and prevalence was higher among Black people, who should be a priority target for protective measures. Surveillance of this form of violence needs to be strengthened in primary care. Prevalence of sexual violence against children and adolescents is high in Brazil and there are many challenges to be addressed.The involvement of a child or an adolescent in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child or adolescent is not developmentally prepared.In Brazil sexual violence is classified according to the following categories: (i) sexual harassment, defined as inappropriate insistence, regardless of sex or sexual orientation, with questions, proposals, pretensions or any other form of forced approach of a sexual nature; (ii) rape, which consists of compelling someone, by means of violence or serious threat, to have sexual intercourse or to practice or allow other libidinous acts to be practiced with them; (ii) child pornography, which includes the presentation, production, sale, supply, dissemination and/or publication of photographs or images with pornography or explicit sex scenes involving children or adolescents, using any means of communication; and (iv) sexual exploitation, characterized by the use of people, regardless of age, sex or gender identity, for commercial and profit purposes, whether for the practice of prostitution, or for exposing naked bodies and sexual intercourse, either live or through published images.Cases of sexual violence against children and adolescents are often underreported by the authorities responsible for this, mainly due to silencing of victims, motivated both by fear of the aggressor and by fear of not being believed by family members.Estatuto da Criança e do Adolescente - ECA), enacted in 1990, guarantees protection from all forms of negligence, discrimination, exploitation, violence, cruelty and oppression, and in this sense, this law made it mandatory to notify suspected or confirmed cases of abuse against children and adolescents.Sistema de Vigilância de Violências e Acidentes - VIVA), created in 2006, was the first initiative to systematize data on violence in the country. As of 2009, the component related to the surveillance of cases of domestic, sexual and/or other interpersonal and self-inflicted violence was integrated into the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação - SINAN), already consolidated nationwide at that time.The Child and Adolescent Statute  in 2010. In that year, 3,105,241 children and adolescents accounted for 29% of the state’s total population.The state of Rio Grande do Sul consists of 497 municipalities and has a population of 10,693,929 inhabitants, according to the most recent demographic census, carried out by the Brazilian Institute of Geography and Statistics , which is the service responsible for developing state health surveillance policies. The competencies and responsibilities of the CEVS/RS were defined by Decree 44.050, dated October 5, 2005.Ficha de Notificação Individual - FNI), available in more detail on the following website: http://portalsinan.saude.gov .br/notificacoes. The FNI is composed of variables, grouped together in blocks, which were collected and reorganized for the purpose of our analysis.SINAN data are published in the state by the Rio Grande do Sul State Health Surveillance Center  Characteristics of the victims- age group ;- sex ;- race/skin color ; and- disability  or disorder  ;b) Characteristics of the aggressors- sex ;- relationship to victim  - the “other” category required mandatory specification, in writing, and was able to be analyzed separately; some of these data were grouped into categories already defined on the FNI, while others generated new categories, such as “blood relative” , “school/carer”  and “non-blood relative” ;- life cycle of the victim ;- recurrence ;- type  - the “other” category was answered in full and, after analyzing each notification, one by one, some of the data were grouped into the four other categories; prior to 2015, the FNI had a fifth category, “violent indecent assault” (atentado violento ao pudor - AVP), which, after the enactment of Law No. 12.015, dated August 7, 2009, became the crime of rape;- co-occurrence ;d) Distribution of the notifications- municipality of notification ; and- type of notifying service .Data source and measurementWe used secondary data from the SINAN, provided by the CEVS/RS, extracted in April 2020 (for the period from 2014 to 2017) and in July 2022 (for 2018). The data made available showed all types of violence against women and men, of all ages. For the purposes of this study, first of all we separated data on sexual violence and then the data in this category relating only to individuals under 19 years old.),. Differences between groups were analyzed using Pearson’s chi-square test. The prevalence of notifications of sexual violence against children and adolescents was obtained as follows: the total number of notifications in the five-year period analyzed, 2014-2017, was divided by the total number of children and adolescents residing in the state . We also calculated notification prevalence, disaggregated by race/skin color, dividing the number of notifications of White or Black victims, referring to the period 2014-2017, by the population of White and Black children and adolescents residing in the state , with a correction factor of 1.04. We chose not to include notifications relating to Asian or Indigenous race/skin color in the analysis, given their low prevalence in the state We described the percentage distribution of notifications by municipality and by type of notifying services. We also calculated notification prevalence according to major municipality , as follows:Ethical aspectsCertificado de Apresentação para Apreciação Ética - CAAE) No. 69992817.5.3001.5312. It was also approved by the Universidade Federal do Rio Grande do Sul Teaching and Research Center, as per Opinion No. 3.999.164, issued on April 19, 2020 (CAAE No. 69992817.5.0000.5347).The research project was approved by the Escola de Saúde Pública Health Research Ethics Committee, an institution linked to the Rio Grande do Sul State Health Department, as per Opinion No. 5.497.842, issued on July 29, 2022, and Certificate of Submission for Ethical Appraisal  victimized children and 4,751 (42.8%) adolescents, totaling 8,716 (78.5%) cases, which represents a prevalence of 281 notifications of sexual violence per 100,000 children and adolescents residing in the state. Most notifications of sexual violence against these children and adolescents related to victims of White race/skin color (78.5%) . The preNotification frequency was higher in the 10-14 age group, and among victims of Black race/skin color, for whom frequency was 42.9%; while among victims of White race/skin it was 36.8%. There was a predominance of female victims (82.2%), in both race/skin color groups. 9.3% and 11.9% of victims of White and Black race/skin color, respectively, had a disability or disorder  .With regard to the aggressors, the majority were male (94.5%), adults (59.3%) and friends/acquaintances of the victims (27.4%), blood relatives (18.2%), father/mother (16.8%) or stepfather/stepmother (14.5%), with no significant differences in relation to the victims’ race/skin color. There was a higher frequency of notifications involving two or more aggressors among victims of Black race/skin color (17.7%) when compared to those of White race/skin color  .As for the place of occurrence, the home of the victims was predominant (76.6%), and this was not related to race/skin color. Recurrence of sexual violence, that is, when the violence was perpetrated more than once against the same victim, accounted for more than half of the cases (60.2%), among children and adolescents of both races/skin colors .The most frequent type of violence was rape (82.9%), followed by sexual harassment (27.2%). The relative frequencies of rape and sexual exploitation were higher among victims of Black race/skin color , when compared to victims of White race/skin color , while sexual harassment was more frequent among victims of White race/skin color, compared to those of Black race/skin color . The main co-occurrences were psychological/moral violence (30.4%) and physical violence (15.8%). Co-occurrence of neglect/abandonment was higher among victims of Black race/skin color (4.6%) when compared to those of White race/skin color  .The city of Porto Alegre, the state capital, had the highest number of cases , followed by Caxias do Sul , Gravataí , Canoas  and Santa Maria . Of the state’s 497 municipalities, 291 (58.5%) had less than 50 notifications and 189 (38.0%) had no notifications, over the five years studied Box 1; . Among tMost of the notifying services were hospitals (62.5%), in particular reference hospitals for comprehensive care for people in situations of sexual violence, which accounted for more than half (56%) of the notifications. The other notifying services were primary health care facilities , which accounted for 4.6% of notifications, and emergency care services, medical outpatient clinics, polyclinics and medical specialty centers, among other health and social services establishments, which accounted for 32.9% of the notifications.Notifications of sexual violence in Rio Grande do Sul, during the period studied, were more frequent among children and adolescents. There was a predominance of (i) pre-adolescent female victims and (ii) adult male aggressors, friends/acquaintances or relatives of the victims, for both race/skin color groups analyzed. Occurrences of sexual violence were more frequent at home, with co-occurrence of psychological/moral violence being most reported. We found higher prevalence and higher relative frequency of rape, sexual exploitation and co-occurrence of neglect/abandonment in victims of Black race/skin color; sexual harassment was more prevalent and frequent against people of White race/skin color. Considering the municipalities of Rio Grande do Sul individually, notifications were mainly concentrated in Porto Alegre; most of the other municipalities in the state had no or few notifications in the five-year period, with Alvorada and Pelotas standing out with the lowest case prevalence. More than half of the notifications were made by reference hospital services for people in situations of sexual violence, while in primary health care services recording of these occurrences was scarce.Although the study was based on official notification data, it is possible that the results do not represent the actual frequency of the event because they included both confirmed cases and suspected cases of violence, which is a limitation. The SINAN data derives from the input of notification forms, filled in by health service professionals, which does not exclude the possibility of information bias. Another limitation of the study refers to the quality of the database, which was directly affected by the high percentage of variables not filled in or filled in as “unknown”, in addition to the exclusion of the “Asian” and “Indigenous” race/skin color categories and the grouping of the “Black” and “mixed race” categories into one, namely “Black”, resulting in only two categories in the study: i.e. “White” and “Black”. However, these populations that were grouped together or excluded deserve greater attention in research on sexual violence, making it important to conduct future studies targeting each of them, even though they are a small part of the general population.,,-,- indicated that the victims are mostly raped by a man, either a relative or an acquaintance, within their own home, which makes it difficult to reveal what happened and contributes to its being underreported.Other studies evaluating the records of sexual violence notified on the SINAN, in addition to police and security force incidents, in recent years, show that in Brazil the frequency of pre-adolescent female victims and victims in age groups corresponding to adolescence is higher.),16-(machista) model, which considers women and children as being the property of men.These results are related to cultural factors based on the dominant male identity, for which the conception of family is influenced by a patriarchal and male chauvinist (conselhos tutelares) and social service reference centers  in the municipality of Feira de Santana, state of Bahia, beween 2001 and 2010, also found that psychological violence was the event most frequently associated with sexual violence.We found a considerable amount of co-occurrence of psychological/moral violence. A case series study that analyzed records of sexual violence and co-occurrences, collected from guardianship councils  in 2015, identified Alvorada as the only municipality in the state of Rio Grande do Sul appearing in the ranking of the most violent municipalities in Brazil, and the municipality of Pelotas as one of those with the highest homicide rates.With the exception of the state capital, Porto Alegre, which concentrated most of the notifications, most municipalities in Rio Grande do Sul had very low numbers of sexual violence; in particular Alvorada and Pelotas had the lowest prevalence rates in the five-year period analyzed. These numbers do not necessarily imply low frequency of sexual violence against children and adolescents. A descriptive study that assessed violent crime in Brazilian municipalities based on national data from the Mortality Information System . We recommend that protection measures aimed at these groups in health services be strengthened. The distribution of notification frequency was low in PHC services, pointing to the need to strengthen surveillance in these services, especially in municipalities with higher rates of violence.


Based on existing systematic reviews and meta-analyse we conducted this comprehensive review to evaluate the quality, effectiveness, and bias of evidence regarding the relationship between probiotic intake and improved constipation outcomes in children. A total of nine meta-analyses and systematic reviews were extracted from 628 articles, summarizing seven effectiveness indicators and the incidence of adverse reactions in the treatment of constipation. According to the results, our study revealed that the intake of probiotics in children with FC significantly improved treatment success rate and defecation frequency, while decreased the recurrence rate of constipation. However, no significant association was detected between probiotics intake and frequency of abdominal pain, stool consistency, frequency of defecation pain, frequency of fecal incontinence of children with FC. The intake of probiotics did not increase the incidence of adverse reactions and demonstrated good safety. Constipation is a common childhood symptom, with functional constipation (FC) accounting for over 95% of all constipation cases . AccordiLactobacillus acidophilus, Bifidobacterium lactis, and L. brevis  independently conducted the literature search. Any disagreements between the two researchers in terms of article selection were resolved by a third investigator (CPJ). Details of the search strategy are provided in We searched systematic reviews and meta-analyses of observational studies and interventional studies from the databases of PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure from their inception to January 6, 2023. The search strategy used a combination of the following terms: constipation AND probiotic, prebiotics, synbioticsMeta-analyses and systematic reviews evaluating probiotic intake and constipation in children with outcomes in children were included regardless of the race, gender, country, or region of the participants. Based on these studies, indicators of effectiveness and safety were summarized. If two or more constipation outcomes existed in a single article, the data of each outcome were extracted separately. If one outcome was assessed in more than one study, articles with the largest number of participants were included. Research with unrelated research content, design that was not meet standards, or incomplete research data were excluded.Two authors (DMY and WYT) independently extracted data, and disagreements were resolved by consensus. The following data were extracted from the eligible studies: name of the first author; journal; year of publication; type of comparisons; type of studies included ; number of primary studies; follow-up time; number of participants in each study; estimated summary effect and corresponding 95% confidence intervals (CIs); outcome. Any difference was resolved by the third investigator (CPJ).The methodological quality of each article was evaluated based on AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) items, which is a reliable strategy for evaluating the quality of systematic reviews and meta-analyses . The GRAI2 statistics. Values <50% indicated acceptable heterogeneity, values >50% suggested moderate heterogeneity, and values >75% were indicative of high heterogeneity . Heterogeneity between studies was assessed using ogeneity . Egger’sr’s test .In additThe detailed process of literature retrieval and selection is presented in The associations analyzed included seven clinical effect outcomes and one adverse event. The effectiveness indicators of probiotic preparations in the treatment of FC in children were reported in the nine included articles and included the following: treatment success rate, defecation frequency, frequency of abdominal pain, stool consistency, frequency of defecation pain, frequency of fecal incontinence, and recurrence rate. The incidence of adverse reactions was analyzed in terms of safety .p < 0.0001)  . Most of 109 CFU . Two RCTchildren , 33.p = 0.02), however, there was significant heterogeneity . Subgroup assessments showed that Asian children had a significantly higher stool frequency with probiotic treatment   . Therefop = 0.04). Gomes et al. (p = 0.017) of abdominal pain was found in a treatment group compared with that in a control group. The remaining four studies showed that there was no significant difference in terms of reducing the incidence of abdominal pain between probiotic treatment groups and control groups. There was no significant difference between the control and probiotic groups in the frequency of abdominal pain at the end of the intervention   .p = 0.27) (Three studies  showed t = 0.27) .p = 0.41) (n = 108) , heterogeneity was considerable   . Pooled n = 108) , 33 showχ2 = 0.32; p = 0.57; I2 = 0%) ; no significant heterogeneity was found   . Based oI2 = 0%) , 33.Four studies , 28, 32 χ2 = 1.01; p = 0.6; 2I = 0%). The most frequently occurring adverse events were abdominal pain, vomiting, and gastroenteritis.Adverse events were similar in the experimental and control groups . No significant heterogeneity was found , and another 4 had significant heterogeneity (>50%). Four studies of included studies were reported to have significant publication bias, whereas this was not detected in the other five studies.The AMSTAR 2 results for each study are presented in Probiotics are often used in the clinical treatment of constipation in children, and many meta-analyses and systematic reviews of their efficacy have been conducted. On this basis, we conducted an umbrella review to analyze whether probiotics can improve constipation in children. We analyzed a total of nine meta-analyses and systematic reviews and summarized seven indicators of effectiveness in treating constipation. According to the results, our study revealed that the intake of probiotics in children with FC significantly improved treatment success rate and defecation frequency, while decreased the recurrence rate of constipation. However, no significant association was detected between probiotics intake and frequency of abdominal pain, stool consistency, frequency of defecation pain, frequency of fecal incontinence of children with FC. The incidence of adverse reactions was low and the safety was good when consuming probiotics. These results suggest that probiotic intake did improve constipation in children, although they cannot improve some symptoms of constipation in children.As we know, probiotics can regulate the gut microbiota. Intestinal microecology consists of intestinal microbiota, intestinal epithelial cells, and intestinal mucosal immune system . The gutBifidobacterium and Lactobacillus. There is still controversy internationally about whether probiotics are needed for children with FC, and some research results indicate that probiotic preparations have an improvement effect on children with FC. In the study of probiotic therapy for FC in children, most studies have heterogeneity in terms of study population, probiotic strains, dosage, study duration, and follow-up. Tabbers et al. , and Alistipes finegoldii (decreased)  . Althougcreased) . Therefocreased) , 46. Pro numbers . On the  numbers , 51. Sec numbers . The mec numbers , 54. Oppid, etc. . SCFAs ce mucosa , 57. Thie mucosa , 59.As fe mucosa , 18. HowSeveral limitations exist in our study. First, only two of the included studies were classified as high quality according to the AMSTAR-2 method due to most meta-analyses being based on observational studies. Second, differences in the type, dosage, and duration of probiotic use may have affected the research results. Third, the diet and physical condition of children may affect the therapeutic effect of probiotics. Finally, the simultaneous use of other drugs can also affect the outcome of treatment. In studies on probiotic therapy in children, the sample size is generally not large enough, which may also have affected our conclusions. Considering this study’s shortcomings, further high-quality research on this topic is needed.MD and YW conducted this research and wrote the paper. SW and MZ designed the study and had primary responsibility for final content. PC and ZZ provided essential materials and analyzed data. All authors contributed to the article and approved the submitted version.This study was supported by 345 Talent Project of Shengjing Hospital of China Medical University.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.


Trypanosoma cruzi and Leishmania spp. infections. In this scenario, it is worth highlighting a group of natural peptide molecules (AMPs and CPPs) that are promising strategies for improving therapeutic efficacy against these neglected zoonoses, as they avoid the development of toxicity and resistance of conventional treatments. This review presents the novelties of these peptide molecules and their ability to cross a whole system of cell membranes as well as stimulate host immune defenses or even serve as vectors of molecules. The efforts of the biotechnological sector will make it possible to overcome the limitations of antimicrobial peptides through encapsulation and functionalization methods to obtain approval for these treatments to be used in clinical programs for the eradication of leishmaniosis and Chagas disease.In 2020, the WHO established the road map for neglected tropical diseases 2021–2030, which aims to control and eradicate 20 diseases, including leishmaniosis and Chagas disease. In addition, since 2015, the WHO has been developing a Global Action Plan on Antimicrobial Resistance. In this context, the achievement of innovative strategies as an alternative to replace conventional therapies is a first-order socio-sanitary priority, especially regarding endemic zoonoses in poor regions, such as those caused by  Leishmania and Trypanosoma comprise a diverse group of unicellular eukaryotic species that are distributed worldwide and are responsible for serious infections in animals and humans. Chagas disease is a zoonosis that is expanding from the Americas to countries around the world because of migratory patterns. Although the disease can be resolved in the acute phase, the development of the chronic phase can lead to complications from cardiomyopathy, arrhythmias, and megaviscera in 40% of cases. As expected, this fact has a significant effect on morbidity and mortality in the local population  and [Lys]3-M-PONTX-Dq3a[1-15]) have been demonstrated to possess trypanocidal activities similar to those of the parent peptide against all three forms of the T. cruzi Y strain but with lower toxicity, better bioavailability, and a lower cost of production 11f action . Anotheroperties . Tachyplo-Padrón , the epic364-282 . The pepal agent . The pepan cells . It has  leakage . Pyllose than Bz . The pepe manner ,139. It e manner . In addid lysine . TemporiThe development of safe, effective, and efficient therapies and vaccines depends on the selection of appropriate biological models and a proper understanding of the advantages and limitations of these models since a well-designed biological model provides a solid foundation for supporting good science and ensuring the most beneficial use of resources. Biological models include in vitro, ex vivo, and in vivo animal models that, in the case of infectious disease research, are intended to emulate the biological phenomenon of interest for a disease occurring in a human or animal. Biological models of infectious diseases, such as leishmaniosis and Chagas disease, allow in-depth research on the molecular mechanisms of the pathology, high-throughput studies on new drugs and genetic targets, and the visualization of the specific effects of new molecules on these microorganisms. Therefore, these models allow scientists to obtain a complete overview of these diseases and perform detailed and efficient studies of possible diagnostic methods and new therapeutic alternatives.https://www.atcc.org/; accessed on 1 June 2023).Over the years, several types of cell line and primary cell cultures have been used to determine the cytotoxic activity of new molecules in vitro. Leishmania spp. and T. cruzi parasites, the most recommended cell types to model the effects of therapies against both parasite species are those isolated from humans, such as U-937 tissue monocytes, because these cells meet the parasites at the site of the insect vector’s bite. Additionally, for T. cruzi, other recommended cells include the Homo sapiens aorta smooth muscle fibroblast-like cell line T/G HA-VSMC (ATCC® CRL 199TM), the Homo sapiens normal esophagus epithelial cell line Het-1A (ATCC® CRL-2692™), and the Homo sapiens normal colon epithelial cell line FHC (ATC® CRL-1831™) because these are tissues for which the different strains of T. cruzi exhibit tropism.Nonetheless, considering the biology of the Homo sapiens liver epithelial-like cell line Hep G2 (ATCC® HB-8065™) and the Homo sapiens kidney epithelial tissue 293T (ATCC® CRL-3216™). Most of these cells are maintained in culture at 37 °C under a 5% CO2 and >95% humidity atmosphere in DMEM or RPMI media , supplemented with 5–10% heat-inactivated fetal bovine serum (FBS), 100 U/mL penicillin, 0.1 mg/mL streptomycin, or 50 μg/mL gentamycin. Because some cell lines may require other specific nutrients, following the American Type Culture Collection (ATCC) instructions , for the handling of each cell line is recommended.In addition, for in vitro cytotoxicity tests, it is also advisable to carry out an initial screening for liver and kidney toxicity, for which the most recommended cells are the 50) or the median lethal concentration (LC50).Primary culture cells include splenocytes, peritoneal macrophages, and bone marrow-derived macrophages or dendritic cells obtained from BALB/c mice and hamsters cultivated in RPMI-1640 media supplemented with 10% of FBS, 50 μg/mL gentamycin or 100 U/mL penicillin, and 0.1 mg/mL streptomycin. Cytotoxic activity is expressed as the concentration of AMP and CPP compounds capable of reducing the cell viability of cells by 50% after 48 h of treatment, expressed as the median cytotoxic concentration (CCLeishmania promastigotes grown at 26 °C in Schneider’s insect medium supplemented with 10% (v/v) heat-inactivated fetal bovine serum plus an antibiotic mixture of penicillin and streptomycin. Like cells, many parasite species/strains are used to evaluate the antiparasitic activities of new molecules. In the case of Leishmania spp., a large number of described species are pathogenic for humans. For cutaneous leishmaniosis, the species that are most prevalent in specific regions are used, such as L. braziliensis, L. panamensis, L. amazonensis, and L. mexicana in Central and South America and L. major and L. tropica in Europe and Asia; for visceral leishmaniosis, L. infantum is used in America and L. donovani is used in Europe, Asia, and Africa. In some Leishmania species, there are strains expressing the green fluorescent protein (GFP) gene as well as the luciferase (LUC) gene.In vitro antileishmanial activity is routinely evaluated using T. cruzi epimastigotes cultured in an LIT hepatic tryptose infusion at 28 °C with 10% fetal bovine serum (FBS), 10 U/mL penicillin, and streptomycin. A 10 µg/mL concentration is usually incubated at pH 7.2 in the presence of the candidate compound to be evaluated, and it is collected during the exponential growth phase. For T. cruzi, the most frequently used strains are the Tulahuen strain Discrete Typing Unit (DTU) VI clones C2 and C4, which express the beta-galactosidase gene [Similarly, to evaluate the trypanocidal activity of a compound, in vitro assays are traditionally used with forms of ase gene ,164,165 ase gene ; Y straiase gene ,168 or ease gene ); Sylvioase gene ; Dm28c sase gene ,170,171;ase gene .50 is calculated on the basis of the mean percentage reduction in parasites compared with the untreated controls. The index of selectivity is calculated by dividing the LC50 or CC50 by the EC50 (IS = LC50 or CC50/EC50).In both types of assays, the corresponding parasite forms are seeded and incubated with different concentrations of the candidate compound whose activity is being evaluated ,174. TheExperimental animal models are models in which the scientist induces a disease or condition in animals . These mMesocricetus auratus) and BALB/c, C57BL/6, and albino Swiss mice [L. infantum in the Mediterranean area, Middle East, Asia, and Latin America) as experimental models has led to great advances in the development of vaccines and immunotherapy against VL [T. cruzi infection, all clinical stages of Chagas disease can be consistently reproduced in Syrian hamsters, including the chronic phase with cardiomyopathy [There are no standardized protocols for the evaluation of compounds in animal models, and researchers have described different protocols. The species most widely used as animal models of the main forms of leishmaniases and Chagas diseases are the Syrian golden hamster  the degradation of AMPs and CPPs by proteases can occur in the bloodstream and the gastrointestinal system; (ii) the inactivation of AMPs and CPPs as a consequence of binding other proteins; (iii) low metabolic stability and oral absorption; (iv) AMP and CPP removal by rapid excretion through the kidneys and liver; (v) potential toxicity and immunogenicity; and (vi) high production costs .Therefore, several drawbacks remain to be resolved for the use of AMPs and CPPS as therapeutic agents. Peptide molecules can be susceptible to degradation by proteases in the body, which can limit their effectiveness as therapeutic agents . ConsideTo face the challenges presented by the current limitations of AMPs and CPPs, different research teams have worked in different fields. Some have used chemical strategies based on glycosylation and lipidation to increase the efficiency and activity of conventional AMPs and CPPs ; others These systems can be functionalized with different biomolecules  that provide binding specificity to different cell types or locations. Of these, aptamers are attracting great interest due to their properties and characteristics . AptamerVibrio vulnificus infection in mice. These bacteria may cause disease in those who eat contaminated seafood or have an open wound that is exposed to warm seawater containing the bacteria. Ingestion of V. vulnificus can cause vomiting, diarrhea, and abdominal pain. In this study, the authors showed the ability of a conjugate of gold nanoparticles and DNA aptamers loaded with AMP to achieve complete inhibition of colonization in different organs, leading to a 100% survival rate among treated mice compared with control mice, which died within 40 h of infection [Leishmania [Trypanosoma proteins [The use of AMPs and CPPs in the treatment of intracellular pathogens has been limited by their instability in vivo and their low penetration capacity in mammalian cells. In this sense, aptamers have shown enormous potential to target other drugs, something that could be of great interest in the case of AMPs and CPPs, as it would favor their clinical application. Thus, Lee et al. demonstrated that HPA3PHis, an AMP loaded in a conjugate of gold nanoparticles and DNA aptamers, was effective against nfection ,198. In nfection . In summishmania ,202,203 proteins ,206,207 Considering the priorities established by the WHO in relation to the need to achieve affordable, safe, and efficient treatments for two of the most relevant neglected zoonoses, leishmaniosis and Chagas disease, AMPs and CPPs represent a potent alternative to conventional antibiotics. Several studies have demonstrated the activity of these natural peptides against intracellular trypanosomatids ,82,208. Therefore, the optimization of AMPs and CPPs using emerging biotechnology and the achievement of conventional therapies combined with the appropriate properties of AMPs and CPPs will allow us to increase the potential of AMPs and CPPs by reducing toxicity and adverse effects and preventing the appearance of multiresistance. The effort being made by scientists around the world in the field of innovative therapies is commendable. Alternatives based on antimicrobial peptide molecules against neglected zoonoses will be a reality in a short period of time.