Teledentistry (TD) can offer a wide range of possibilities in the field of oral medicine. Oral potentially malignant disorders (OPMDs) are hard to detect, and even harder to diagnose correctly. With the help of TD, OPMDs can be detected and diagnosed by a remote specialist. Our aim was to investigate whether TD could provide a reliable diagnostic method compared with clinical oral examination (COE) in the diagnosis of OPMDs.A systematic search was conducted in three databases  until November 2021. We included studies that compared telediagnosis and COE, both made by experts. Pooled specificity and sensitivity were calculated and visualized on a two-dimensional plot. Risk of bias was assessed using the QUADAS-2 tool, and the level of evidence is shown with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool.Of the 7,608 studies, 13 were included in the qualitative and 9 in the quantitative synthesis. Using TD tools in the detection of oral lesions (OLs) showed high specificity  and sensitivity (0.93 95% CI = 0.17–1.00). In the differential diagnosis of lesions, we found high sensitivity and specificity (0.942 95% CI = 0.826–0.982 and 0.982 95% CI = 0.913–0.997), respectively. We summarized the available data on time-effectiveness, screening person, referral decision, and technical settings.Detecting OLs with TD tools might lead to earlier diagnosis, treatment, and stricter follow-up of OPMD. TD may offer a great substitution for COE in the diagnosis of OLs, and thus, fewer referrals could be made to special care, resulting in a greater number of treated OPMDs. Through these solutions, the transfer of electronic health records, teleconsultation, telediagnosis, online therapy planning, follow-up, remote patient monitoring, online research, and tele-education can be applied to dentistry.3 Teledermatology, where evidence for telediagnosis is based on image capturing, is one of the most investigated and developing fields in telemedicine.4 Recent research in teledermatology shows contradictory findings about the diagnostic accuracy of the field,6 however, this research has not yet been performed in oral medicine (OM).As visual information can include important details about a clinical case, a photograph-based telediagnosis depends on image resolution.7 In developing countries such as India and Malaysia where smokeless tobacco  is popular, the problem arises.8 Other risk factors can include infections, solar radiation, dental hygiene, and genetic factors.8 A low-resource setting and the lack of specialists in rural areas lengthen the diagnosing procedure, allowing the manifestation of oral potentially malignant disorders (OPMDs). TD could help in bridging this problem. Providing high-risk populations with a general oral mucosa screening could decrease the rising amount of OC.The correct diagnosis of premalignant lesions is essential. Due to the fact that oral cancer (OC) in an early stage is asymptomatic, it lacks patient-reported symptoms: ulceration, bleeding, and induration.9 Detection and follow-up of OPMDs at an early stage could stop their manifestation to OC. Also, the similarities between precancerous lesions and some benign lesions cause difficulties in differential diagnosis.7 Therefore, many unnecessary referrals are made by primary dentists to OM specialists, resulting in wait time and travel difficulties for patients.10Diagnosing oral lesions (OL) can be difficult due to the variability of presence and the lack of training in OM.11TD has the potential to connect patients with dentists via the online space, thus improving access to care in rural areas.This systematic review and meta-analysis aimed to collect available data on how OM could benefit from TD solutions. Due to the lack of data about different TD tools and concise data about the use of TD in OM, an extended summary is needed.Our aim is to investigate the existing TD tools in the diagnosis of OLs using clinical oral examination (COE) as a reference standard. The main outcome is the presence and the differential diagnostic accuracy of OPMDs, which can lead to lowering the number of referrals to special care.12 while we followed the Cochrane Handbook.12 The protocol of the study was registered on PROSPERO (registration number CRD 42021282645) with no deviations from it.Reporting of this systematic review and meta-analysis is based on the recommendation of the PRISMA 2020 guideline,The systematic search was conducted on October 25, 2021, and was revised on October 11, 2022, in the following electronic databases: MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search key we used in each database is detailed in In vitro and animal studies were also excluded.The search applied no filters. Only English language articles were considered eligible. In addition, the reference lists of eligible studies were also searched. Nonoriginal articles  and nonpeer-reviewed articles (gray literature) were excluded. Study eligibility was determined based on the PICO framework: adults with suspected OLs (P), who were examined using TD tools  were acceptable with a reference standard (C) of COE or biopsy. Specificity and sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were considered the included outcomes (O). Regarding the study type, observational studies were considered eligible.The selection was performed by two independent review authors (E.U. and Z.D.). After the duplicates were removed using reference management software , the two authors independently screened titles, abstracts, and then full texts. Disagreements were resolved by a third independent reviewer (O.N.).Data were collected by two authors independently (E.U. and Z.D.) based on a predefined data collection form. The disagreements were resolved by a third independent author (O.N.).The following data were extracted: first author, year of publication, type of study, country, study population, mean age, surveyed risk factors, number of participants, target condition definition, person conducting telediagnosis, type of photography tool, description of TD tool, and reference standard.The comparison of a new diagnostic test (TD) with the gold standard of the field (COE) is conventionally summarized in a two-by-two table called the diagnostic contingency table. It contains the numbers of true-positive (TP), false-positive (FP), true-negative (TN), and false-negative (FN) cases. The most common measures calculated based on the table include sensitivity, specificity, accuracy, and PPV and NPV. All these data were collected in a predefined data table.13 to define OPMD lesions in those articles that have only the final diagnosis listed. We considered the WHO classification of OLs14 as the standard decision base in cases of questionable diagnosis. The final table was discussed with an OM expert (O.N.).We established a detailed diagnosis classification table based on Haron's predefined list12 we used the QUADAS-2 tool15 for risk-of-bias assessment. This was performed by two review authors (E.U. and Z.D.). Disagreements were resolved by a third independent author (O.N.).Based on the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy,16 The endpoints of the outcomes were assessed by two independent reviewers (E.U. and Z.D.). In case of disagreement, a third independent reviewer resolved it (O.N.).Certainty of evidence was evaluated based on the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) workgroup's recommendations.17 for the investigated outcomes.We made the GRADE evidence profiles with GRADEpro GDT SoftwareTwo by two contingency tables were extracted from the studies containing TP, FP, FN, and TN values. Where studies published data corresponding to more than one remote expert, we randomly selected one of them. We repeated the analysis using the contingency tables of previously nonselected experts as a sensitivity analysis.19 Ellipsoids of this analysis reflect the weights of the studies according to the method by Burke et al.20 Univariate analyses of sensitivity and specificity were performed using the generalized mixed-effect approach.21 Statistical analyses were carried out using the online tool described in Freeman et al.22 and the meta package of R statistical software (version 4.1.2.). The statistical analyses followed the advice of Harrer et al.23 Further details of the synthesis methods are described in We used the bivariate model of Chu and Cole and Reitsma et al.24–33 By the end of the process, 10 articles were found eligible for the quantitative synthesis,34 and 4 articles were excluded due to lack of data.33 The selection process and Cohen's kappa values are presented using a PRISMA flowchart  . Fitting the bivariate model was not possible in this analysis due to the small number of available studies.Our pooled analysis of 3 articlesSupplementary Table S2.As the exact number of TP, TN, FP, and FN lesions was not mentioned in every article, the abovementioned classification table was able to help us resolve the problem, as can be seen in Supplementary Table S3) for the diagnosis of OPMD or OC lesions. Estimated high sensitivity and specificity of nine pooled articles34 showed that TD can be a reliable tool for differential diagnosis of OLs , as shown in Supplementary Figure S1. Heterogeneity is low , as shown in Supplementary Figure S1.We assessed the available data (Supplementary Table S4). This result confirmed the findings of the main analysis; thus, the outcome shows that the results do not depend on the examiner's knowledge (S3).Conducting sensitivity analysis, the resulting sensitivity and specificity are 0.953 (CI = 0.856–0.986) and 0.983 (CI = 0.930–0.996), respectively. See Supplementary Data for further details of the extractions  and virtual examination . Perdoncini et al.29 listed the transportation time , which shows that mostly people from rural areas attended the clinic. The COE took 10.44 min on average (SD: 2.88). In the case of the WhatsApp messaging platform, Petruzzi and De Benedittis10 measured an average distance of 70 km (SD: 78 km).No statistical analysis could be performed on time-effectiveness due to the heterogeneity of reported data. Namakian et al.25 showed that a trained frontline health care worker could detect OPMD with a PPV of 45%. They also studied the efficacy of community health care workers (CHWs) in the diagnosis of the presence of OL, where they found a kappa score of 0.92 between CHWs and onsite specialists.24 Therefore, not only dentists but also trained CHWs could take part in the detection of OLs.Birur et al.28 however, its policy showed variability. Fonseca et al.27 recorded that an average of 35.4% of the examined patients could be treated in primary dental care. Haron et al.13 recorded a kappa value of 0.892 (CI: 0.843–0.940) for referrals using a predefined list.The referral decision was measured in four articles,3 found a correlation between using better resolution mobile phones as photograph-taking devices in diagnosing lesion category: the higher the resolution, the higher the diagnostic agreement (accuracy: 0.515–0.881). Using a better mobile phone helped not only in better detection (sensitivity: 0.813), but also in correct diagnosis (sensitivity: 0.93).The technical setting of TD tools varied in the available articles. Haron et al.29 investigated the accuracy of RT video consultation with a specialist; 91% of the photographs were of good quality, and the internet connection was stable in 58% of the cases.Perdoncini et al.32 to simulate primary dental care settings. The images then were sent to the specialist via e-mail, thus avoiding internet connection problems.A professional camera was used in two articles33 Not only dentists, but also dental hygienists and patients sent homemade photographs of OLs. WhatsApp was tested by Vinayagamoorthy et al.,33 where a sensitivity of 0.981 (examiner 1) and 0.987 (examiner 2) was found for exact lesion diagnosis.Receiving photographs and testing the role of free chat applications in dentistry can simulate population-based screening.15 our results for risk-of-bias assessment are presented in Supplementary Figures S4, S5, and S6. Most of the domains showed low risk of bias, however, having inappropriate exclusion criteria in patient selection in one article meant that only people with risk factors were involved in the actual study,27 and in another study, the patients were selected by having/not having OL/OPMD/OC.3 The index test result domain has unclear risk in those articles where COE (index test) was made by the same person who made the telediagnosis with a fixed, predefined washout period.30Using the QUADAS-2 tool,35 Certainity of evidence Table can be seen in Supplementary Table S5. The PRISMA checklist can be seen in Supplementary Table S6.Due to the small number of available studies, publication bias could not be assessed by performing the methodology of Deeks et al.29According to the high sensitivity and specificity in our study, TD could successfully help in primary dental care in the field of OM. Store-and-forward systems could be used in telediagnosis , and RT solutions could be used in teleconsultation .36 Image-based diagnosis by a specialist may help primary dental care facilities in the decision of referral to special care.Visual examination is extremely important (and remains the primary diagnostic tool) in both dermatology and OM, causing a rapid technical rise in both teledermatology and TD.25 The differential diagnosis of OLs is important due to treatment planning reasons. TD could support general dentists in OL management through connection with OM specialists, enabling early diagnosis and correct treatment of oral (pre)malignant lesions.37 Knowing the best available treatment and prevention could lead to less manifestation of OC. Furthermore, referring only OPMDs and malignant OLs might result in a higher percentage of treated patients.Also, TD could promote organizing population-based OL screening programs in the future.As the prevalence of OC is rising, the correct diagnosis of premalignant lesions is essential. In developing countries, low-resource settings and the lack of specialists in rural areas make the diagnosing procedure longer, allowing manifestations of OPMD. TD could help in solving this problem.33 Also, in one case, the general dentist could send his or her own diagnostic opinion, compromising the impartiality of the diagnosis.30TD tools in the diagnosis of OLs show high accuracy, however, there are weaknesses in the available data that need to be mentioned. The protocol of diagnosis by the same person was followed by several articles, which despite the washout time (average 3 weeks) still brings into question the reliability and correctness of the results.38 however, in Europe, it varies from country to country, and a consensus has not been made yet about the competencies and limits of OM specialists.39 This fact questions the use of the term OM “specialist” in the articles. In addition, experience in the field does not guarantee a correct diagnosis using TD tools. Lack of information in the online form and the lack of in-person personalized questions may complicate the diagnosing process.Education in the field of OM starts during the predoctoral phase, however, it varies afterward. A huge difference can be spotted regarding specialists: for example, in the United States, this field is a recognized dental specialty of the American Dental Association,40 or population-based screening.24 This could increase the efficacy of patient flow in OM practices.Referring every patient with an OL to special care might overload OM praxis. A high number of referrals may be avoidable using a pretriage system41 however, we cannot predict the level of dysplasia based on clinical images. Diagnosing the presence and type of OL could lead to targeted treatment and prevention of manifestation to OC.41 Our results showed both high specificity and sensitivity in the detection of OLs, meaning that TD tools could be used as a pretriage system in the diagnosis of OLs.OC is unique compared with other cancers because visual detection at an early stage is possible with COE,13Correct diagnosis of an OL is necessary before treatment, however, not all patients need to be referred to an OM specialist. Our study showed high sensitivity, meaning that TP OPMD could be successfully diagnosed via TD image-sharing tools . We found high specificity, meaning that TN lesions that do not necessitate referral to a specialist are correctly diagnosed, affirming previous articles' clinical data.According to our knowledge, this is the first meta-analysis on this specific topic. We used rigorous methodology and followed a previously registered protocol. We selected for eligibility only those articles in which the clinical diagnosis (reference standard) was made only by doctors. Due to the strict inclusion criteria, we gained higher data quality . We did not include publications with retrospective or case–control designs.Regarding the limitations of this article, within the available data regarding the detection of OLs, we found significant heterogeneity among the included articles. The reason for this, despite the strict inclusion criteria, could be the included heterogenous population . The methodology of applied TD tools was heterogeneous, meaning that RT and SAF systems were pooled together. The referral decision was not defined in each of our selected articles, and so, we could not include it in a quantitative analysis.A future photograph-taking protocol for OLs could be used in primary dental care. We suggest establishing the technical setting first, as telecommunication tools require a firm technical background. Also, a standardized questionnaire could be used in the future to provide more details about the patient.We suggest that researchers use biopsy as a reference standard (replacing COE) to have an objective diagnosis. Furthermore, exact lesion diagnosis could be helpful in comparison with other publications' results, and referral decisions could be counted based on these data.Detecting OLs with TD tools could lead to early diagnosis, treatment, and stricter follow-up of OPMDs. TD offers a great substitute for face-to-face dental visits in the detection and differential diagnosis of OLs, and thus, fewer referrals could be made to special OM care. Being a time-effective solution, when conducted in a proper way, access to care could be widened with the use of these tools.


Conclusion: The results of the study indicate the need for regular densitometry in patients with HCU and also the use of additional calcium and vitamin D3 supplementation. It is also necessary to perform a comprehensive analysis of the diet and metabolic controls.Background: Classical homocystinuria (HCU) is an inborn defect of methionine metabolism caused by a deficiency of the enzyme cystathionine β-synthase (CBS). The main symptoms of classical homocystinuria are lens subluxation, bone lesions, vascular disease and developmental delay/intellectual disability. The treatment method for HCU is a methionine-poor diet supplemented with amino acid preparations. The aim of the study was to examine the relationship of dietary factors, metabolic compensation and selected skeletal parameters in patients with HCU. Methods: Bone mineral density measurements (DXA) were performed in pediatric patients with HCU, and blood levels of selected amino acids, minerals and vitamins, as well as dietary nutritional value, were analyzed. Results: A total of 11 patients with HCU whose median age was 9.3 years were enrolled in the study. The median DXA total body less head of HCU patients was −0.4 z-score, and the lumbar spine was −1.4 z-score. Despite supplementation, calcium intake was below the age norm. Average vitamin D3 intake was in line with recommendations, but 36% of patients had reduced blood levels. Bone mineral density depended on blood levels of 25-hydroxyvitamin D, homocysteine and methionine, as well as on BMI, age and intake of natural protein (R CBS gene. Consequently, elevated levels of methionine and homocysteine in the blood/plasma and urine as well as accumulation of homocysteine in various tissues are observed [Classical homocystinuria HCU, # 236200) belongs to a group of rare diseases:inborn errors of metabolism classified as aminoacidopathies. It is an autosomal recessive disorder affecting the catabolism of the sulfur amino acid methionine caused by cystathionine β-synthase (CBS) enzyme deficiency associated with biallelic pathogenic variants in the observed ,2. The i36200 belSince December 2013, all newborns in Poland are screened for classical homocystinuria (newborn screening program). However, false negative results could be obtained due to assessing the methionine concentration only as a first-tier test from a dried blood spot.In those cases, the disease is usually diagnosed later as a result of selective screening tests, including plasma/serum aminoacidogram, with elevation in both methionine and total homocysteine levels ,4.Clinical symptoms of HCU include short-sightedness (an early sign of the disease), dislocation or retraction of the lens of the eye, Marfan-like appearance, epilepsy, thromboembolic events, osteoporosis, intellectual disability and psychiatric and behavioral disorders ,3.The first-line treatment method for HCU is a methionine-restricted diet supplemented with protein replacers (without methionine) . ProteinThe purpose of reducing the supply of natural protein in the diet is to lower the serum concentration of methionine and homocysteine, thereby reducing their negative effects on the body. However, some deficiencies of vitamins and minerals such as B vitamins, iron, calcium, copper, zinc and essential fatty acids may occur ,11. Due ®), which participates in the remethylation of homocysteine to methionine and helps to maintain normal homocysteine values [Supplementation with vitamin B6, B12 and folic acid, which are involved in methionine remethylation, is also used in HCU patients [The aim of this study was to examine the relationship between bone mineral density and selected parameters of calcium-phosphate economy with dietary management and metabolic control in Polish children with classical homocystinuria.A retrospective observational single-center  study was performed in 2021. A total number of 11 patients with classical homocystinuria, remaining under dietary and metabolic care, were enrolled. Dietary recommendations were made on the basis of the patient’s age, weight, laboratory results and dietary standards for HCU patients regarding the amount of natural protein and protein derived from an amino acid preparation, e.g., HCU Anamix, HCU Lophlex, HCU Cooler and HCU Express ,8,9.Dietary assessment was performed on the basis of a 24 h dietary intake history, including amino acid preparations and supplementation used, immediately prior to examination of blood levels of selected vitamins, minerals and amino acids and whole skeletal and lumbar spine densitometry. At the same time, height and weight were measured in all patients using a stadiometer  and a scale (Radwag C 315.O). The measurement of body height was conducted without shoes, headgear and pinned-up hair for girls. The patient stood upright with their arms along the body, their back to the stadiometer, and their head, shoulders, buttocks and heels touched the device. During the measurement of body weight, the patient stood in underwear, upright in the middle of the scale, looked ahead and distributed their body weight on both legs . Weight The program Diet 6.0  was usedThe second part of the study was the analysis of the results for albumin, selected vitamins, minerals and amino acids in the patients’ blood. Serum calcium and albumin concentrations were determined by colorimetric method, phosphorus by photometric method, vitamin D (25OHD) by chemiluminescence method and amino acid concentrations by ion exchange chromatography (EIC). The values of the aforementioned parameters were related to laboratory standards according to the child’s age . Blood sBone mineral density measurements were conducted with dual-energy X-ray absorptiometry method (DXA). Prodigy Advance densitometer , with software v. 14.0 was used. Scan modes were chosen automatically by the software, based on body dimensions. Total body less head (TBLH) and lumbar spine (L2–L4) measurements were conducted according to the International Society for Clinical Densitometry recommendation . Z-scoreThe study was conducted in full conformance with the principles of the “Declaration of Helsinki”  and Good Clinical Practice guidelines.The study was retrospective, and data obtained from patients were anonymized. The study was approved by the Children’s Memorial Health Institute Bioethical Committee, Warsaw, Poland (36/KBE/2020).Written consent was obtained for all subjects from at least one caregiver with parental responsibility, and written assent was obtained from the subject if appropriate for their age and level of understanding.Descriptive statistics were used to examine the characteristics of patients, the nutritional value of their diet, the use of protein substitutes, the concentration of albumin, ferritin, selected vitamins, minerals and amino acids in the blood and bone mineral density parameters. Data are presented as mean and standard deviation, median, minimum and maximum values, with a 95% confidence interval.Univariate and multivariate regression analyses based on Spearman’s rank correlation test were used to determine the relationship between the studied characteristics. To describe the fitting of the model, R-squared statistics and standard estimation error were used.p ≤ 0.05. Analysis was conducted using Statgraphics Centurion 18.1.12 .The significance level of the analyses performed was taken as n = 5) were taking anhydrous betaine (Cystadane®). In total, 83% of HCU boys were of normal weight, while 17% were underweight. Meanwhile, 40% of HCU girls were underweight, the same percentage of girls were overweight, and only 20% were of normal weight  with HCU aged 2.5–16 years. In only two patients, the diagnosis was obtained as a result of the neonatal screening program. Less than half of the patients  bone mineral density (BMD) was −0.5 (range −1.7 to 1.1). The median z-score value of the lumbar spine BMD was −1.4 (range −2.6 to 1.5), corresponding with the broad age range . TBLH BM2 = 59.3%, p = 0.039). TBLH BMD was also associated with age, BMI and 25-hydroxyvitamin D levels . In contrast, lumbar spine mineral density indices (z-score) were dependent on 25-hydroxyvitamin D, calcium, homocysteine and methionine . Furthermore, lumbar spine mineral density depended on protein intake from amino acid preparations   were dependent on natural protein, magnesium and methionine intake (R= 0.026) .p = 0.004). Similarly, plasma methionine concentration was directly proportional to BMI values. A directly proportional correlation was observed for 25-hydroxyvitamin D concentration and intake with diet and supplements   .The median value of serum albumin concentration was 44.6 g/L (range 42–48 g/L), with none of the children having a value lower than the recommended norms . The medThe median dietary energy intake was 1527 kcal/d , with 2/3 of HCU patients meeting the recommendations for dietary energy supply, but the dietary energy value of 27% of patients, mainly girls, was lower than dietary recommendations. Similarly, recommendations for natural (dietary) protein intake were met by 73% of patients , and only 2 girls and 1 boy consumed less than recommended protein intake from natural sources, 2 of whom had abnormal blood homocysteine levels. In contrast, all patients realized recommended protein intake derived from an amino acid preparation . In turn, despite the supplementation used, 73% of patients did not meet the standard for dietary intake of calcium (RDA 1000 mg/d) . Vitamin D3 intake was in line with Polish nutritional recommendations . It was observed that 2/3 of children and adolescents with HCU met the recommendations for dietary intake of phosphorus  .The analysis of collected data shows that BMD significantly lower than 0 (the expected mean Z-score in the population) can be observed in Polish children and adolescents with classical homocystinuria. In the study of Lim and Lee 2012) on five Korean pediatric patients with HCU, the mean lumbar mineral density z-score was reduced but was within the narrow age norm . Similar on five There is a known relationship between higher homocysteine levels and an increased risk of bone complications, including osteopenia and osteoporosis in both children and adults with HCU ,23,24,25A negative correlation between blood methionine and homocysteine concentrations and BMI values was reported in the literature ,31. In oVitamin D3 plays an important role in bone mineralization. Among other things, it is responsible for the intestinal absorption of calcium and phosphorus . All theCalcium is the main component of bone tissue and is essential for proper mineralization of the skeleton. When there is an insufficient supply of calcium from the diet, the body begins to release calcium from the bones, which results in impaired bone mass gain and consequently increases the risk of fractures . PatientA low-protein diet, despite the use of amino acid supplements that are fortified with vitamins and minerals, can be a deficient diet ,34. ThesIn our study, 73% of patients were found to meet the recommendations for natural protein intake with the diet, while the rest consumed too little. The diet of the vast majority of children was of normal energy content. A multivariate correlation analysis showed that natural protein intake was dependent on the energy content of the diet. A possible explanation for this relationship may be observed due to inclusion of food such as French fries and chips, which provide protein in addition to a large number of calories. Our study showed a directly proportional relationship between protein intake from an amino acid preparation and lumbar spine mineral density. The same relationship was observed in a study by Geiger et al. conducted among patients with PKU . This maThe present study was limited by several factors. One was the small study group, which is related to the rarity of classical homocystinuria in Poland. Other limiting factors were the lack of follow-up over a longer period of time and the lack of a reference group of appropriately selected children/young adults without HCU. Despite the limiting factors, this is the first such study in Poland in a group of patients with HCU, and this indicates the need for monitoring and further research.Due to the restrictive diet of patients with classical homocystinuria and the consequent possibility of nutritional deficiencies, there is an increased risk of osteopenia and osteoporosis. In Polish pediatric HCU patients, bone mineralization was unsatisfactory. The diet with supplementation of most patients with respect to standards provided adequate levels of energy, protein and vitamin D3 but not enough calcium. The results for albumin, calcium, phosphorus, homocysteine and methionine blood levels were normal in the vast majority of cases, but lower than optimal blood 25-hydroxyvitamin D levels were observed. Patients with HCU need regular densitometric measurements, as well as dietary analysis for calcium and vitamin D3, and protein from both natural sources and methionine-free amino acid preparations. The above results indicate the need for additional supplementation with the aforementioned components in doses adapted to measurements of bone mineral density and their intake from the diet.


The aim of this study is to evaluate the influence of the body mass index (BMI) and the metabolic syndrome (MetS) parameters on oxidative and nitrosative stress in overweight and obese subjects.2, the overweight group  with a BMI between 25 and 29.9 kg/m2 and the obese group  with a BMI ≥ 30 kg/m2.Individuals were divided into three groups: the control group  with a BMI between 20 and 24.9 kg/mG3 presented higher advanced oxidation protein products (AOPPs) in relation to G1 and G2  whereas G2 and G3 had lower levels of nitric oxide (NO)  compared to G1. Adjusted for the presence of MetS to evaluate its influence, the levels of AOPPs did not differ between the groups, whereas NO remained significantly lower. Data adjusted by the BMI showed that subjects with higher triacylglycerol levels had higher AOPPs (p = 0.001) and decreased total radical-trapping antioxidant parameter/uric Acid (p = 0.036). Subjects with lower high-density lipoprotein (HDL) levels and patients with higher blood pressure showed increased AOPPs  and lower NO levels . Subjects who presented insulin resistance had higher AOPPs (p = 0.024).Nitrosative stress was related to BMI, and protein oxidation and nitrosative stress were related to metabolic changes and hypertension. MetS components were essential participants in oxidative and nitrosative stress in overweight and obese subjects. Obesity and overweight are chronic disorders of multifactorial origin, which can be defined as an increase in the accumulation of body fat . ChangesThe harmful effects of free radicals, which are mainly represented by reactive oxygen species (ROS) or reactive nitrogen species, have been implicated in the physiopathology of overweight, obesity, hypertension, endothelial dysfunction, and MetS ,5, suggeAlthough markers of oxidative stress have been studied in obese and overweight patients with and without MetS, we are not aware to date of studies evaluating the influence of body weight on oxo-nitrosative stress in the other components of MetS.In a previous study performed by our group, we verified that an increase in oxidative stress is mostly attributable to obesity in patients with MetS , but thiPatients from the Internal Medicine Ambulatory of the University Hospital of Londrina, Paraná, Brazil were chosen to participate in this cross-sectional study. Three hundred and thirty patients agreed to participate in the study. Inclusion criteria were patients (both genders) aged from 18 to 65 years. Exclusion criteria were thyroid, renal, hepatic, gastrointestinal, infectious or oncological diseases and the use of lipid-lowering drugs, drugs for hyperglycemia, anti-inflammatory drugs, hormone replacement therapy, and antioxidant supplements. For ethical reasons, patients who were taking antihypertensive drugs were not excluded and were allowed to continue taking the same dose of the drugs.2. The overweight group consisted of 120 subjects with a BMI between 25 and 29.9 kg/m2, and the group with obesity consisted of 79 subjects with a BMI ≥ 30. MetS was defined following the Adult Treatment Panel III criteria. A diagnosis of MetS was arrived at for subjects with at least three of the following five characteristics: . This clinical investigation was conducted according to the principles expressed in the Declaration of Helsinki.Written informed consent was obtained from all the participants, who acknowledged that they cannot be identified via the paper and that they are fully anonymized.All mandatory laboratory health and safety procedures have been complied.Anthropometric measurements and laboratorial parameters were assessed. Body weight was measured to the nearest 0.1 kg in the morning through the use of an electronic scale, with individuals wearing light clothing and no shoes; height was measured to the nearest 0.1 cm through the use of a stadiometer. BMI was calculated as weight (kg) divided by height (m) squared. WC was measured on standing subjects midway between the lowest rib and the iliac crest. Three blood pressure measurements taken with a 1-min interval after the participant had been seated were recorded on the left arm. The mean of these measurements was used in the analysis. We considered the current use of antihypertensive medication as an indication of high blood pressure.® kits: total cholesterol, HDL, low-density lipoprotein (LDL), triacylglycerol (TG), glucose and uric acid (UA). Plasma insulin level was determined by chemiluminescence microparticule immunoassay . The homeostasis model assessment insulin resistance (HOMA-IR) was used as a surrogate measurement of insulin sensitivity. HOMA-IR = fasting insulin (U/ml) x fasting glucose (mmol/L)/22.5. IR was considered when HOMA-IR ≥ 2.5  using Dade BehringIR ≥ 2.5 .Samples for evaluating oxidative stress and total antioxidant capacity were analyzed with e thylenediamine tetraacetic acid as an anticoagulant and antioxidant. All samples were centrifuged at 3,000 rpm for 15 minutes, and plasma aliquots were stored at −70ºC until assayed. All stress measurements were performed in triplicate.CL-LOOH in plasma was evaluated as described previously by Gonzales Flecha and cols. . CL-LOOHAOPPs were determined in the plasma using the semi-automated method described by Witko-Sarsat and cols. . AOPP coTRAP was determined as reported by Repetto and cols. . This meSH groups of proteins were evaluated in plasma samples through a spectrophotometric assay based on 2,2-dithiobisnitrobenzoic acid (DTNB), as reported previously , and the-) and nitrates (NO3-) using cadmium beads for the reduction of nitrate to nitrite. The concentrations of these metabolites were later determined according to the method proposed by Griess , and the NO values were inversely associated  with the presence of MetS (data not shown).The association between the oxidative stress parameters and the individual components of MetS was measured, and the values were adjusted by BMI, sex, age and ethnicity; the results are shown in Multiple regressive stepwise analyses were performed . After aThe redox state was similar in healthy, overweight and obese subjects when controlled for the presence of MetS, and therefore, the principal finding of the present study was that oxidative stress evaluated through lipid and protein oxidation in patients with obesity is mainly related to the presence of MetS and is less related to BMI. However, nitrosative stress with decreased NO bioavailability was associated with BMI, independently of the presence of MetS. In addition, this study verified that protein oxidation was associated with several individual components of MetS, including insulin resistance.The present data are partially in agreement with our previous study, which showed that increases in oxidative stress markers in overweight subjects were only verified in the presence of MetS . HoweverAlthough an increase in oxidative stress in patients with obesity is an undisputed issue and can be caused by several factors , the pre2-) via the nicotinamide adenosine diphosphate oxidase pathway. This anion reacts rapidly with NO to form peroxynitrite (ONOO-) – thus inactivating NO and leading to endothelial dysfunction, one of the mechanisms responsible for hypertension in these patients (Our data are also in accordance with that of previous studies, which showed that hypertriacylglycerolemia, hypertension, lower HDL cholesterol values and insulin resistance are essential factors in provoking oxidative stress ,19,20. Opatients  – whereaOur results show an association between the presence of insulin resistance and increased levels of protein oxidation. Although several reports have established the importance of insulin resistance and oxidative stress in the development of both diabetes and cardiovascular disease ,25, the It has been suggested that AOPPs are an early marker of MetS and are the most appropriate parameter for the determination of oxidative stress in MetS patients . AOPPs aChanges in NOx levels have been linked with disorders of metabolic and cardiovascular homeostasis that can culminate in obesity-induced IR and endothelial dysfunction. Serum NOx were shown to be increased in MetS and be associated with other metabolic components such as BP, BMI, waist-to-hip ratio, and fasting plasma glucose in cluster analyses . In addi2 or greater accounted for approximately 34% and 62% of hypertension in men and in women, respectively (Overweight is highly associated with arterial hypertension, independently from the occurrence of MetS, and a BMI of 25 kg/mectively . NO playectively . Hyperteectively . This stThe following limitations have to be considered in the present study. The first limitation is the small number of participants. Second, the food pattern and physical activities of the individuals were not measured. Third, the antihypertensive drugs the patients were taking, such as angiotensin-converting enzyme inhibitors, may elevate plasma adiponectin levels, which in turn can increase NO levels . Fourth,In conclusion, only nitrosative stress was related to BMI, whereas protein oxidation was related to each component of MetS. In addition, both NO and advanced oxidative protein products were related to hypertension. In general, MetS components were essential participants in overweight and obese subjects, but hypertriacylglycerolemia was the parameter that showed the highest degree of redox imbalance. Although more studies are warranted to confirm the present data, this study reinforces the importance of concomitantly analyzing oxidative and nitrosative stress to obtain a more complete picture of overweight, obesity and associated conditions.


Background: Tinnitus severity is generally assessed by psychometric and audiological instruments. However, no objective measure exists to evaluate the subjective discomfort and suffering caused by this hearing phenomenon. The objective of this work was to determine the possible blood parameters for diagnostics and therapy. Methods: We measured tinnitus distress by using the Tinnitus Questionnaire (TQ) and collected tinnitus-related audiological measures, namely the hearing threshold (HT), tinnitus loudness (TL), and sensation level . Blood samples were taken from 200 outpatients of the Tinnitus Centre of the Charité, and 46 routine blood count parameters were examined. The possible interactions were determined by (robust) linear models. Results: Tinnitus distress and audiological measurements were largely uncorrelated but could partly be predicted by selected blood parameters. First, the erythrocyte counts predicted tinnitus distress to a small extent. Second, the levels of vitamin D3 explained about 6% of tinnitus loudness and, age-dependently, the hearing threshold variability. Last, the levels of uric acid explained about 5% of the sensation level variability. Conclusions: Tinnitus is a multidimensional phenomenon. The marginal influences of blood markers suggest the possible roles of inflammation and oxidative stress produced by psychological or somatic burdens. Clinically, a vitamin D substitution (in older patients) might have a hearing-protective effect. Tinnitus is a widespread phenomenon affecting at least 14% of the European population .In a recent review, Deklerck and colleagues summarized the non-otologic risk factors for tinnitus . When anNew definitions differentiate between “tinnitus” as an auditory/sensory phenomenon and “tinnitus disorder” as the combination of the auditory component and associated suffering . AccordiA previous study of our research group investigated associations between blood parameters and perceived stress in the same sample of tinnitus patients . In the In this study, we classify the examined blood parameters into four major groups, three of which approximately correspond to the structure displayed in direct inflammation markers, indirect inflammation markers, and hematological markers. The redox network activity (Group II) is also divided into two subgroups: (1) enzymes and (2) co-enzymes. Metabolic activity (Group III) is divided into four subgroups: (1) lipid metabolism, (2) blood levels for the hepatorenal function of liver function and kidney function, (3) purine metabolism, and (4) vitamins, minerals, and trace elements (cf. [We divided the immune activity group (Group I) into two large subgroups. The first subgroup reflects the cellular immune responses, and the second subgroup represents inflammation and can be divided into three further subgroups: nts (cf. ). See FiIn recent years, biomarker studies have been conducted increasingly ,25. HoweThus, the research task at hand mainly aims at identifying possible tinnitus-related blood parameters and their potential link to the above-mentioned four outcome groups. Note, however, that tinnitus loudness and sensation level are co-determined by a person’s hearing ability. A reciprocal relationship between hearing ability and tinnitus distress is possible, but not assumed ,26. HearAll blood parameters were collected once. Multiple analyses were performed: the determined blood parameters were correlated with the questionnaire scores measuring the tinnitus distress and audiological measures. We investigated whether certain blood parameters are linked to hearing loss, tinnitus loudness, sensation level, or tinnitus distress.N = 200, 51% are female; the average age is 54.7 years). These patients self-referred to the Tinnitus Centre at Charité Universitätsmedizin Berlin between April 2016 and August 2017. The inclusion criteria included chronic tinnitus , an age of 18 years or older, and having completed the Tinnitus Questionnaire and the Perceived Stress Questionnaire [Our study is based on the questionnaire data and blood markers from patients with chronic tinnitus . Patients’ hearing thresholds were measured using pure tone audiometry alongside the tinnitus frequency, tinnitus loudness (dB HL), and sensation level (dB SL). In detail, for pure tone audiometry, the measurements were performed binaurally for the frequency range between 0.25–8 kHz at eight steps . The hearing threshold (variable HT) was determined by increasing the decibels (dB) in the measured frequency ranges. The hearing threshold (in dB) is the minimal threshold at which a tested individual perceives the sound wave of the presented sinusoidal tones. For this study, we calculated the average hearing threshold across all frequencies ,31.Tinnitus matching is an audiological examination used to approximate the psychoacoustic tinnitus parameters. Tinnitus matching was carried out by the ENT specialist, who adjusted the sounds presented to the patients via headphones in such a way that the sounds were as close as possible to the type and frequency of sound and the subjectively perceived tinnitus level. For the remainder of this paper, the subjectively perceived tinnitus level is denoted as tinnitus loudness and corresponds to the variable TL (in dB). The sensation level (variable SL) is calculated from the hearing threshold  in the tinnitus frequency minus the tinnitus loudness.All statistical analyses were carried out using the statistical software R , versionp-values for multiple comparisons was carried out by the method of Benjamini and Hochberg [The possible impact of the blood markers was assessed in two steps. First, we carried out simple correlation analyses for each marker with HT, TL, SL, and TQ, respectively. When the normality assumptions were violated (assessed via the Shapiro–Wilk test), we relied on Spearman’s rank correlation. For the Gaussian samples, we calculated the common correlation coefficient of Pearson. In this step, a correction of the resulting Hochberg  to contrR2. To decide which model is preferred, we mainly relied on the model selection criterion, BIC. When two models had an almost equal BIC, we considered the significance of the included terms as well as the F-tests for a model comparison. We checked the residual normality of the finally selected model by means of the Shapiro–Wilk test. When non-normality was suggested by the test, we repeated the analysis with a robust MM-type regression approach. For this regression type, we relied on the lmrob function from the robustbase package [KS2014, as suggested by Koller and Stahel [R2 statistic with the boot package [Second, we assessed the potential impact of each marker on the variables HT, TL, SL, and TQ, together with age and sex as covariates. To determine the best model for each of the response variables, we included age and sex as covariates in our linear models when a significant effect was detected. To find the best model, we followed a bottom-up approach. That is, we successively included the strongest predictors and their interaction in terms of  package  with thed Stahel . In this package ,37 throuR2), the results presented here rely on simple linear modeling, where the within-subject observations are considered independent. To ensure that this simplification was justified, we also considered the measuring side as the covariate. However, this covariate never showed a significant effect and therefore did not occur in the remainder of this paper. In addition, we verified our findings by repeating the analyses via linear mixed-effects models. All results obtained were identical; therefore, we refrain from presenting them here for the sake of readability.On a minor note, the variable HT has been recorded twice for each patient (left/right). This leads to a statistical setting with repeated measures. To ensure comparability of the results obtained for the different response variables .For a first understanding of our response variables HT, TL, SL, and TQ, and the covariates of sex and age, we illustrated the simple associations seen in The first step was to investigate potential links between HT, TL, SL, and TQ, respectively, and our recorded blood parameters were to be carried out by means of simple association measures as well. However, such an approach may lead to erroneous conclusions because the effects substantially change when taking the covariates of age and sex into account. Nevertheless, we present these results in R2 of 26.9% (see R2 = 19.4), followed by vitamin D3 (additive increase to R2= 21.8) and sex (additive increase to R2 = 20.5). The interaction of age and vitamin D3 suggests that the coefficient of vitamin D3 is positive at younger ages, i.e., higher vitamin D3 levels are linked to a higher hearing threshold. This effect inverses approximately between the ages of 60 and 61. From this age on, the coefficient possesses a negative sign; thus, higher vitamin D3 levels are linked to lower hearing thresholds.For the log-transformed HT, the best model incorporates sex, age, and vitamin D3, whereby the latter two also interact, resulting in an 6.9% see  below. TRecall from above that the TL is a strong predictor for HT. To ensure the stability of our estimation results, we also built a model similar to the one presented above but with TL as an additional predictor. This leads to a model for HT with TL, age, and vitamin D3 as the predictors, where the sex effect disappears. Nevertheless, the model interpretation remains comparable to the one with age as a predictor . MoreoveR2 of 10.9%. Adding vitamin D3 to this model raises the R2 to 16.6%, indicating a contribution of vitamin D3 of approximately 5.7%. The estimated coefficients (p = 0.084).The results for TL are different from those obtained previously for HT. More precisely, the strongest predictor for TL is age, and the corresponding univariate model achieves an ficients  below shSimilar to the previous section (but with inversed roles), we also investigated the model’s stability by including HT as a predictor for TL. The corresponding results are very similar. In short, HT replaces age as the predictor, and the impact of vitamin D3 remains see .R2 of 5.44% . The strongest link was detected for erythrocytes, where an able see  below.R2 when predicting TQ, PSQ, TL, and HT, respectively.It is known that a self-assessment of tinnitus distress via psychological questionnaires involves other aspects of the tinnitus phenomenon than tinnitus loudness or sensation level. Even currently, there are no valid standards on how to measure and classify tinnitus or impairment due to tinnitus. Hearing status plays a critical role in experiencing tinnitus loudness (though not necessarily distress), even in individuals with mild to moderate hearing impairment .Our simple correlation analyses of HT, SL, TL, TQ, age, and sex suggest an age dependency of both hearing ability and tinnitus loudness. Moreover, a positive correlation is present for both HT and TL, as well as HT and TQ. Sex does not seem to play a role in the correlation calculations. Tinnitus occurrence and hearing loss are closely linked ,39. StudThe absence of a correlation between tinnitus loudness and tinnitus distress is known from the literature . In the When considering simple correlations, there seems to be a link between hearing ability and those blood parameters that indicate oxidative stress  in younger participants, whereas for older participants (approx. greater than 60 years old), the opposite effect was true . It is noteworthy, however, that the vitamin D3 levels do not exceed the reference range for our sample. Consequently, we can assume that excessive supplementation of vitamin D3 can lead to vitamin D toxicity (VDT), which is linked to hypercalciuria, hypercalcemia, elevated 25(OH)D > 150 ng/mL (>375 nmol/L), and may result, among others, in hearing loss [However, the studies are inconsistent, and, to our knowledge, D3 supplementation is not recommended in any national or international tinnitus guideline. This may well be related to the low explanatory power: in our model, vitamin D3 possesses only less than three percent explanatory power in terms of the ing loss , which ding loss  confirmeIn conclusion, a hearing-protective additional intake of D3 may be considered individually for older people. In any case, the expected therapeutic effect is marginal.Exposures to ototoxic and cytotoxic drugs are recognized as factors that increase the risk of developing tinnitus. These factors are known to cause the death of cochlear hair cells by apoptosis rather than necrosis . ResearcThrough our modeling approach, we observed that both age and the vitamin D3 level are positively related to tinnitus loudness, not tinnitus annoyance per se , can impact the auditory system . OtoacouR2) on the one hand. On the other hand, the sign of our effect points towards a decrease in SL with increasing uric acid levels, which should not play a role in dietary advice.Our results indicate a small influence of uric acid on the measured sensation level of tinnitus. This should, however, not be over-interpreted given the comparably low predictive power  but significant effect was observed. In this context, note that the erythrocyte levels differed significantly between men and women . Hence, the effect of the sex variable may most likely result from the sex-specific difference in the erythrocytes. In addition, we could not detect a significant age effect on tinnitus distress, as it has been observed in previous studies . This me, e.g., ,69, whicR2 of almost 37.8%, highlighting the importance of considering construct overlap. Whilst erythrocytes, age, and sex also enter the model, they possess only little predictive power  . In shoIn addition to the statistical analyses presented in this paper, we also conducted a multivariate regression approach for each of the variables, HT, TL, SL, and TQ. More specifically, we relied on an elastic net regression with all the blood markers and the covariates of age and sex as predictors to investigate the possibility that multiple markers jointly possess predictive power. However, compared to the analyses presented in this paper, the results of the elastic net approach (not shown) did not reveal any supplementary information. In particular, no additional clinically relevant impact of the blood markers was discovered.p-values for multiple comparisons. Together with the low contribution to the R2, this underlines that these blood marker effects should be considered with caution. In order to avoid such difficulties and to better determine effect sizes, further investigations via a controlled experiment would be needed. In addition, we considered only age and sex as covariates and could have neglected other important variables .Another limitation also results from the fact that we investigated the effects of erythrocytes, uric acid, and vitamin D3 when considering the covariates, although, in principle, these effects vanish when correcting the resulting R2 values in In any case, given the low predictive power of even our selected blood parameters, one may consider drastically increasing sample sizes in future studies  and distress-related questionnaires, depending on the research question investigated. With the multi-dimensionality of the tinnitus construct, the main concern of this work was to determine possible biomarkers for diagnostics and therapy of tinnitus via the blood parameters. However, in our sample, the predictive power of the blood parameters on tinnitus-related impairments is, in principle, of limited clinical relevance. For tinnitus distress, the erythrocytes seem to be an important factor as a hematological inflammation marker. A different study design could help quantify a potential relationship between tinnitus distress and erythrocytes.For hearing as well as the closely related tinnitus loudness, vitamin D3 appears to be a factor of interest in our data in combination with age. The tinnitus sensation level could vary in intensity due to increased uric acid levels. For clinical practice, it can be recommended, especially in older patients, a controlled supplementation of vitamin D3 could be considered a hearing-protective procedure.


Different classification algorithms were performed for TA, TSS and MI. Linear, quadratic and Mahalanobis discriminant analysis  were found to be the best sample detection methods. The accuracy of the classification methods was 100% for all investigated parameters and cultivars.The FT-NIR technique was used for rapid and non-destructive determination of plum ripeness. The dry matter (DM), titratable acidity (TA), total soluble solids (TSS) and calculated maturity index (MI: TSS/TA) were used as reference values. The PLS correlations were validated via five-fold cross-validation (RMSECV for different parameters: DM: 0.66%,  Prunus nigra, Prunus americana), Chinese (Prunus simonii) and Japanese  species .,19.PrunuThe dry matter content (DM), titratable acidity  (TA), total soluble solids content (Brix°) (TSS), pH and the maturity index calculated from the sugar/acid ratio (MI = TSS/TA) were determined to determine the ripening stage. Three parallel measurements were made for each parameter.The reference methods have already been described in detail in our previous work .−1, and the final spectral image was obtained by averaging 32 sub-spectra.The FT-NIR spectra were recorded, and the data were processed using a Bruker MPA FT-NIR instrument . The diffuse reflectance spectra were recorded with a resolution of 16 cmA rotating quartz sample holder (Ø 85 mm) was used to provide the largest possible surface area. Spectra were taken from the original fruit sample; no sample preparation was applied. Five spectra were recorded for each sample. The evaluation was performed using the average of the parallel spectra .Spectral data were evaluated using OPUS 7.2 . Chemometric evaluation  was performed using the Classification Learner application of Matlab 2022b  and Unscrambler 10.4  software.PCA is an unsupervised pattern recognition technique. Several algorithms, including Singular Value Decomposition (SVD) and NIPALS, can be used to find the principal components. The major practical difference between the two methods is that, unlike for NIPALS, in SVD, the scores are scaled so that the sum of squares of the scores of each component is equal .2 for calibration, Q2 for validation), the root mean square error , the number of the latent variables (PLS factors), the value of the residual prediction deviation (RPD) and the bias. The calculation of these parameters is based on the following mathematical relationships:The most important metrics of the PLSR model are the coefficient of determination ;N = number of samples;2 = squared coefficient of determination for validation.Q2 and Q2 should be as close to 1 as possible, and that RMSECV and RMSEP and the associated bias (which should be no more than one-tenth of the mean squared error) should be as low as possible. Residual prediction deviation (RPD) is a model-specific quality parameter calculated from R2 and Q2, but as it is not an independent datum, not everyone uses it. Nevertheless, experience shows that this parameter helps to qualify the model. If the RPD > 3 (this means Q2 > 0.89), the model is considered excellent for quantitative evaluation [During model building, the main objective is to ensure that the characteristic parameters take the optimal value. This means that Raluation ,23.The maximum number of PLS factors was set to ten depending on the number of samples tested to avoid the under- or overfitting.Data preprocessing was performed in order to reduce variations in the spectral data  using the following methods: straight-line subtraction (SLS) standard normal variate (SNV), multiplicative scatter correction (MSC), derivatives  or a combination of SLS, SNV and MSC with FD or SD algorithms ,25,26.The PLSR models were validated through random three-fold cross-validation and test set validation. For the latter, the dataset was split in a 70:30 ratio . The training and test samples were randomly selected. However, the allocation of the samples also took into account that both datasets should cover the full range of measurement parameters.Different supervised learning algorithms were performed  using spectral data with different classification criteria based on maturity of the sample. All models were validated using a random five-fold cross-validation procedure .P), true-negative (TN), false-positive (FP) and false-negative (FN) values, correctly classified results NCORR and total results NTOT using the following equations [The model performance was evaluated based on commonly used classification metrics, such as sensitivity, specificity, precision and accuracy. These were calculated based on the number of true-positive SeThe measurement results provided by the reference methods and the reference data available in the literature are summarized in −1 wavenumber range. A vibrational transition of the bonds and functional groups of sugars and organic acids can be detected in this range.In comparing the spectra of the two cultivars, characteristic differences can be seen in the raw spectra  in the 5−1 range is related to the color of the samples and therefore should be ignored. Differences between the first-derivative spectra of cultivars can be observed in several wavenumber ranges  and surface inhomogeneity can be eliminated via spectra derivation. Therefore, a qualitative comparison of the spectra on the first or second derivatives is appropriate. The difference in the 12,500–11,000 cmr ranges . The difhe fiber ,36.The vibrational regions of the important parameters for the mature state—DM, TA and TSS—are marked in different colors in Chemometric assessment—including PCA, PLS and classification methods—were performed using Unscrambler 10.4 and the Classification Learner application of Matlab software.PCA was performed using the SVD algorithm with 10 principal components to cover the variability of the samples.A five-fold random validation was used as a control.The following criteria were set in the PCA algorithm: the ratio of calibrated to validated residual variances should be 0.5, the ratio of validated to calibrated residual variance should be 0.75, and the residual variance increase limit should be 6%.It can be concluded that based on the residual variance , the firIn examining the three principal components, it can be seen there are some samples that fall outside the 95% confidence interval (ellipse) a,b.2 relationship need to be examined . Since high residual variance is associated with less important spectral regions, these samples need not be excluded from the model.It was observed that samples with high F residuals but low Hotelling’s T2 but low F residuals, i.e., samples lying in region C of the plot, are well described by the model (sample S16). However, such samples may be influential to the model.Samples with high Hotelling’s T2 and influence the model. In our case, there were no such samples.The classic outlier samples, which are located in region D, have high F residuals and high Hotelling’s TScore plot analysis was used to examine the impact of the reference data. Correlation loadings were calculated for each variable for the displayed principal components, as shown in The TSS value is located at the 100% ellipse. The DM is close to the 100% ellipse and is on the positive side, as is the TSS value. In contrast, the TA is in the negative range as expected, as the titratable acidity and the total soluble solids content of the sample move in the opposite direction during ripening.The pH point is in the positive range between the 50 and 100% ellipse. This is interesting because pH and TA change in opposite directions due to the nature of pH. However, it should be noted that pH is not a robust property and therefore not the best indicator of the state of maturity. The first principal component is clearly determined by the TSS value (PC-1 = 95%), while PC-2 is determined by DM (PC-2 = 4%). Titratable acidity has a small effect (PC-3 = 1%) b.The PLSR models with the best statistical parameters are summarized in 2 > 0.900 and RPD > 3 were obtained for both cross-validation and test set validation for all parameters tested except for dry matter content.Prediction models for QA good model has also been established for the statistical properties of pH, but this relationship is only apparently correct. The pH values had a very narrow measurement range (2.95–3.99) during the tests, often only varying within one hundredth of a percent. It was concluded that this property is not sensitive enough to determine maturity; therefore, this model is not included in Classification models were tested according to maturity (mature/immature) and variety (Stanley/Elena). Taking into account the literature data and our measured results , the TA As a first step of the spectrum-based classification, ten principal component PCA data reductions were performed. Classification models were then established for the mature/immature samples based on each of the investigated properties .The best-performing relationships were identified via different types of discriminant analysis .Taking into account the reference data and the spectral data, it can be concluded that the same samples were classified as mature based on the parameters TA, TSS and TSS/TA by the two datasets, except for one sample. This one sample was S21, whose TSS fell within the range established for mature samples but whose TA was 1.16% by weight, i.e., outside the range of ≤1.00% established by us. Therefore, this sample was proved to be immature based on TA.Unfortunately, as described earlier, DM and pH values are not considered good indicators of maturity status. The relationship between DM values and maturity is not fully clear.The same problem arises for pH values for the PLSR model. Therefore, no classification was performed for either DM or pH.Using the classification models applied to the spectra, mature/immature samples could be classified with 100% accuracy.For the different varieties, the classification of Stanley and Elena samples based on spectra analysis alone was also perfect, with 100% accuracy.Ripeness is generally characterized by values of TA, TSS and MI. Measuring the hardness of the flesh of the fruit could be added in order to refine the evaluation of ripeness .An extension of the sampling period is also recommended. A longer sampling period would result in establishing categories of immature, medium mature, mature and over mature. The meaning of ‘ripe’, which is different in the sense of commerce, storage and canning, could also be specified.w/w, RMSECV: 0.66%, w/w, RMSEP: 0.65%, w/w) titratable total acidity , total soluble solids  and maturity index  of plum samples.A non-destructive FT-NIR technique was successfully developed for the determination of the dry matter  and Mahalanobis discriminant analysis (MDA) produced the most favorable results.The classification of mature and immature samples was performed with 100% accuracy for the TA, TSS and MI = TSS/TA parameters.Consequently, it can be stated that the determination of the mature state can be made based on TA, TSS and TSS/TA values.The relationship between the studied parameters and plum varieties was also investigated. It was found that the models developed were able to distinguish between the Elena and Stanley varieties with 100% accuracy. This is very important as the varieties have more or less different characteristics, so their uses may also differ. In summary, prediction models provide rapid quality control, even on the production line. Classification models based on spectral databases allow for rapid, even automatic, identification of varieties and maturity status.


Introduction: The aim of this study is to analyze the available scientific evidence regarding the quality of life (QoL) and sexual function (SF) in patients affected by cervical cancer (CC) after surgical and adjuvant treatments. Materials and Methods: Preliminary research was conducted via electronic database  with the use of a combination of the following keywords: SF, QoL, and CC. The principal findings considered in the present review were the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered, and the principal findings concerning SF and QoL. Results: All studies were published between 2003–2022. The studies selected consisted of one randomized control study, seven observational studies (three prospective series), and nine case control studies. The scores used were focused on SF, QOL, fatigue, and psychological aspects. All studies reported a decreased SF and QOL. The most developed questionnaires were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression scale (HADS), and the Female Sexual Distress Scale (FSDS). Discussion: All studies reported a decreased SF and QOL. In addition to the perception of body image, several factors coexist in influencing the outcomes such as the physical, hormonal, psychological. Conclusions: Sexual dysfunction after CC treatment has a multifactorial aetiology which negatively affects the quality of life. For these reasons, it is important to follow and support patients with a multidisciplinary team  before and after therapy. This type of tailored therapeutic approach should become a standard. Women should be informed about possible vaginal changes and menopausal symptoms after surgery and on the positive effects of psychological therapy.  Cervical cancer (CC) is the fourth most common neoplasm among women, with a highest incidence in young women . In 2019In recent years, thanks to the strengthening of screening programmers, through the Pap Test, the Human Papilloma Virus (HPV) DNA test and the HPV vaccination, there has been a significant decrease in incidence and an increase in survival rates for CC: ,6,7,8,9.In May 2018, the World Health Organization (WHO) has launched a global call for action to eradicate cervical cancer ,11,12,13A significant percentage of CC patients experienced frequent sequelae after treatment, such as decreased sexual desire, vaginal dryness, dyspareunia, depression, and anxiety. These aspects acquire greater relevance considering that the most CC patients are relatively young. Currently, the quality of life (QoL) of cancer patients has gained more relevance than in the past, and the efficacy of treatment is not the only aspect to evaluate. In this context, especially for young patients, achieving regular sexual function is extremely important ,29. HoweMany recent reviews focused on quality of life and the sexual function of patients with cervical cancer and have only evaluated the sexual dysfunctions of patients undergoing chemo- radiotherapy plus interventional radiotherapy ,36,37. TFurthermore, it is unclear whether the dysfunction is attributable to surgical sequelae, radiotherapy, chemotherapy, or psychological aspects related to cancer. In fact, psychological factors alone caused by the cancer diagnosis may also negatively influence sexual functioning independently of the type of treatment or stage of cancer.During oncological evaluation and follow-up, information and communication about sexual issues is often lacking. The aim of this study is to analyze the available scientific evidence regarding QoL and especially the sexual function (SF) of patients affected by CC after surgical and/or medical and radiological treatment.This systematic research has been performed in agreement with the Preferred reporting items for Systematic reviews and Meta-analysis statement (PriSMa). A comprehensive literature research on electronic databases  was conducted from inception until July 2022. The primary research strategy was identified with the use of a combination of the following medical relevant headings terms (MeSH) and keywords: “sexuality and cervical cancer”, “sexual function and cervical cancer”, “cervical cancer and sexual dysfunction”, “sexuality and gynecological cancer”, “sexual dysfunction and gynecological cancer”, “sexual dysfunction and cervical cancer”, “cervical cancer and Quality of Life”, and “gynecologic cancer and Quality of Life”. Studies evaluated that were not in line with the aim of the study, case reports, papers based on animal models or laboratory studies, and non-English language articles were excluded. The electronic research and the eligibility of the studies were independently assessed by two of the authors . In addition, references in the included articles were reviewed to identify additional eligible articles. Differences were discussed with a third reviewer (SC) for data extraction.The main findings considered in the present review were the study design, the number of patients included in each study, information about the pathology (histology and stage of disease), the questionnaires administered, and the principal findings concerning SF and QoL. The data extracted were the author, year of publication, number of patients included, study population characteristics , main outcomes, main findings, and sexual and quality of life questionnaires. After the initial research, a total of 12177 titles were extracted from the Pubmed database, MEDLINE, and Cochrane Library using the keywords previously mentioned. After the first revision, 122 unique studies were extracted. After further revision, 25 articles were selected, out of which 18 studies were ultimately eligible for the present review following a full text evaluation. The selection process is illustrated in A total of eighteen studies treating both SF and QoL in patients affected by CC were extracted. All studies were published between 2003 and 2022 and are reported with the main findings and characteristics shown in The selected studies were represented by one randomized study, eight observational studies (three prospective studies), and nine case control studies. Different validated scores were used to assess SF and QoL in the different studies; however, the most frequently administered questionnaires were the European Organization and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30), the Quality of Life Questionnaire for Cervical Cancer (EORTC QLQ-CX24), the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression scale (HAD S), the Sexual Function-Vaginal changes Questionnaire (SVQ), and the Female Sexual Distress Scale (FSDS).The study of Kirchheiner et al.  reportedp ≤ 0.001). Regular hormonal replacement therapy (HRT) was associated with a significant improvement in vaginal dryness (p = 0.015), vaginal shortening (p = 0.024), and pain during intercourse (p = 0.003).These symptoms were negatively correlated with sexual enjoyment . Moreover, CC survivors had more severe menopausal symptoms and worse self-body image. Furthermore, SF was impaired, as women with CC had more anxiety about sexual performance and worse vaginal functioning (p < 0.01). The sub-analysis performed, based on the treatment received, demonstrated that sexual dysfunction was more severe in women who underwent radiotherapy. Moreover, patients who received both surgery and radiotherapy experienced a higher decrease in SF than women that only had surgery. In addition, chemotherapy was linked to dyspareunia (odds ratio [OR]), 1.6; 95% CI, 1.4–2.0), anxiety about sexual performance , and insufficient vaginal lubrication  in a multivariate analysis. Finally, a high association between sexual problems and a QOL decrease in CC cancer survivors was recorded. The study by Park et al.  reportedJensen et al.  prospectp = 0.008) and sexual interest.Compared with controls, CC patients experienced significantly severe orgasmic dysfunction and uncomfortable sexual intercourse due to a reduced vaginal length during the first 6 months after radical hysterectomy, reporting severe dyspareunia during the first 3 months . However, there was no significant difference in SF. Fourteen patients (40%) did not have sexual intercourse either before or after irradiation. Dyspareunia was significantly reduced (p = 0.009) after therapy, while vaginal function in terms of lubrification improved significantly.Ljuca et al.  evaluateBakker et al.  analyzedp = 0.004) and RH/radiotherapy (p = 0.008). However, no differences were recorded compared to women treated with RH/radiotherapy/brachytherapy (p = n.s.). Higher levels of sexual distress were significantly correlated to vaginal symptoms such as dryness, sexual pain, worry, anxiety, depression, and body image concerns.The severity of vaginal sexual symptoms reported by sexually active participants was significantly different according to the treatment received: patients who underwent radiotherapy/brachytherapy reported significantly higher vaginal discomfort than women who underwent RH (p < 0.01), and it persisted during the 2-year follow-up; furthermore, the intensity of orgasm and sexual arousal was significantly reduced at 1 year of follow up. CC survivors reported more deep dyspareunia (p < 0.01) and abdominal pain during intercourse at 2 years after treatment (p < 0.01) than healthy women. Moreover, worse psychological functioning before surgery and at 6 months after surgery were reported in the CC patients compared to healthy controls, as no differences were recorded at the 2-year follow-up. Aerts et al.  prospectIn CC patients, the quality of their before the surgery was better than in healthy controls, while it decreased during the first year of follow-up compared to the interval before surgery.n = 33) in comparison to a control group (n = 37) of women without a history of cancer using the FSFI test. SF decreased among the CC survivors, and 59.5% of women reported that the diagnosis and/or treatments of CC interfered with their sexuality. No differences were noticed with regard to sexual frequency in active women among the two groups. The mean scores of the cancer group were statistically inferior (p < 0.05) than those of the control group in all of the FSFI domains and in the total score. The mean total score in cancer survivors was 21.72. A FSFI score lower than 26 is indicative of sexual dysfunction. The authors reported that 64.9% of CC women reported vaginal stenosis or shortening; 59.5% were sexually inactive, and among those sexually active, 80% complained of sexual dysfunction.Correa et al.  investign = 104), with 45 months of median interval from diagnosis, and the healthy women group (n = 104). The authors did not record any statistical difference in SF between the two groups. It should be noted that, during the enrollment, 38.2% (91/238) of CC survivors and only 10.6% (28/265) in the control group were excluded due to the absence of sexual activity within 3 months.Lee et al.  comparedFifty-two patients who underwent surgery for early CC cancer were enrolled by Carter et al.  to assesIn a Swedish study by Hofsjo et al. , 34 patiThe women with cancer complained of worsening SF. The highest relative risk (RR) was reported for insufficient vaginal lubrication (RR 12.6), vaginal elasticity reduction (RR 6.5), reduced genital swelling when sexually aroused (RR 5.9), and the reduction of vaginal length during intercourse (RR 3.9). The frequency of orgasm was also lower in CC patients. De Rosa et al.  investigPlotti et al.  retrospep < 0.001) and physical well-being, social well-being, and functional well-being (p = 0.001). Instead, the correlation was not significative with psychological well-being (p = 0.223).Bae et al.  reportedp = 0.30). In the laparoscopic group, 75% of women reported an impaired SF, 20% reported no change, and 5% reported an improvement post-RH; in the laparotomy group, the proportions were 55.5%, 33.4%, and 11.1%, respectively. In addition, at the time of FSFI administration, 14 (36.8%) women had not yet resumed sexual activity (8/20 (40%) in the laparoscopic group vs. 6/18 (33%) in the laparotomy group; p = 0.74). Serati et al.  comparedn = 46) or control group . The intervention group received a 4-week PERMA model-based multidisciplinary team  psychological intervention in addition to the usual care. The PERMA model is based on five independent elements: positive emotion (P), engagement (E), relationships (R), meaning (M), and accomplishment (A).A unique published randomized control study  analyzedp = 0.005 at 3 months post-intervention; mean difference: −4.36, p = 0.001 at 6 months post-intervention), compared to the control group. In addition, the levels of depression and well-being in the intervention group were better in the intervention group (p < 0.05).The authors analyzed the FSFI, the Self-rating Depression Scale, and the index of well-being to assess their aims at baseline and at 3 and 6 months after intervention. The SF was significantly improved in the intervention group  within the first 3 months after the end of radiotherapy treatment.Cerentini et al.  tested tStanca et al.  used theAll studies showed a general decrease of SF in patients with CC. However, the reasons for the increase in sexual dysfunction were different. The stage of the disease and the consequent therapeutic treatment were the two most important factors for sexual dysfunction. However, most studies had a sample with different cancer stages and with patients who underwent different treatments.Several studies, such as those by Park, Stanca, Plotti, Bakker and Serati et al. ,50,52,55Sexual dysfunction after CC treatment has a multifactorial aetiology which negatively affects the QoL. The most frequent causes of sexual dysfunction are psychological factors such as depression, loss of interest in sex, anxiety, and the presence of surgical scars that affect body self-image. Another important psychological factor is the fear of cancer recurrence that affects all aspects of life ,57,58. FQoL encompasses several aspects of a person’s life in addition to a healthy sexual life, such as work activities, friendship, hobbies, and sport. The balance between all factors determines a healthy equilibrium, and therefore a positive spectrum of life quality. Conversely, factors negatively influencing the right balance can determine a chain reaction that contributes to a decrease in wellness. A cancer diagnosis and consequent surgical and/or medical treatments could be one of the most relevant destabilizing factors. Considering the CC characteristics and its development in the genital area, the impact on SF becomes more relevant, especially in young women with an active sexual life.As previously mentioned, patients affected by CC can experience relevant changes in different aspects of life, such as the psychological state (such as anxiety and stress), body appearance, malnutrition (particularly during adjuvant therapy), relationship misunderstandings with their partner, and functional and anatomical problems. Undoubtedly, the impact of CC on QoL, as reported in the literature, could be different depending not only on the treatment adopted, whether surgical, medical, and/or radiation therapy but even by age, personal characteristics, and social aspects.The surgical approach that is most adopted for CC treatment is the RH. The procedure consists of the resection of the parametrium and part of the vagina. The radicality of the surgery depends on the disease stage. This surgical approachis often associated with post-surgical complications, due to the radical nature of the surgery and neurological dysfunction. The nerves’ damage may cause: bladder function, intestinal dysfunction, vaginal shortness and dryness. The CC surgery could often be associated with chemotherapy and radiotherapy, which could enhance the genital dysfunction. All of these physical aspects associated with the psychological status could significantly interfere with SF and QoL.The surgical approach could be endoscopic (laparoscopic or robotic) or laparotomic, depending on the different clinical and oncological aspects and the hospital’s internal guidelines.p = 0.004) (p = 0.002).Following the Laparoscopic Approach to Cervical Cancer (LACC) trial , the surSeveral studies in the literature have evaluated the advantages of endoscopy both for benign pathology and oncology ,63,64.Minimally invasive surgical techniques employed on gynaecologic cancers, such as ovarian and endometrial cancer, have demonstrated advantages in improving surgical and aesthetic outcomes in selected cases ,66,67, wThe limitation in the choice of surgical approach, based on the literature data, could contribute to a further increase in sexual dysfunction. Moreover, given the young average age of CC diagnosis and the impact of invasive treatments, the SF and QoL aspects need to acquire more relevance, and they should be considered in all phases of the treatment path, from counselling to follow-up ,69.Radiation therapy has an impact equivalent to surgery on SF, reducing the vaginal length and enhancing the vaginal dryness due to an actinic reaction.The CC patients frequently undergo both surgery and radiation therapy, with the consequent reduction of the length and elasticity of the vagina. Even for patients submitted to exclusive chemo-radiation, the effects of brachytherapy are often superimposable.As a consequence, for all these patients, sexual intercourse may be difficult and painful, and most of them are not able to achieve fulfilling sexual intercourse.p < 0.05) in all questionnaires. This control study confirmed the negative impact that cervical cancer with medical therapy can have on women. However, a limit of the study was that the main treatment consisted of a combination of chemotherapy, radiotherapy, and brachytherapy, and did not include patients who underwent surgery. In fact, it is currently unclear whether the sexual dysfunction is attributable to surgical sequelae, chemo-radiotherapy, both, or all of these therapies.Recently, Beltran et al.  investigCancer survivors experience a loss of interest in sex and a consequent decrease in sexual activity, especially immediately after the treatment. In fact, the negative impact on the woman’s life is higher at the beginning of the treatment plan . The mosAll of these influencing factors are relevant, and it is important to know them in order to be able to attend to them promptly and effectively.For these reasons, as confirmed in the study by Galicaa J. et al. , is impoThis type of tailored therapeutic approach should become a standard treatment, as the principal goal is not only to fight the pathology but also to achieve a good QoL for patients.This article aims to give an overview of the latest findings related to QoL and SF in CC treatment. The most important limitation of this review is related to the heterogeneity of the available studies. The available studies present different designs and a significant heterogeneity of patients who underwent different treatments. Moreover, the studies were conducted during different periods, from 2003 to 2022, and the treatments adopted are not sufficiently comparable due to the evolution of therapeutic strategies over time. Finally, the most significant shortcoming is the fact that most of the studies had a small number of patients, and the tests used are different and not always comparable. It is clear from all studies that CC has an impact on Qol and SF, but it is unclear whether it is more related to a psychological condition or to a consequence of medical or surgical treatments. Prospective studies using standardised questionnaires are needed to reach definitive conclusions.The current study, however, despite the limitations previously reported, did result in some important findings. The impact of medical (chemoradiation therapy) vs. surgical treatment on SF remains controversial because the studies reported different conclusions .Some authors have suggested that there are no significant differences in SF and QoL depending on the surgical approach, and that most CC cancer patients report an improvement of SF and the disappearance of vaginal problems over time. However, based on the results of most studies, the combined approach of surgery and radiotherapy seems to have the most negative impact on SF .A key aspect remains that, after CC diagnosis, both patients and their families and care professionals should focus not only on treating cancer, but must not forget that an adequate quality of life must be maintained.In this field, the personalisation of cancer treatment is essential, and must take into account such factors as age, social status, and expectations. Furthermore, it is important to provide psychological and psychophysical support, not only during treatment but also afterwards. Moreover, several studies have proven the importance of different types of support, in addition to psychotherapy including: exercise, yoga, and biofeedback ,79,80,81Over the years, thanks to technological innovations, surgical and medical treatment approaches have reduced their physical impact, while maintaining the same levels of efficiency. Although this is an important point, it cannot be considered sufficient to overcome the entire impact on the QoL and SF of cancer patients, which can only be achieved with constant support. It is relevant that sexual disfunction after CC treatment tends to improve over time ,83. EvidIndeed, it is important to understand that the psychological aspects related to cancer treatment and the consequent impact on QoL and SF are related to several factors that might be different in patients, such as age, social status, work, geographical area, religion, etc. Consequently, it is crucial to adapt the treatment according to the patient’s characteristics. A relatively new factor that should be taken into account is cancer prevention and screening. Even though screening programmes and cancer prevention strategies are still relatively ineffective for most cancer diseases, CC has a great potential for reduction through prevention and early detection. This should publicised more widely, as it seems to be the key strategy in terms of fighting CC.In 99% of cases, CC is caused by HPV infection ,87,88, aThis study aimed to furnish a complete overview of QoL and SF aspects in CC patients. As previously reported, the available literature presents some discrepancies in terms of the heterogeneity of studies, the small number of cases, and the use of different questionnaires; thus, even the different study results are not always in accordance, making it impossible to reach definitive conclusions.However, despite the limitations, it was possible to reach certain conclusions:First of all, the evidence confirms the importance of a multidisciplinary approach for CC patients, which should focus, in a first phase, on understanding the patient’s characteristics and expectations, with the aim of tailoring the best treatment options for them. The second phase should be aimed at offering patients the best psychological support, with the goal of understanding their needs and preventing them from feeling alone in their fight against cancer. This phase should even be supported by a balanced diet and physical activities, which are an integral part of oncological and psychological therapies.Psychological support remains crucially important for all oncologic patients. Several studies have demonstrated that psychological support has a positive impact on treatment adherence and oncologic outcomes ,108.Third, the therapeutic approach should be tailored not only based on pathology, but also on patient characteristics and expectations, because, as demonstrated in some studies ,110, somFourth, it is necessary to conduct prospective studies with validated questionnaires in the near future in order to evaluate the impact and possible benefits on SF and QoL of different treatments. These studies should investigate all possible factors involved in potential changes of SF. Several investigations should be conducted on surgical techniques and approaches  and the impact of different treatment modalities  on sexual function.Future perspectives on CC treatment, including the improvement of QoL and SF, should be directed towards overcoming the pathology through cancer prevention, with the aim of eradicating a disease that has a significant oncological and social impact and often affects young patients.