Bothrops bilineatus) is an arboreal snake that is currently represented by two subspecies (B. b. bilineatus and B. b. smaragdinus) that comprise a species complex, and its distribution is in the Amazon and the Atlantic Forest. The rarity of encounters with this snake is reflected in the low occurrence of cases of snakebites throughout its geographic distribution and the resulting low number of published clinical reports. However, in some areas, B. bilineatus proves to be more frequent and causes envenomations in a greater proportion. Herein, we review the main aspects of the species complex B. bilineatus, including its biology, ecology, taxonomy, morphology, genetic and molecular studies, geographic distribution, conservation status, venom, pathophysiology and clinical aspects, and epidemiology. In addition, the different antivenoms available for the treatment of envenomations caused by B. bilineatus are presented along with suggestions for future studies that are needed for a better understanding of the snakebites caused by this snake.The two-striped forest-pitviper ( Bothrops bilineatus) is an arboreal snake that is currently represented by two subspecies (B. b. bilineatus and B. b. smaragdinus) that comprise a species complex, and its distribution is in the Amazon and Atlantic Forest, though it is absent in intermediate open and dry habitats , bico-de-papagaio (Mato Grosso and Rondônia), cobra-papagaio (Amazonas and Pará), jararaca-pinta-de-ouro (Pará), paraamboia (Pará), surucucu-de-patioba (Pará) and surucucu-pingo de ouro, surucucu-de-ouricana, ouricana, patioba (Bahia) (víbora-loro (Bolivia), loro and palo verde (Ecuador), loro machaco (Peru), mapanare verde and mapanare rayada (Venezuela) . Known mainly as  (Bahia) , 10, 14.nezuela) .Bothrops bilineatus has been classified as belonging to the B. taeniatus species group by all recent studies that are focused on the systematic of Bothrops . At theMiranda,  based onMiranda,  split Boo et al. , which iBothrops . TherefoB. bilineatus was described by Wied-Neuwied (1821) as Cophias bilineatus, based on two individuals from Brazil (“Brasilien”). Although undefined in the original description, the type’s location was restricted by Hoge and Lancini  and in the Amazonian regions of Colombia and Ecuador . The eastern limits of the distribution of the Western Amazonian lineage seem to be represented by the Orinoco and Negro Rivers . PresentB. b. bilineatus in any subsequent publication. Based on his results, we can suppose that the Atlantic Forest lineage represents B. b. bilineatus, but the allocation of the Guiana Shield lineage into this subspecies or in a new currently undescribed taxon is still open for investigation. The Western Amazonian lineages probably represent the subspecies B. b. smaragdinus, and the morphological limits between this lineage and the Central Amazonian lineage seem to be unclear, as well as the limits between the distribution of both lineages. He also suggested that there is evidence to support a possible split of the Western Amazonian lineage into two taxa, one in the north and the other in the south. The Central Amazonian lineage likely represents an undescribed taxon for the B. bilineatus complex, which is morphologically and genetically distinct   in his udistinct .B. bilineatus will certainly change in the next years. The subspecies will be probably elevated to the species level and at least two new taxa will be described for the complex  and females with 260 mm (3.7 g), 265 mm (3.7 g) and 265 mm (4.1 g)  . In Pará (4.1 g) . Althoug (4.1 g)  reportedBothrops bilineatus occurs in lowland rainforests, especially those associated with watercourses , while others are more generalist, feeding on various animal groups    . Bothropand bats , 60–65. and bats  observedand bats , usuallyB. bilineatus is that of waiting, and the snake often uses the caudal decoy behavior  that feed preferentially on anurous amphibians and, during their development, the adult individuals lose this light coloration at the tip of the tail and cease to perform this behavior (B. bilineatus retain the distinct coloration of the tip of the tail (white or brown) and continue to use the caudal decoy tactic during hunting activity, probably because ectothermic prey (anurous amphibians and lizards) continue to be important in their diet  and arboreal species  (B. bilineatus is the one that has been recorded at higher heights (up to 18 m high)  , with some records of them staying longer; two (9 times) and three (6 times) days, with two specimens that were observed for 15 and 17 days.Among the species of eniatus) , 67, 68,ree days . In a loB. bilineatus was more frequent during the dry season in a lowland forest in the western Amazon, while its congeneric B. atrox was more abundant in the rainy season  migrate vertically to lower heights in search of more humid environments and B. bilineatus would also probably be more active in this forest strata in search of this type of prey.Studies of communities and populations of snakes in the Amazon and the Atlantic Forest have shown that these animals present more activity and are thus more frequent during the wettest and warmest months , 48, 70,Bothrops bilineatus is a viviparous snake, with data recording mating between July and August when in captivity, and gestation from 191 to 208 days and parturition in February  were the most abundant toxins with the predominance of the PIII-class; snake venom serine proteinases (SVSP), C-type lectin-like proteins (CTL), phospholipases A2 (PLA2), cysteine-rich secretory proteins (CRISP), and L-amino acid oxidases (LAAO) were also detected in all samples, representing the major components of their venom proteomes. Bradykinin-potentiating-like peptides (BPPs) and the tripeptide inhibitors of SVMPs were also abundant in the three samples analyzed in one of the studies , SVSPs are catalytically active proteins that are able to catalyze the polymerization of fibrinogen into fibrin and are commonly termed thrombin-like enzymes. SVSPs also activate coagulation factors and induce platelet aggregation by cleavage of PAR1-receptors. Anti-coagulant activities of SVSPs have also been described including the activation of plasminogen and protein C, as well as the kallikrein-like activity  values for Brazilian (102.92 μg) and Peruvian (92.74 μg) B. bilineatus in mice (18-20 g)  , 84.Bothrops bilineatus is classified as Highest Medical Importance (Category 1) in Ecuador, Peru, Colombia and Guyana and of Secondary Medical Importance (Category 2) in Brazil, Bolivia and Venezuela. Although they are highly venomous snakes, exact epidemiological or clinical data are lacking and they are less frequently implicated because of their behavior, habitat preferences, or occurrence in areas remote from large human populations.B. bilineatus venoms thus explains the signs of envenomations presented by human patients bitten by these snakes, including the local inflammatory reaction, local tissue damage, and coagulation dysfunctions , though it displays lower activity when compared to other venoms from Bothrops, Crotalus, and Micrurus snakes, which is possibly due to the low amounts observed in B. bilineatus venom proteomics   with neglected systemic myotoxicity when administrated IV  were capable of reducing cell infiltration, indicating that lipid mediators are involved in the venom-induced response   . Indeed,e damage . Thus, tB. bilineatus venom is capable of promoting hemostatic alterations. This is reported for venoms from other Bothrops species and is due to the abundance of SVMPs, SVSPs, and CTLs, which are hemostatically active toxins that are capable of interfering in several events such as the coagulation cascade, platelet function, and fibrinolysis. Moreover, SVMPs are potent hemorrhagins that consist of a class of toxins capable of acting on extravascular targets, such as matrix extracellular components of endothelial basal membranes, in order to induce vessel disruption and consequently local and systemic hemorrhage , as well as the presence of thrombin-like toxin(s). As a result, B. bilineatus venom was found to promote hemostatic alterations, as cited by Silva  the development of an unclottable state, associated with the consumption of hemostatic factors, and culminating in hemorrhagic events; and (2) the formation of intravascular thrombus, resulting in the reduction/cessation of tissue permeability and causing end-organ failure   , 36% in olombia)  and 5.3%olombia) .Bothrops bilineatus was the most commonly found species during night searches, and corresponded to 54% of the snakes, which was more than B. atrox (20.7% of the encounters)  and even close to the ground (heights of 30 to 40 cm)  , which co 40 cm) , 129.B. bilineatus occur mainly during activities within forests, such as during the opening up of new trails [e.g. (Euterpe precatoria)  was very often found on the “piaçaba” (Leopoldinia piassaba) and that they were often bitten during the extractivism of this palm. In two cases of snakebite caused by B. bilineatus during the acai extractivism, the extractivists were 4 and 8 m high climbing the acai palm and the snake was on a neighboring tree (B. bilineatus) on the acai palm or on a neighboring tree. The evidence indicates that B. bilineatus usually hunts waiting at the top of the acai trees or in the neighboring trees, waiting for small mammals  that will feed on the fruits of acai, and may eventually bite the extractivists  . The greironment Figure 3ironment  mentioneing tree . Silva eing tree  interviectivists .B. bilineatus snakebite is the use of animal-derived antivenoms. So far, there are three different antivenoms (AV) that can be used to treat B. bilineatus envenomation: (1) Bothrops AV (2) Bothrops-Crotalus AV and (3) Bothrops-Lachesis AV  was able to recognize B. bilineatus venom by cross-reactivity; however, when B. b. bilineatus proteins were analyzed individually, it demonstrated low reactivity for some of them  within 24 hours after starting treatment with Colombian, Brazilian and Ecuadorian antivenoms  and endothermic adults , are characterized by differences in the composition of their toxins that are related to the animal groups on which they feed. The hunting tactic of caudal decoy to attract amphibians that is widely used also by adult individuals instigates the conduct of studies on possible ontogenetic variation of toxins.Some species of B. bilineatus makes the knowledge about the therapy relatively incipient, which when associated with the peculiar epidemiological circumstances of the snakebite usually involving higher regions of the body and associated with human activities within forests, provides the need to expand the clinical and epidemiological studies with this snake.The scarcity of clinical reports of poisoning by Bothrops bilineatus is a species complex encountered in forests of the Amazon and the Atlantic forest, which presents arboreal habits and different population densities throughout its geographical distribution, being generally uncommon in some areas and relatively more abundant in others. These differences in the abundance of B. bilineatus probably reflect in the proportion of cases of snakebites in each region and their rarity in much of its geographical distribution.The snake B. bilineatus, usually occurring at heights greater than the height of a human being, tends to link the snakebites with human activities within the forest  when it is on the lower strata of the vegetation or when the person is climbing palm trees during extractivism. Its green coloration and sedentary behavior make B. bilineatus well camouflaged in the environment, which increases the chances of it not being seen and, when approached or touched by a human, its defensive response often ends in an envenomation. Since extractivism often requires climbing palm trees and other trees, care and attention are essential in order to prevent envenomations by this snake.The arboreal and forest habits of PS and WM conceived the main idea of this work. All authors designed and wrote most of this review’s topics. FC, MA, and WF elaborated the figures of this review article. All authors corrected the manuscript and provided important contributions during the development of this work. All authors contributed to the article and approved the submitted version.Conselho Nacional de Desenvolvimento Científico e Tecnológico  and Fundação de Amparo à Pesquisa do Estado de São Paulo . WM acknowledges funding support from Fundação de Amparo à Pesquisa do Estado do Amazonas . MP (Snakebite Roraima project coordinator) acknowledges funding support from Hamish Ogston Foundation - Global Snakebite Initiative.We thank The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: To establish a pre-operative acute ischemic stroke risk (AIS) prediction model using the deep neural network in patients with acute type A aortic dissection (ATAAD).Methods: Between January 2015 and February 2019, 300 ATAAD patients diagnosed by aorta CTA were analyzed retrospectively. Patients were divided into two groups according to the presence or absence of pre-operative AIS. Pre-operative AIS risk prediction models based on different machine learning algorithm was established with clinical, transthoracic echocardiography (TTE) and CTA imaging characteristics as input. The performance of the difference models was evaluated using the receiver operating characteristic (ROC), precision-recall curve (PRC) and decision curve analysis (DCA).Results: Pre-operative AIS was detected in 86 of 300 patients with ATAAD (28.7%). The cohort was split into a training  and validation cohort  according to stratified sampling strategy. The constructed deep neural network model had the best performance on the discrimination of AIS group compare with other machine learning model, with an accuracy of 0.934 (95% CI: 0.891–0.963), 0.921 (95% CI: 0.845–0.968), sensitivity of 0.934, 0.960, specificity of 0.933, 0.906, and AUC of 0.982 (95% CI: 0.967–0.997), 0.964 (95% CI: 0.932–0.997) in the training and validation cohort, respectively.Conclusion: The established risk prediction model based on the deep neural network method may have the big potential to evaluate the risk of pre-operative AIS in patients with ATAAD. Pre-operative acute ischemic stroke (AIS) is one of important factors that affects the outcomes of surgical treatment and long-term post-operative survival in patients with acute type A aortic dissection (ATAAD) . AlthougComputed tomography angiography (CTA) and transthoracic echocardiography (TTE) have shown high sensitivity in the evaluation of high-risk plaque and vascular anatomy , and thuNeural network has become a popular algorithm for medical data analysis, especially for classification tasks, because it allows us to solve quite complex classification tasks , 9. UnfoOur previous study using univariate and multivariate analysis found that the true lumen diameter ratio of the ascending aorta (aAO), the common carotid artery (CCA) dissection, and the aortic valve insufficiency may be associated with pre-operative AIS . HoweverBetween January 2015 and February 2019, a total of 300 ATAAD patients, diagnosed by aortic CTA and with no history of ischemic stroke or cerebrovascular disease, were retrospectively included in this study. ATAAD patients were divided into two groups according to the presence (AIS+ group) or absence (AIS- group) of pre-operative AIS. Clinical characteristics, TTE imaging information and CTA imaging information were collected. Detailed information was shown in ATAAD was defined as any non-traumatic dissection of the aorta proximal to the left subclavian artery presenting within 14 days of symptom onset (This study complied with the Helsinki Declaration (2000) and was approved by the institutional review board of Xijing Hospital affiliated with the Fourth Military Medical University (20120216-4). Informed consent was obtained from each patient or their legal representative.CTA examinations were performed using a second-generation dual source CT machine  with a high-pitch spiral scan mode. Patients underwent combined CTA imaging of the neck and aorta in the cranio-caudal direction. For all scans, patients were in a supine position with both arms raised. Each patient received an injection of 70 ml of iopromide  at a flow rate of 5 mL/s, followed by 40 mL of saline solution at a flow rate of. Bolus tracking was performed on the suprarenal descending aorta with an attenuation threshold of 100 HU. The scanning parameters were as follows: tube voltage of 100 kV, reference tube current of 300 mAs per rotation, pitch of 3.0 and slice collimation of 2 × 128 × 0.6 mm by means of a z-flying focal spot. The CTA images were transferred to an external workstation  for further postprocessing. Finally, CTA characteristics were identified from each patient CTA imaging by two experts with at least 10 years' experience on radiology imaging.In this study, dataset is stratified split into training (70%) and validation (30%) cohort. A four layers deep neural network was performed with all the clinical, TTE and CTA imaging characteristics as input. The random search method  was usedWhereγ is a adjust factor andγ>0In addition, the univariate and multivariate stepwise logistic regression analysis  , the 10-For Uni + Multi analysis model, characteristics with significant difference between AIS+ and AIS- group in univariate model were included in the construction of multivariate stepwise logistic regression model. For CV LASSO model, all variables were selected through CV LASSO algorithm. For SVM, RF, NN and DNN model, all variables were included in the construction of the model. The first difference between NN and DNN was that the number of nodes for each hidden layer in NN was manually set according to number of input characteristics, while, for DNN, these number was optimized through random search method, which could make the performance of model to the best. The second difference was the weight initialization .https://www.python.org/). The other conventional machine learning model was implemented with R software .The training and validate of the deep neural network and DBN were implemented using TensorFlow 2.0 with GPU support on a Python 3.8 platform  curve as well as precision recall curve (PRC) analysis and the area under the curve (AUC) was calculated. The best cutoff point was obtained by the Youden-index of ROC curve, then accuracy, sensitivity, specificity, positive predictive rate, and negative predictive rate were calculated. To estimate the clinical usefulness of the different models, decision curve analysis (DCA) was conducted by calculating the net benefits at different threshold probabilities , the incidence of hypotension  and tamponade  were significantly higher in the AIS+ group compared to the AIS- group, the systolic blood pressure  and the incidence of the chest and back pain  and were significantly lower in the AIS+ group compared to the AIS- group. Other clinical characteristics did not differ significantly between the AIS+ group and AIS- group. Detailed clinical and TTE imaging characteristics are shown in Pre-operative AIS was detected in 86 of 300 patients with ATAAD (28.7%). Among clinical and TTE imaging characteristics, the age  and the true lumen diameter ratio of the aAO  were lower in the AIS+ group than in the AIS- group. The intimal flap plaque , the CCA dissection , the innominate artery or CCA from false lumen , the low density of the unilateral ICA , the low density of vertebral artery , and the subclavian artery dissection  were higher in the AIS+ group than in the AIS- group. Other CTA imaging characteristics did not differ significantly between the AIS+ group and AIS- group. Detailed CTA imaging characteristics are shown in Among CTA imaging characteristics, the true lumen diameter of the aAO , 0.921 (95% CI: 0.845–0.968), sensitivity of 0.934, 0.960, specificity of 0.933, 0.906, and AUC of 0.983 (95% CI: 0.967–0.997), 0.964 (95% CI: 0.932–0.997) in the training and validation cohort, respectively . The ROCIn this study, four potential risk factors related to pre-operative AIS in patients with ATAAD were found using the neural network method. After CV LASSO regression, we found the age, the true lumen diameter ratio of the aAO, the CCA dissection, the low density of unilateral ICA exhibited the highest importance to the four risk factors, which might suggest that these four characteristics were more important to the assessment of pre-operative AIS. The corresponding results were discussed in detail below.Dumfarth et al. pointed out that the pre-operative infractions in ATAAD patients were more likely to occur in the right cerebral hemisphere, which was consistent with our observations . They alIn the construction of classifications or a prediction model, the univariate and multivariate analysis only takes those characteristics that have significant difference between AIS+ and AIS− group into account and do not consider the information between characteristics. Although the traditional machine learning based feature selection method, such as LASSO regression, SVM and RF, can consider the information between characteristics, this kind of method remains those characteristics that have relatively big contribution to the model. The NN method can make the most use of all the input characteristics, deeply take all the information between them into account, select and merge them into several factors that important to the classifications or prediction model , and thuThis study had some limitations. Firstly, the data used in this study was from a single hospital. Future studies are needed that consider multi-center data to validate the reliability of our constructed risk model. Secondly, this study was a retrospective study, so dataset may contain some bias. Future studies are needed to collect larger amounts of perspective data to the validate results of this study and provide a more objective and scientific theoretical basis for the prevention and treatment of pre-operative AIS in patients with ATAAD. Thirdly, this study only looked at pre-operative data. Future study will use both pre- and post-operative data to further improve the risk model.In summary, this study provided a risk prediction model using deep neural network method to predict the occurrence of pre-operative AIS in patients with ATAAD. This risk model can provide information that is useful for identifying which ATAAD patients are at high risk of AIS before surgery, and therefore, help doctors decide whether patients need follow-up examinations or surgery, and decide the best timing for it.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Xijing Hospital affiliated with the Fourth Military Medical University (20120216-4). The patients/participants provided their written informed consent to participate in this study.HZ, WD, and MZ contributed to the conception and design. RX and JW contributed to the acquisition of data. ZX, JR, and WW contributed to the and analysis of data. HZ, ZX, and MZ contributed to the interpretation of the results. HZ and ZX contributed to the manuscript writing. YZ, WD, and MZ contributed to the manuscript reviewing. All authors contributed to the article and approved the submitted version.This study has received funding by the National Natural Science Foundation of China under Grant No. 81870218, the Subject Boosting Project of Xijing Hospital under Grant No. XJZT18ML20, and the Key Research and Development Plan of Shaanxi Province under Grant No. 2020SF-151.JR and WW were employed by the company GE Healthcare China. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Net survival, estimated in a relative survival (RS) or cause-specific survival (CSS) framework, is a key measure of the effectiveness of cancer management. We compared RS and CSS in men with prostate cancer (PCa) according to age and risk category, using Prostate Cancer data Base Sweden, including 168,793 men younger than age 90 years, diagnosed 1998–2016 with PCa. RS and CSS were compared according to age and risk category based on TNM  stage, Gleason score, and prostate-specific antigen level. Each framework requires assumptions that are unlikely to be appropriate for PCa. Ten-year RS was substantially higher than CSS in men aged 80–89 with low-risk PCa: 125%  versus 85% . In contrast, RS and CSS were similar for men under age 70 and for all men with regional or distant metastases. Both RS and CSS produce biased estimates of net survival for men with low- and intermediate-risk PCa, in particular for men over 80. Due to biases, net survival is overestimated in analysis of RS but underestimated in analysis of CSS. These results highlight the importance of evaluating the underlying assumptions for each method, because the “true” net survival is expected to lie between the limits of RS and CSS. CIconfidence intervalCSScause-specific survivalNPCRNational Prostate Cancer RegisterPCaprostate cancerPSAprostate-specific antigenRSrelative survivalProstate cancer (PCa) is a common cancer in high-resource countries. The incidence of PCa has risen during the last 2 decades, mostly due to an increased detection of low- and intermediate-risk disease due to testing of serum levels of prostate-specific antigen (PSA) and ensuing ultrasound guided biopsies of the prostate , 2. ConcIn Sweden, the incidence of PCa, age-adjusted to the world population, increased over 1998–2017 from 74 to 94 per 100,000 men, and PCa mortality decreased from 22 to 14/100,000 . In men Mortality is considered to be a robust measure of progress in cancer control because it is not substantially affected by overdiagnosis. However, the total change in PCa mortality has been quite modest, despite large efforts devoted to early detection and early treatment of PCa, due to the fact that a large proportion of men who die of PCa are over age 80, for whom PCa might be overreported as a cause of death , 7.Mortality captures the combined effects of primary prevention (which affects incidence), secondary prevention, and treatment. It is also desirable to measure the effectiveness of cancer management  using a measure that is not affected by changes in incidence. Net survival is a measure of patient survival that is independent of changes in incidence and independent of background (noncancer) mortality. Net survival is interpreted as the probability of survival in the hypothetical situation in which death can occur only due the disease under study. It can be estimated using 2 different frameworks; relative survival (RS), based on comparison with a disease-free background population, or cause-specific survival (CSS), based on classification of underlying cause of death.In population-based studies of cancer survival, the relative survival framework is considered most suitable for estimating net survival , 8. RS rMultiple registry-based studies have compared these 2 measures of survival for men with PCa, and RS has consistently been higher than CSS , 7, 9–11The aim of this study was to compare RS and CSS according to age and risk category in men with PCa in a large population-based cohort with comprehensive data on cancer characteristics, treatment, and cause of death. A unique feature of our study is that we have detailed data on comorbidity of both men with PCa and matched comparators, which can potentially be used to correct the well-known bias in RS.The National Prostate Cancer Register (NPCR) of Sweden holds information on 98% of all incident PCa cases since 1998, as compared with the Swedish Cancer Registry, to which reporting is mandated by law. NPCR contains detailed data on cancer characteristics, diagnostic workup, and primary treatment. Using the unique Swedish personal identity number, NPCR has been linked to a number of other nationwide health-care registers and demographic databases—including the Patient Registry, the Prescribed Drug Registry, the Cause of Death Registry, and the longitudinal integration database for health insurance and labor market studies—to construct the Prostate Cancer data Base Sweden . This reWe used Prostate Cancer data Base Sweden, version 4.1, and categorized the study population by age and risk category at date of diagnosis. Age groups were defined, in years: <70, 70–79, and 80–89; men 90 years or older at diagnosis were excluded due to short life expectancy. Risk category was defined according to a modified National Comprehensive Cancer Network categorization: 1) low-risk: clinical  stage T1–T2, Gleason score 6, and PSA <10 ng/mL; 2) intermediate-risk: T1–T2 and Gleason score 7, or PSA 10–19.9 ng/mL; 3) high-risk or locally advanced: T3, Gleason score 8 or above, or PSA 20–49.9 ng/mL; 4) regional: T4, N1, or PSA 50–99.9 ng/mL; and 5) distant metastases: M1 or PSA ≥100 ng/mL.Follow-up started at the date of diagnosis and ended at December 31, 2017, date of emigration, or date of death, whichever occurred first.RS was estimated with the Ederer II method . ExpecteInternational Classification of Diseases codes for discharge diagnoses excluding PCa in the Patient Registry . Comorbidity at date of diagnosis was classified by use of the Charlson Comorbidity Index, which is a weighted sum of a number of Registry . ComorbiRegistry . MatchinThe analysis was performed using R, version 3.4.2 , using packages survival, relsurv, and Matching. The Research Ethics Board in Uppsala approved the study.A total of 168,793 men diagnosed with PCa were registered in NPCR during the study period . At dateThe RS and CSS for the entire cohort at 5 years after diagnosis were 90% and 87%, respectively, and 84% and 77%, respectively, at 10 years. Men older than 80 with low-risk PCa at diagnosis had a particularly large difference between 5-year RS and CSS, 116% : 112, 121) versus 96% , and these differences were also seen in men with intermediate-risk PCa and to a lesser extent in men with high-risk PCa .In contrast, 5-year RS and CSS were similar for men under 70 with low-risk PCa, 103%  versus 100% , as well as for all men with regional or distant metastases, with a difference of 3% or less between RS and CSS estimates.).The difference between RS and CSS for men over 80 continued to increase at 10 years after diagnosis: 125%  versus 85%  for low-risk PCa and 109%  versus 72%  for intermediate-risk PCa. The difference in RS and CSS did not substantially increase at 10 years for men over 80 with high-risk disease or for regional or distant metastases .).Ten-year RS in men under 70 with low-risk PCa was 105%  compared with a 10-year CSS of 99% , whereas in men under 70 with regional or distant metastases RS and CSS were comparable, with a difference of 3% or less .After matching on comorbidity (based on Charlson Comorbidity Index and Drug Comorbidity Index), educational level, and marital/partnership status, the RS decreased from 116% to 106% at 5 years and from 120% to 104% at 10 years for men with low- or intermediate-risk PCa . The decThe RS of men aged 80–89 years with low- or intermediate-risk PCa and those with high-risk PCa matched to comparators in Prostate Cancer data Base Sweden only by calendar year and age resulted in RS similar to that estimated by the life table method. Matching to comparators 1 year younger than their case resulted in RS similar to that from additionally matching by same age, comorbidity, educational level, and marital/partnership status . MatchinIn this population-based registry study, RS was substantially higher than CSS for men with low- and intermediate-risk PCa, in particular for men aged 80–89 years. For these men, RS was above 100%, suggesting that older men diagnosed with PCa are healthier than their age-matched comparators in the background population. The low CSS suggests misclassification bias resulting in an inflated proportion of very old men who were adjudicated PCa as cause of death. The “true” net survival lies between RS and CSS and is a useful metric of long-term outcome of cancer care. Combining results from these 2 frameworks of net survival is helpful to interpret changes in cancer mortality.The NPCR of Sweden has a 98% capture rate compared with the Swedish Cancer Registry, to which reporting is mandated by law. Thus, our study included virtually all men diagnosed with prostate cancer in a well-defined population during a 19-year period with a recent end of follow-up. In addition, completeness and validity of data in NPCR have been assessed and found to be high, and we also had access to data of high quality from other national health-care registers and demographic databases . To our Our study has some limitations. Despite the large study population, there were relatively few men aged 80–89 years who were alive 10 years after diagnosis. Matching analysis using a Drug Comorbidity Index could be performed only for men diagnosed during 2007–2016, because the Prescribed Drug Registry, on which this index is based, started in July 2005. Although this limits the number of cases in the study, we argue that the restriction in study period is an advantage because these results are more representative for men currently diagnosed with PCa than if we had used the entire NPCR with men diagnosed from 1998.Our observations are in accordance with other studies on RS and CSS in men with PCa, which have all shown higher RS compared with CSS—and the difference has been higher in men with less-advanced cancer and in older men , 7, 9–11The Ederer II method was used to estimate RS in our study. Newer methods are available, such as the Pohar-Perme estimator, which is considered the only truly unbiased estimator of net survival in that it adjusts for dependent censoring with inverse probability weighting . HoweverGeneral population life tables include men with PCa when expected survival probabilities are estimated. For cancer at most sites other than the prostate this is not an important issue; however, PCa is a common disease among older men and accounts for 5%–7% of all deaths in Swedish men older than 80 years and will hence decrease survival in the general population . Our anaIn men with low- or intermediate-risk PCa, RS was substantially higher than CSS, in particular among men over age 80. The reasons for this discrepancy are likely related to biases. In the relative survival framework, net survival is overestimated in older men with low-risk PCa due to a “healthy screening effect.” In our analysis, we were able to limit but not eliminate this bias by using comparators matched by age, comorbidity, educational level, and marital/partnership status. However, despite this matching, RS was still above 100% at 5 years after diagnosis for men with low- to intermediate-risk PCa. Unmeasured factors related to good health explain the higher survival rate of these men compared with the general population. Men diagnosed with PCa over age 80 are likely to be a selection of healthy men with a long life expectancy, because in order for a prostate biopsy to be considered for a man over 80, he must be fit. Furthermore, RS might be substantially affected by public health awareness and educational level, which could differ between populations.The matching on age and calendar year was repeated using younger comparators to estimate the absolute difference in biological age of men with PCa compared with the general population of the same chronological age. Our results indicated that men aged 80–89 with low- or intermediate-risk PCa were biologically approximately 1 year younger than their chronological age. This difference might in fact be even larger; RS was still above 100% after this adjustment, which only accounted for differences in comorbidity, educational level, and marital/partnership status.Cause-specific survival relies on correct assessment of the cause of death, and this is likely increasingly difficult with age because very old men often have high comorbidity. According to a study by Fall et al. , the valIn men with regional or distant metastatic PCa at diagnosis, RS and CSS resulted in very similar estimates in all age groups. The risk of misclassifying cause of death in men with advanced disease at diagnosis is small because most of these men die from PCa. Furthermore, men with metastatic PCa are likely more similar to the background population in terms of general health than men with low-risk PCa, because a symptomatic man is likely to undergo prostate biopsy even if he is frail.RS is considered the preferred framework for estimating net survival in population-based cancer studies because there is a risk of misclassifying cause of death, which is the basis for CSS . HoweverThe interpretation of data on mortality in men with PCa is difficult due to old age at diagnosis, long disease trajectory, and high competing risk for death. For example, in Sweden there has been a recent increase in life expectancy, with a >40% decrease in death from myocardial infarction, leaving more older men at risk of a PCa diagnosis and PCa death . Hence, Both RS and CSS are affected by biases that drive the estimates in opposite directions. RS overestimates net survival whereas CSS underestimates it. The preferred method of net survival analysis depends on the underlying assumptions that therefore need to be evaluated considering the disease under study, characteristics of the population, and reliability of the adjudication of cause of death. The “true” net survival aims to measure the disease course in the absence of competing risk and lies somewhere between the estimates obtained by RS and CSS. Therefore, RS and CSS can be used to interpret changes in mortality rates, especially in men with PCa, of whom most die of other causes. We argue that our findings are generalizable to other populations with a similar age distribution, PCa incidence, and health-care system.With an aging population and more widespread screening in the near future in many countries, the number of older men diagnosed with low-risk PCa will increase. The importance of correctly assessing net survival in these men will therefore be essential to evaluate cancer care. For this group of men, our access to PCa-free comparators allowed us to overcome a significant amount of bias due to incomparability in relative survival. In future studies, access to a comparative cancer-free cohort can be useful to complement analysis of net survival, and further matching on characteristics might be warranted to effectively overcome residual incomparability bias.In conclusion, net survival is an important metric for assessing cancer care and is measured by relative survival or cause-specific survival. For men with low- and intermediate-risk PCa, both relative survival and cause-specific survival provide biased estimates of net survival. Relative survival overestimates survival and cause-specific survival underestimates survival, and the difference is particularly strong among very old men. The “true” estimate of net survival for these men will be between the estimates of relative survival and cause-specific survival. For young men and in particular in men with advanced PCa, relative survival and cause-specific survival yield very similar estimates.


To evaluate the usefulness of thoracic excursion as a biomarker in patients with amyotrophic lateral sclerosis (ALS).We measured the forced the vital capacity (FVC), thoracic excursion, baseline-to-peak diaphragmatic compound muscle action potential (DCMAP) amplitude, diaphragm thickness at full inspiration (DTfi), Medical Research Council (MRC) sum score for muscle strength, and arterial partial pressures of oxygen and carbon dioxide and administered the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) and modified Medical Research Council (mMRC) Dyspnea Scale. The test–retest reliability of thoracic excursion was determined.r = 0.678, p < 0.001) than DCMAP amplitude  and DTfi . It was also correlated with ALSFRS-R score , MRC sum score , and mMRC Dyspnea Scale score  and was the most sensitive parameter for assessing dyspnea and FVC. Thoracic excursion decreased as FVC declined in the early and late stages, there were no differences in DCMAP amplitude and DTfi between the early and late stages, and ALSFRS-R score and MRC sum score decreased only in the late stage. Thoracic excursion was well correlated with respiratory function and is useful for predicting respiratory and general dysfunction in patients with ALS regardless of stage.Thirty-four patients with ALS and 26 age- and sex-matched healthy participants were enrolled. Thoracic excursion measurement had excellent test–retest reliability (intraclass coefficient: 0.974). Thoracic excursion was more strongly correlated with FVC ( Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder in which respiratory dysfunction occurs with disease progression. Eventually, the diaphragm and other muscles of respiration are involved, resulting in respiratory muscle paralysis, which is the primary cause of death. Respiratory function is most frequently assessed using the pulmonary function test (PFT). PFT parameters, such as forced vital capacity (FVC) and forced expiratory volume in 1 s, have been found to predict hypoventilation  and survThis study was approved by the Ethics Committee of Nara Medical University . All study procedures were performed in accordance with the ethical standards of the ethics committee, Declaration of Helsinki, and Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan (UMIN: 000042222). All participants provided written and verbal informed consent after receiving information about the study.We included all patients diagnosed with definite, probable, or possible ALS based on the modified El Escorial criteria  who visiWe selected control participants from the in- and out-patients of the Departments of Neurology at Nara Medical University Hospital, Nara and Minami Nara General Medical Center, Nara. We excluded control participants with subjective breathlessness and those who could not walk.The participants were administered the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R). Total ALSFRS-R scores range from 0 to 48, and low scores strongly predict a poor outcome. In addition, ALSFRS-R consists of three subscales, which were scored separately: bulbar function , extremities function , and respiratory function . We used a cutoff score of 38 because patients with an ALSFRS-score <38 have a high 1-year mortality rate . AdditioThoracic excursion from maximal inspiration to maximal expiration was measured using a measurement system  that continuously measured chest expansion and automatically recorded the data. The measurement of thoracic excursion had high intra- and inter-rater reliability and validity . A wire We performed electrical phrenic nerve stimulation at the neck to elicit a DCMAP, which was recorded using surface electrodes. The active electrode was placed over the xiphoid process, and the reference electrode was placed at the costal margin 16 cm away from the active electrode . The phrDT was measured between the anterior and mid-axillary lines with the participant in the supine position using a Logiq S8 ultrasonography machine  with a high-resolution 3–12 MHz linear probe in the B mode , 20. ThePFT was performed with the participants seated upright. Spirometry was used to test pulmonary mechanics through the measurement of the percent-predicted FVC, forced expiratory volume in 1 s, forced expiratory and inspiratory flow rates, and maximal voluntary ventilation. These values are used to assess the ability of the lungs to quickly move large volumes of air through the airways and to identify airway obstruction. To identify the parameter that is most involved in the decline in FVC, we divided the participants into the severe , mild , and no restriction (≥80%) groups. The two patients who were not able to perform PFT because of difficulty in breathing were included in the severe group.r) were calculated to evaluate the associations between thoracic excursion and respiratory function. Based on the r values, the correlation was categorized as weak (r = 0.30–0.39), moderate (r = 0.40–0.59), or strong (r = 0.60–1.00). We used the t-test to compare the two groups and the Tukey–Kramer post-hoc test for multiple comparisons. Statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS version 22.0 .Based on the assumption that the difference in thoracic excursion between the groups would be 0.8 cm with a standard deviation of 1.0 cm, we set a target sample size of 26 participants in each group (ALS group and control group) to ensure that the power is at least 80% with a two-sided significance level of 0.05. Intraclass coefficients were calculated to determine the test-retest reliability of the measurement of thoracic excursion; both “test” and “re-test” were performed by the same examiner. The Shapiro–Wilk test was used to assess the distribution of the data, and Pearson's correlation coefficients  and DTfi . Thoracic excursion was strongly correlated with FVC  and DTfi  were only moderately correlated with FVC. Conversely, there were no correlations between thoracic excursion and the patients' clinical characteristics, such as age at examination , age at onset , disease duration , and body mass index . Likewise, thoracic excursion was not correlated with age at examination  and body mass index  in control participants.Thoracic excursion was moderately correlated with DCMAP amplitude  and FVC  and weakly correlated with DCMAP amplitude  and DTfi . Patients with an mMRC Dyspnea Scale score of 1–4 had a significantly lower thoracic excursion than those with a score of 0 . In contrast, DTfi was weakly correlated with ALSFRS-R score , and DCMAP amplitude was not correlated with the ALSFRS-R score  and bulbar function score . Contrary to this, thoracic excursion correlated only with ALSFRS-R extremities function score , not with bulbar function score . Additionally, in bulbar-onset ALS patients, FVC correlated strongly with ALSFRS-R bulbar function score  and moderately with extremities function score . In contrast, FVC correlated strongly with ALSFRS-R extremities function score  and weakly with bulbar function score  in spinal-onset ALS patients. Similarly, thoracic excursion was strongly correlated with ALSFRS-R extremities function score in both spinal-onset  and bulbar-onset ALS .ALSFRS-R score was strongly correlated with thoracic excursion  or bed (in supine). The other limitation in this study is that thoracic excursion in excessively obese patients may not be measured accurately. The wire of the measurement system does not shrink easily because of subcutaneous fat. Additionally, in this study, we have attempted to tackle the major challenges associated with identifying a surrogate biomarker for evaluating respiratory function and prognosis in patients with ALS. However, floor and ceiling effects could not be adequately analyzed. A large-scale longitudinal study is necessary to confirm the results of this study.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Nara Medical University Hospital. The patients/participants provided their written informed consent to participate in this study.NIg and TM: conceptualization and writing—original draft preparation. NIg, NIw, and NY: performed data acquisition and interpretation. MO: performed formal analysis. AK and KS: supervision. All authors have read and agreed to the published version of the manuscript.This work was supported by the Ministry of Education, Culture, Sports, Science, and Technology of Japan under grant KAKENHI No. 20K19453.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Numerous studies suggest a relationship between depression and metabolic syndrome, which is likely influenced by age. Interestingly, functional imaging analysis has shown an association between functional connectivity in the default mode network (DMN-FC) and components of metabolic syndrome, which is explored in this study.Methods: From a larger longitudinal cohort study on healthy aging, 943 individuals were extensively characterized for mood and cognition. Among these, 120 individuals who were selected for displaying extreme cognitive performance within the normal range (good and poor performers) were further studied. Here, in a cross-sectional design, using confirmatory factor analysis (CFA), the association between metabolic dysfunction and depressive mood as a function of age and its relationship with DMN-FC was studied.Results: Metabolic dysfunction was modeled as a second-order latent variable using CFA. First-order latent variables were obesity, glucose dysmetabolism, lipids imbalance, and blood pressure. Using multiple linear regression models, this study observed that metabolic dysfunction, glucose dysmetabolism, and lipids imbalance were linearly associated with depressive mood, and the association with obesity was U-shaped. The association of metabolic dysfunction, obesity, and glucose dysmetabolism with depressive mood is positive for the younger individuals in our sample and vanishes with aging. The FC of the right superior temporal gyrus with the DMN correlated with both obesity and depressive mood. In participants with higher obesity scores, FC increased with higher GDS scores, while in those with lower GDS scores, FC decreased. Age and blood pressure were associated with a more complex pattern of association between FC of the right supramarginal gyrus and GDS score.Conclusion: The association of metabolic dysfunction with depressive mood is influenced by age and relates with differential patterns of DMN-FC. The combination of the effects of age, mood, and metabolic dysfunction is likely to explain the heterogeneity of DMN-FC, which deserves further investigation with larger and longitudinal studies. Depression is a highly prevalent mood disorder, affecting an estimated 300 million people worldwide  is a cluster of metabolic abnormalities associated with high risk of developing type 2 diabetes and/or cardiovascular disease. According to the International Diabetes Federation, it is defined by the presence of visceral adiposity and at least two of the following conditions: hyperglycemia, dyslipidemia (high triglycerides and/or low HDL cholesterol), and hypertension ] and depression measures .Of notice, the association between MetS and depression seems to be bidirectional. Pan et al. , in a meMetS constitute a heterogeneous metabolic group and the contribution of each of its components differs between individuals. CFA has been used to construct a hierarchical four-factor model that represents MetS by insulin resistance, obesity, lipids, and blood pressure, which may help to determine the contribution of each component to the overall syndrome  within the DMN, as well as between the DMN and other brain regions in patients with depression  utilize the latent variable model of MetS, referred to as metabolic dysfunction; (2) explore, in a cross-sectional investigation, the potential association of metabolic dysfunction and its components with depressive mood in older individuals; (3) assess the impact of advancing age in the strength of those associations; and (4) evaluate the impact of the interaction between metabolic dysfunction, age and mood upon DMN-FC.The study was conducted in accordance with the Declaration of Helsinki (59th Amendment) and was approved by the Portuguese national ethical committee  and by the local ethics review boards . The study goals and the psychological and clinical assessments were explained to the participants, of whom all gave informed consent.n = 560; 53.3%) and age . All the participants were local community-dwellers. Most were retired  and located in the medium socio-economic stratum of the Graffar scale . For age and gender, the distribution of this database differs in <2% of that of the distribution for the Portuguese population, as estimated by the Portuguese authority on statistics   using the local area health authority registries as described elsewhere  and overall “poor” performance (n = 60) group, based on their, within normal range, neuropsychological testing (including mood)] were selected for a more comprehensive characterization, including a functional MRI (fMRI) session. Of those, nine refused to have an MRI, four were excluded due to brain lesions, three were excluded due to excessive head motion during the scan, and five were excluded due to missing data. Following exclusions, 101 participants ultimately were included in the fMRI analysis. A detailed characterization of both samples is presented in From the initial cohort, 120 participants [matched for gender and age—overall “good” cognitive performance , height (m), and abdominal perimeter (cm). Weight and height were subsequently used to calculate body mass index (BMI). Fasting blood glucose, fasting insulin, triglycerides, and high-density lipoproteins were measured using standard methods in a certified laboratory. Blood pressure was assessed three times during the evaluation and the mean value was used. The Geriatric Depression Scale  was used to assess mood.2, 30 interleaved slices, slice thickness = 4 mm, imaging matrix 64 × 64, and field of view (FOV) = 224 mm. T1-weighted structural images for anatomical reference were obtained using a magnetization-prepared rapid acquisition by gradient echo (MPRAGE) sequence with voxel resolution 1.0 × 1.0 × 1.0 mm, FoV = 234 × 234 mm2, FA of 7°, 176 slices, and TE/TR of 3.48/2730 ms. Before any data processing and analysis were undertaken, all acquisitions were inspected by an experienced neuroradiologist who confirmed that they were not affected by critical head motion and that participants had no brain lesions.The participants were scanned on a clinically approved Siemens Magnetom Avanto 1.5 T  MRI scanner in Hospital de Braga using a Siemens 12-channel receive-only head coil. During the resting-state fMRI acquisition, using gradient echo-weighted echo-planar images (EPIs), the participants were instructed to keep their eyes closed and to attempt to think about nothing. The imaging parameters were: 180 volumes, Repetition Time (TR) = 2s, Echo Time (TE) = 30 ms, Flip Angle (FA) = 90°, in-plane resolution = 3.5 × 3.5 mmPreprocessing of fMRI data was done using FMRIB Software Library (FSL v5.07) tools. The first five volumes of the acquisition were removed to exclude possible magnetic field inhomogeneities. After this, the data underwent slice timing correction followed by head motion correction. Next, motion scrubbing  was performed with Multivariate Exploratory Linear Optimized Decomposition into Independent Components (MELODIC), distributed with FSL. ICA is a data driven analysis that isolates components or non-overlapping spatial maps corresponding to regions that manifest coherent time-courses. The software estimated group-wise spatial maps that correspond primarily to Resting State Networks (RSNs) and automatically estimated the number of independent components. A dual regression analysis was used to study subject-specific components.n) and percentage (%) for categorical variables. Pearson correlations were calculated to measure the strength of the association between the quantitative variables studied. Structural equation models (SEM) were used to model metabolic dysfunction in a fashion similar to that reported by Shen et al. , Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA). To determine the cross-sectional associations of the GDS score with each of the composite scores previously calculated , Multiple Linear Regression Models (MLRM) were performed controlling for age, gender, years of formal education, smoking habits, alcohol consumption, and physical activity. Besides regression coefficients , betas and measures of model fit  and standard deviation (SD) for continuous variables and in frequency . Minimum cluster size was estimated using 3DClustSim  with the DMN template mask and a significance level of 0.05 . Anatomical labeling was performed by a combination of visual inspection and anatomical automatic labeling (AAL) atlas , the interaction of metabolic dysfunction (or components) with age, the interaction of metabolic dysfunction (or components) with GDS score, and the interaction of metabolic dysfunction (or components) with age and GDS score. The requirements for multiple linear regression analysis were met and the variables were mean-centered to avoid multicollinearity issues. Age, gender, and GDS score were used as covariables when not used as interest variables. For each participant, the mean Z score of the clusters with significant interactions were extracted and the values were used to generate heat maps that allowed visualization of the interaction of the moderator with the association between the focal predictor and the dependent variable.M = 67 years and SD = 9.17, 47.8% females). The exclusion of the 107 participants with missing data did not significantly change the composition of the original cohort.Demographic, metabolic, and lifestyle characterization of participants are presented in r = 0.106, p < 0.01), but not with the other parameters. Metabolic parameters were significantly associated among themselves, with the exception of systolic blood pressure with HDL cholesterol, and diastolic blood pressure with fasting glucose and HDL cholesterol.Information on the prevalence of significant depressive symptoms and metabolic risk factors according to the IDF classification for MetS , lipid imbalance , obesity , and blood pressure .The fit of the model was confirmed by CFI = 0.981, TLI = 0.958 and RMSEA = 0.048. The model demonstrated that metabolic dysfunction could be summarized by four components defined by metabolic risk factors. Metabolic dysfunction was strongly a function of glucose dysmetabolism, moderately of lipid imbalance and obesity, and modestly of blood pressure. Specifically, metabolic dysfunction was explained by glucose dysmetabolism  and explained approximately 18% (R2 = 0.179 to 0.185) of the variance of the GDS score.To test the association of metabolic dysfunction and its components with depressive mood, MLRM  was usedIn all the models, male gender, higher education , alcohol consumption, and physical activity higher than three times per week were significantly associated with a lower GDS score.p = 0.029), glucose dysmetabolism , and lipids imbalance  were significantly associated with a higher GDS score. Furthermore, no linear association between depressive mood and obesity was observed, but a significant association between depressive mood and the quadratic term for obesity (Obsety2) was observed , obesity , and glucose dysmetabolism . This moderating effect of age reflects a positive correlation between the measured variables in younger participants, but one which diminishes with advancing age. The association of the quadratic term of obesity with the GDS score (The effect of age on the association between metabolic dysfunction (or its components) and mood was tested through moderation analysis in MLRM . A signiDS score  was not p = 0.592) indicating that lipids imbalance is positively associated with GDS score regardless of age. Also, no moderating effect of age was observed upon the association of blood pressure and GDS score , indicating that blood pressure and mood are not significantly associated with one another at any age in the study population.The association between GDS score and the lipids imbalance component was not moderated by age  in the association between GDS score and DMN-FC was tested. An interaction between obesity and GDS score was observed in the right superior temporal gyrus ; Table 2B = 0.021, p = 0.02), but was not significant for those with higher blood pressure (mean blood pressure + 1 SD) . Also, in the group of older participants (mean age + 1 SD), a decrease in the FC accompanied the GDS score increase in those with lower blood pressure (mean blood pressure −1 SD) , while the opposite pattern was observed for those with higher blood pressure (mean blood pressure + 1 SD)   . No otheIn this study, the association between metabolic dysfunction and depressive mood in community-dwellers aged 50 years and older was investigated, and the relationship between those factors with DMN-FC. This study showed that depressive mood is linearly associated with metabolic dysfunction, glucose dysmetabolism, and lipid imbalance. Conversely, the association of obesity with depressive symptomatology was U-shaped. The influence of age upon the strength of the association of depressive mood with metabolic dysfunction, obesity, and glucose dysmetabolism was substantial. Of notice, obesity can modify the association of GDS score with FC in the DMN, and the interaction of age with blood pressure also affect the association of GDS score with the FC in the DMN.Glucose dysmetabolism appears to be the essential feature of metabolic dysfunction, in accordance with other cross-sectional and longitudinal models  and by the local ethics review boards . The patients/participants provided their written informed consent to participate in this study.CP-N, JR, PM, PCo, and JB performed the statistical analysis. CP-N, JR, PM, TC, LA, RM, PCo, and JB contributed to the data analyses and discussion. NS maintained the database and organized the neurocognitive/psychological sessions. PCu organized the evaluation sessions, participant recruitment and collected the data. CP-N, TC, and LA collected the data. AC, RM, PM, and JS collected and processed fMRI data. CP-N wrote the first draft of the manuscript. JP, NS, and JB conceived and designed the study. NS had access to all the data in the study. All the authors revised the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To investigate the association between sleep disorders and dry eye disease (DED) in Ningbo, China.Our data came from the Yinzhou Health Information System (HIS), including 257932 patients and was based on a 1:1 matching method (sleep disorder patients vs. patients without sleep disorders) during 2013–2020. Sleep disorders and DED were identified using ICD-10 codes. Cox proportional hazards regression was used to identify the association between sleep disorders and DED.P < 0.01). Sleep disorders were positively associated with the diagnosis of DED , when sex, age, hypertension, diabetes and other systemic diseases were adjusted. In the sleep disorders patients, advancing age, female sex, and presence of coexisting disease  were significantly associated with the development of DED by the multivariate cox regression analysis .In addition, there was a significantly positive association between estazolam and the incidence of DED in both sleep disorder and non-sleep disorder groups .The eight-year incidence of DED was significantly higher in participants with diagnosis of sleep disorders (sleep disorders: 50.66%, no sleep disorders: 16.48%, Sleep disrder was associated with a three-time increased risk of DED. This association can be helpful in effective management of both sleep disorders and DED. Sleep disorder, defined as an abnormality in sleep quality or quantity, has become a major social health concern throughout the world –3. SleepDry eye disease (DED) is a multifactorial disease of the ocular surface characterized by a loss of tear film homeostasis, causing tear film instability and hyperosmolarity, as well as ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles . The incPrevious studies have found that aging, female sex, systemic diseases  are associated with DED development , 15, 16.Yinzhou District, located in the Yangtze River Delta, is one of the core areas of Ningbo. According to the statistical yearbook of Yinzhou District, by the end of 2018, there were 1.34 million permanent residents in Yinzhou District. Data on hospital visits were obtained from the Yinzhou Health Information System (YHIS), which seamlessly links the health information archives, chronic disease registration system, resident death registration system and hospital outpatient system of permanent residents in Yinzhou District, and can provide real-time treatment information of patients in 2 general hospitals, 3 specialized hospitals, 24 community health service centers and 248 community service stations in the whole district. The health information of each resident living in Yinzhou is integrated into YHIS. Detailed information about this system has been described in the previous research .Medical information was classified according to the ICD-10 . In this study, we first excluded all patients who were deceased, we selected hospital visits for sleep disorders (ICD-10: G47) and DED  during 2013–2020. We excluded patients diagnosed with DED before sleep disorders. Finally, we identified 128,966 patients with sleep disorders between 2013 and 2020. To design the matched cohort study using the sleep disorder patients as the case group, we established the control group by propensity score matching by adjusting for same sex, same age range and same date of diagnosis for sleep disorders. We used a 1:1 matching method to select the control group  who were not diagnosed with sleep disorders. Finally, the data used in this study included 257,932 patients from 2013 to 2020.The outcome variable of this study is whether DED will occur after patients were diagnosed with sleep disorders. If diagnosis of DED , it was defined as DED diagnosis, and classified the patient as the DED diagnosis group. In this study, sleep disorders were defined as organic sleep disorders (ICD-10: G47), including insomnia, hypersomnia, narcolepsy/cataplexy, sleep apnea, disorders of the sleep-wake schedule and other sleep disorders. In the study, we included the following independent variables: gender, age, medical history , and medication history of sleep disorders. The ages were classified at 10-year intervals: under 29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, over 70 years. At present, the clinical drugs for insomnia mainly include benzodiazepine receptor agonists (BZRAs), melatonin receptor agonists, orexin receptor antagonists, antidepressants and etc. , 34. We P < 0.20 in univariate regression analysis were included in multivariate cox regression analysis to determine the association between sleep disorders and DED, and studied the association of other independent variables with DED. All statistical analyses were performed using SAS statistical software version 9.2 . A P < 0.05 was considered to be statistically significant.In order to study the relationship between DED and sleep disorders, we first determined the frequency and percentage of people with DED diagnosis. Next, we performed a log rank test and generated a survival curve to compare the diagnostic rate of DED between patients with and without sleep disorders. Finally, we performed survival analysis using the univariate cox regression analysis, and then variables with Using the 1:1 propensity score matching method (patients with sleep disorder vs. patients without sleep disorders), we analyzed 257,932 patients with or without sleep disorders between 2013 and 2020. P < 0.05 for log rank test).P < 0.05). Then we included variables with P < 0.20 from the model 1 for multivariate cox regression analysis. By the multivariate regression analysis, sleep disorders were positively associated with the diagnosis of DED , with a three-time increased risk. Among the independent variables, the risk of diagnosing DED was higher in women than in men . Compared with young people who were <30 years, increased age was associated with DED diagnosis (P < 0.01), and the risk was the highest in the population aged 40–49 years . In addition, only heart disease was positively associated with the diagnosis of DED (P < 0.01). At the same time, other coexisting systematic diseases did not have significant association with the diagnosis of DED (P > 0.05).P < 0.01). The sleep medicine with statistical significance (P < 0.05) in multivariate cox regression analysis are shown in Next, we analyzed the effect of sleep drugs on DED in the general population. P < 0.01). Additionally, we analyzed the using condition of sleep medicine and its association with DED in sleep disorders patients. P < 0.20 in univariate cox analysis were included for multivariate cox analysis), the variables of female and 30–39 years significantly increased the DED diagnosis (P < 0.01) in the sleep disorders patients. However, the results comparing anxiety with DED were not statistically significant (P = 0.08). As is shown in P < 0.05). Contrarily, diazepam and lorazepam showed negative correlation with DED (P < 0.05).Similarly, we performed Cox proportional hazard model in the sleep disorder group to determine the relationship between the independent variable and DED. The results of regression analysis are presented in the P = 0.01). P < 0.05).In the same way, we analyzed the relationship between the independent variable and DED in the patients without sleep disorder by performing Cox proportional hazard model. The results of regression analysis are presented in the In the current study, we found that sleep disorder is a risk factor of DED, with a three-time increased risk to the subjects without sleep disorders. Besides, the use of estazolam increased the risk of DED regardless of the presence of sleep disorder.In our study, the 8-year incidence of DED in the study population was 33.57%. Many previous population-based studies have indicated a correlation between sleep disorders and DED –27, 35. The association between sleep disorders and DED are based on physiological findings. Sleep disorders are often related to autonomic nerve dysfunction, which could affect the parasympathetic fibers in the lacrimal gland, resulting in reduced tear secretion , 38. SleOur results also found that use of sleep medications in the sleep disorders was significantly associated with DED. Kawashima et al. have demonstrated that sedative antidepressants could significantly decreased tear break-up time of DED patients . AntidepThe advantage of current study lies in the large sample size based on data from an integrated health care network covering a whole district in southeast China. Most of the previous studies used questionnaires , 26, 27,In conclusion, our findings suggest that sleep disorders is a potential risk factor for DED and the use of sleep medicines might be associated with dry eye development. Patients with sleep disorders or those using sleep medicines should be monitored for development of dry eye.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board of the affiliated Ningbo Eye Hospital of Wenzhou Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.QZ designed the study. SL, FW, ZL, and KF analyzed the data. YS and JB checked the data. QZ and SL wrote the manuscript. HW revised the manuscript. PS, HL, and WC instructed the whole study and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was financially supported by the Chinese National Key Research and Development Projects(2019YFC0840708).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Childhood overweight and obesity constitute one of the primary public health problems that need to be addressed in advanced societies. The Canadian Assessment of Physical Literacy (CAPL) constitutes one of the most significant initiatives to prevent and combat the issue of childhood obesity in Canada. This assessment is one of the most closely aligned with the concept of a child’s physical literacy and could be a broader alternative to the mere assessment of physical fitness as it assesses the multiple aspects that compose it. Despite its important implications, there is a lack of such studies in Spain. Due to this, the present study aims to establish the level of physical literacy in overweight and non-overweight children in Extremadura (Spain), analyse the differences between them and examine the association among body composition and physical literacy domains. The results showed that most of the non-overweight children in Extremadura (Spain) had higher levels of physical literacy than their overweight counterparts who present lower performance. Furthermore, physical literacy of overweight children was significantly lower compared to non-overweight children. Normal range of body composition values were associated with better total physical literacy and their domains, so a better physical literacy is associated with healthier body composition values.r from −0.223 to −0.507) were found, except for the knowledge domain. Conclusions: Most of the non-overweight children had higher levels of PL than their overweight counterparts. The PL of overweight children was significantly lower compared to non-overweight children. Healthier body composition values were associated with a better PL.Background: Childhood obesity is a major health challenge in modern societies; therefore, prevention and management policies are needed. This study aims to establish the level of Physical Literacy (PL) in overweight and non-overweight children in Extremadura (Spain), analysing the potential differences between them and exploring their relationships with body composition. Methods: A single-measure cross-sectional study was performed with 135 children, who were taken anthropometric measurements and administered The Canadian Assessment of PL Development (CAPL-2) to assess their level of PL. The CAPL-2 covers four domains and participants to be classified into four levels: beginning, progressing, achieving, and excelling. Statistical analysis included descriptive and correlations. Results: Significant differences between overweight and non-overweight participants were found. Non-overweight participants had higher scores in all the domains included in PL, with the PL level of overweight children mainly being in the two lowest levels. Inverse correlations between body composition variables and PL in all domains ( Childhood overweight and obesity, defined as an excessive accumulation of body fat, represent one of the major public health issues that need to be addressed in advanced societies . SpecifiPhysical Literacy (PL) is well-defined as the physical competence, motivation, confidence, knowledge and understanding to participate in physically active lifestyles, and is formed by four domains: physical, psychological, social and cognitive ,9,10. PLThe Canadian Assessment of Physical Literacy (CAPL) constitutes one of the most significant initiatives to prevent and combat the issue of childhood obesity in Canada . This asDespite its important implications, to the best of our knowledge, there is a lack of such studies in Spain . Few stuA total of 72 participants were needed to reach a power of 95% to detect a difference of 0.31 between the null hypothesis correlation of 0.29 (very low or close to zero association) and the alternative hypothesis correlation of 0.60 (high association) . The sigA single-measure cross-sectional study was carried out with 135 children aged between 8 and 12 years (not overweight: 83 (61.5%); overweight: 52 (38.5%), 63 (46.7%) being male and 72 (53.3%) female. Participants were recruited through different educational centres in Extremadura (Spain).Participants met the following eligibility criteria: (1) aged 8–12 years; (2) authorised by their parents or legal guardians; (3) children agreed to participate in the study; (4) not having pathologies that prevent participation in physical fitness tests or practice.The Bioethics and Biosafety Committee of the University of Extremadura approved the study , following the Helsinki Declaration updates, modified by the 64th General Assembly of the World Medical Association  and the Law 14/2007 on Biomedical Research.Several tools were utilized to assess PL and body composition of participants. Procedures were conducted according to the study protocol WOMO , which aThe measurements were conducted under standardized conditions, according to the WHO guidelines , previouHeight was determined using a height rod  located on a vertical surface perpendicular to the ground, in cm, up to the nearest mm. It was assessed standing up, with balanced shoulders and relaxed arms along the body.Bodyweight and FM were measured with a bioimpedance meter , as bioelectrical impedance analysis (BIA) technology has been used in studies offering high reproducibility in assessing both FM (ICC = 0.88) and %FM (ICC = 0.66) . MoreoveDaily behaviour domain. The total score is made up of the scores of 2 components: total steps using an activity wristband  and a self-administered question about the minutes of physical activity per week performed for at least 60 min.Physical competence domain. The final score is calculated as the sum of 3 components: abdominal plank , ProgresThe motivation and confidence domain assessed confidence and the motivation to be physically active. The scores are obtained by summing 4 parts: intrinsic motivation, competition, predilection and appropriateness, scoring from 1 to 30 points.Knowledge and understanding domain . The scoThe Canadian Assessment of PL Development (CAPL-2) was applied ,25. ThisThus, the CAPL-2 total score is formed by the sum of the 4 domains scoring from 0 to 100 points. According to their total score, gender and age, the participants are classified into 4 different levels: beginning, progressing, achieving and excelling. The beginning and progressing levels describe children without an optimal level of PL; the achieving one describes children who have met the minimum level and the excelling level describes children who demonstrate a high level of PL .IBM SPSS Statistics 24 software  was used for statistics. Mean . Likewise, Mann–Whitney U-test was used with non-parametric variables . Differences were considered significant for p ≤ 0.05. To quantify the association among the different variables, Pearson’s (parametric variables) and Spearman’s correlation coefficients (non-parametric variables) were applied. After applying Bonferroni post-hoc correction [Kolmogorov–Smirnov and Levene’s tests were applied to check normality and homogeneity of data, respectively. Independent Student’s rrection , the alprrection : 0.30 toSignificant differences between overweight and non-overweight participants were found. Specifically, non-overweight participants had higher scores in all the PL domains, in its total score, and lower in weight, height, BMI, FM and %FM see .The PL level of overweight children is mainly in the two lowest levels, beginning and progressing. However, their non-overweight counterparts are mostly placed at the excelling level (42.2%), showing the same level in physical competence (38.6%) and motivation (41%). Both overweight and non-overweight children are mostly at the progressing level in the daily behaviour and knowledge domains .Lastly, correlations between body composition and PL domains and PL total score are shown in This study aimed to establish the PL level in overweight and non-overweight children in Extremadura to investigate possible differences between them and to analyse the association between body composition and PL. We found a lower level of PL in overweight compared to non-overweight children. Therefore, significant differences were established between them for all domains of the CAPL-2. In addition, this study displays the existence of a slight to moderate inverse correlation between body composition and all the domains of PL, except in the knowledge domain. These results are relevant and support the establishment of measures for the prevention and management of obesity in children and adolescents.Related to their level of PL, 63.9% of non-overweight children were in the highest levels (achieving and excelling), while 71.2% of overweight children were in the lowest levels (beginning and progressing). Compared to previous studies, a higher percentage of non-overweight children reached higher levels of PL. In a study conducted in Canada , only 44Regarding the differences between overweight and non-overweight children on PL and its domains, it was found that the total score mean on the CAPL-2 for non-overweight children was 71.7 points. This score is significantly higher than that obtained for their overweight counterparts, with an average of 60.76. Our results also agree with those reported by Nystrom et al. , who alsSignificant differences between overweight and non-overweight children have been previously reported in several studies for the different domains. Concerning daily activity, it has been found that obese children perform less daily activity related to physical activity than non-obese children ,33,34. RFurthermore, our study observed an inverse correlation between FM and %FM with PL and its domains. Specifically, higher BMI, FM and %FM values were associated with lower PL total score and every domain score. Nystrom et al.  noted thr = −0.191). It could be because although knowledge is an important element for physical activity promotion, it may not be sufficient to change this behaviour [Regarding the knowledge domain, no correlation was obtained with body composition variables except for BMI , so cultural differences may influence the generalisation of results. Moreover, it was not possible to establish causal relationships among PL and body composition due to the cross-sectional design of this study.Most of the non-overweight children in Extremadura (Spain) have higher levels of PL (sufficient and excellent) than their overweight counterparts, which presents lower performance (insufficient and in progress). Furthermore, PL of overweight children was significantly lower compared to non-overweight children. A normal range of body composition values were associated with better total PL and their domains, so a better PL is associated with healthier body composition values.


Air trapping is a predictive index for a decline in lung function and mortality in patients with chronic obstructive pulmonary disease (COPD). However, the role of air trapping in COPD exacerbation has rarely been studied. Therefore, this study aimed to investigate the impact of air trapping as a continuous parameter on COPD exacerbation.To evaluate air trapping, we identified the ratio of residual volume (RV) to total lung capacity (TLC) of patients with COPD from the Korean COPD Subgroup Study (KOCOSS) cohort, which is a multicenter-based, prospective, consecutive cohort in Korea. The primary outcome was a development of COPD exacerbation during 3 years of follow-up.p for interaction = 0.002).Of 2,181 participants, 902 patients measured the RV/TLC ratio in the baseline enrollment, and 410 were evaluated for assessing the development of COPD exacerbation. Of 410 patients, the rate of moderate to severe exacerbation and severe exacerbation was 70.7% and 25.9%. A 10% increase of RV/TLC ratio increased the risk of the moderate to severe exacerbation by 35% and severe exacerbation by 36%. In subgroup analysis, an interaction effect between triple inhaled therapy and the RV/TLC ratio for severe exacerbation nullified the association between the RV/TLC ratio and severe exacerbation  showed an association with an increased risk of COPD exacerbation, particularly in patients who have not undergone triple inhaler therapy. The Global Initiative on Obstructive Lung Disease (GOLD) defines Chronic Obstructive Pulmonary Disease (COPD) as a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation . DespiteAir trapping, which is common in chronic respiratory diseases, occurs when the lungs become abnormally enlarged due to peripheral airway obstruction , 6. Air Although one study found that the RV/TLC ratio was associated with COPD exacerbation, it performed the only simple Cox regression analysis and did not assess the severity of exacerbation in–depth . Consequ1) to forced vital capacity (FVC) <0.7. A previous study has described more detailed information about this cohort (The Korean COPD Subgroup Study (KOCOSS) cohort is a multicenter-based, prospective, consecutive cohort to explore risk factors of COPD progression. Study participants' enrollment and baseline measurements were performed from December 2012 and October 2014. Inclusion criteria were as follows: (1) physician-diagnosed patients with COPD, (2) aged ≥ 40 years, (3) positive respiratory symptoms, and (4) post-bronchodilator ratio of forced expiratory volume in one second . The absolute value was used, and there was no additional adjustment following the American Thoracic Society (ATS)/European Respiratory Society (ERS) recommendations .The outcome was the development of COPD exacerbation, which was observed prospectively over 3 years. The COPD exacerbation was defined as worsening of respiratory symptoms such as sputum, cough, and dyspnea . Moderat2). Occupational exposure was defined as respondents who answered “yes” to the question “Did you work in a dusty or bad air environment?”. Symptoms were assessed using a modified Medical Research Council (mMRC) dyspnea scale and COPD Assessment Test (CAT) score  measured using spirometry as recommended by the ATS/ERS (1 (Body mass index (BMI) was calculated by dividing the weight by the square of the height (kg/mT) score , 18. Pre ATS/ERS . The KorS/ERS , and categorical variables were expressed as numbers with percentages. In the analysis of the p-trend, we used the Jonckheere-Terpstra test for continuous variables and the Cochran-Armitage test for categorical variables. The rate of COPD exacerbation was assessed with the number of exacerbations, by classifying into the 4 IQR groups of the RV/TCL ratio and a density plot was used to analyzed the frequency of COPD exacerbation.1 %-predicted, smoking amount, triple inhaled therapy, cardiovascular disease, hypertension, and diabetes mellitus were included for adjustment. The non-linear relationships between the RV/TLC ratio and the risk of COPD exacerbation were further explored by restricted cubic spline curve analysis adjusted for previously mentioned variables using “rms” package of R. The FEV1 %-predicted was categorized by the rounded value of median in the adjustment due to the strong correlation with the RV/TLC ratio . In the adjustment for subgroup analysis, sex was excluded due to the small portion of the female. Subgroups of continuous variables were divided by the median value at the baseline. To evaluate the effect of triple inhaled therapy on COPD exacerbation, a sensitivity analysis was performed after excluding triple bronchodilator users. A two-sided p-value <0.05 was considered statistically significant. We performed all statistical analyses using R version 4.0.3 .In the multivariable analysis, a 10% increase of RV/TLC ratio increased the risk of the moderate to severe exacerbation by 35% and severe exacerbation by 36% . Of cate1/FVC ratio than those without severe exacerbation history.As shown in 2, smoking amount ≥40 pack-years, no occupational exposure, no triple inhaled therapy, hypertension, and no diabetes mellitus . In contrast to the analysis results in triple bronchodilator users, sensitivity analysis showed that an increased RV/TLC ratio was associated with COPD exacerbation in single or dual bronchodilator users   . HoweverAs a marker of air trapping, the RV/TLC ratio had a J-shaped relationship with the risk of moderate to severe exacerbation, suggesting a positive correlation with the risk of COPD exacerbation. Recently, several papers have been published that the frequent exacerbation history affects the prognosis or mortality of patients with COPD, and the clinicians are interested in a new concept of “frequent exacerbator phenotype” –26. In aThe S-shaped relationship between the RV/TLC ratio and the risk of severe exacerbation appears likely that other factors may have diminished the need for hospitalization in patients with a very high RV/TLC ratio , 28. AnoIn subgroup analysis, triple inhaler therapy modulated the effect of the RV/TLC ratio on the risk of severe exacerbation. According to the GOLD guidelines, the most favored patients with COPD for triple inhaled therapy are those with severe airflow limitation and frequent exacerbations in spites of dual bronchodilator therapy . SeveralThe limitations of our study should be addressed. First, the 3 years of follow-up may not be adequate for assessment of the relationship between the RV/TLC ratio and COPD exacerbation. However, the KOCOSS cohort is an ongoing study, and long-term results will be reported in the future. Second, the loss to follow-up was substantial and may not be random in this cohort, which could lead to selection bias. Third, the number of female patients in the cohort is small because the majority of middle-aged and elderly smokers are male in Korea . Fourth,Beyond these limitations, our study has strengths. To the best of our knowledge, this is the first prospective study investigating the value of the RV/TLC ratio as a continuous variable using a non-linear analytic method in patients with COPD. In addition, we suggest a possible effective intervention for patient with an increased RV/TLC ratio. We hope that more research will be reported on the clinical significance of the RV/TLC ratio.In this prospective cohort study, we found an association of air trapping (representing RV/TLC ratio as a continuous parameter) with an increased risk of COPD exacerbation, particularly in patients who have not undergone triple inhaler therapy. This association was still valid for severe exacerbations.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of each participating medical center. The patients/participants provided their written informed consent to participate in this study.YK: conceptualization, investigation, writing—original draft, and writing—review and editing. SK: conceptualization, methodology, writing—original draft, and writing—review and editing. CR and CL: supervision, validation, and writing—review and editing. JL: investigation, validation, and writing—review and editing. DK: investigation, project administration, and writing—review and editing. K-CS: supervision, project administration, and writing—review and editing. KJ and KY: supervision, funding acquisition, project administration, and writing—review and editing. YP: conceptualization, supervision, validation, and writing—review and editing. All authors approved the final version of the manuscript.This work was supported by the Research Program funded Korea National Institute of Health .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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