Aims: To examine the extent of social stigma toward diabetes among Singapore's multi-ethnic general population and determine whether this differs across socio-demographic sub-groups.Methods: Data for this study came from a nationwide cross-sectional study. A diabetes stigma questionnaire comprising Social Distance Scale and Negative Attitudes and Stereotyping Scale was administered to those respondents who had not been diagnosed with diabetes. Exploratory factor analysis was conducted to determine the dimensionality of the instruments and validated using confirmatory factor analysis. Multiple linear regression analysis was conducted to examine associations between socio-demographic factors and measures of diabetes stigma.Results: In all, 2,895 participants were recruited from the general population giving a response rate of 66.2%. Factor analyses found that a one-factor model resulted in an acceptable fit for both stigma scales, which measured social distance and negative attitudes and stereotyping, respectively. Multiple linear regression analyses identified Indian ethnicity (vs. Chinese), higher personal income (≥SGD2000 vs. < SGD 2000) and having close friends or family members who had been diagnosed with diabetes to be significantly associated with lower social distance scores while those aged 50–64 years and those with secondary and vocational education (vs. degree and above) were significantly associated with higher social distance scores. Those with a personal income of SG$2,000–3,999 and SGD $6,000 and above, and those with close friends or family members diagnosed with diabetes were significantly associated with lower negative attitudes and stereotyping scores. In contrast those aged 35 years and above, those with primary education and below, and those of Malay ethnicity were significantly associated with higher negative attitudes and stereotyping scores.Conclusions: The study found a relatively low level of stigma toward diabetes in the general population of Singapore, although some stigmatizing beliefs emerged. While greater knowledge of diabetes could reduce stigma, anti-stigma messaging should be incorporated into the “War on Diabetes” programme in Singapore. Diabetes is a serious, chronic condition due to its high prevalence and adverse economic and social impact. The International Diabetes Federation estimates that nearly half a billion of the world's population lives with diabetes today. This figure is estimated to reach 700 million by 2045 at current incidence rates   in 2016 to mitigate the public health and economic impacts of diabetes, focusing on T2DM as it is a largely lifestyle-based (and preventable) condition. Since then, the Ministry of Health (MOH) has set in motion a whole-of-nation combat against diabetes by establishing the “Diabetes Prevention and Care Taskforce” and implementing programs and initiatives across schools, public spaces, organizations, and public health institutions  defines stigma as a “mark of shame, disgrace or disapproval that results in an individual being rejected, discriminated against and excluded from participating in several different areas of society.” Health-related stigma commonly impacts individuals with chronic health conditions, and the individuals believe that others  perceive a personal characteristic or attribute as deviant and display negative attitudes or discriminate against them ; ability to understand and speak in English, Chinese, Malay, or Tamil; and living in Singapore at the time of the survey. All residents who were uncontactable due to incomplete or incorrect addresses, and those living outside the country during the survey period were excluded from the study. Those who were unable to understand the questionnaire due to cognitive difficulties as well as those with severe physical or mental disorders who were unable to answer the questionnaire on their own, were also excluded from the study. Data were collected through face-to-face interviewer-administered questionnaires via computer-assisted personal interviews (CAPI) using handheld tablets. Participants were asked to indicate their language of preference when informed consent was sought from them.Approval for conducting the study was obtained from the Institute of Mental Health's Institutional Research Review Committee and the National Healthcare Group's Domain Specific Review Board (NHG DSRB Ref 2018/00430). Research related activities were initiated only after obtaining written informed consent from the participants. Parental consent was sought for those aged 18–20 years as the official age of majority in Singapore is 21 years and above.The sample size estimates were produced by running statistical power calculations for binary proportions to determine what sample sizes are necessary overall and subgroups to produce a precise estimate with a margin of error ≤ 0.05. Based on data from an earlier study that examined knowledge of diabetes and risk factors . The response options ranged from 1 to 4, from “definitely willing, probably willing, probably unwilling, to definitely unwilling” with higher scores reflecting the desire to distance themselves socially from someone with diabetes. Similarly, 7 items assessed negative attitudes and stereotyping toward diabetes and people with diabetes . The response options ranged from 1 to 5, from “strongly agree, agree, neither agree nor disagree, disagree, to strongly disagree” with the “strongly disagree” option reflecting lower negative attitudes. The items were reverse-scored, and thus, higher negative attitudes and stereotyping scores indicate higher diabetes stigma.In all, 7 items assessed social distancing, which assessed the willingness of people without diabetes to socialize with someone with diabetes, work closely with them, marry someone in their family etc.  to extract the factors. The derived factors from the EFA were then applied to the second subsample  and validated using confirmatory factor analysis (CFA). EFA examined the polychoric correlations with robust unweighted least squares (ULSMV) estimator. A Crawford-Ferguson equamax (CF-EQUAMAX) rotation was then applied to obtain a more discriminating factor structure. Several criteria were used to determine the number of factors in EFA, such as eigenvalues , visual sighting of scree plot, identifying the pattern of loadings on each factor   was conducted to determine the dimensionality of the scales on the first subsample  Brown, , and rob) Brown, . Missingn = 2,440). The majority of participants were aged 18–49 (62.4%), ethnic Chinese (76.9%), married (59.7%), and employed (72.4%). In all, 2,895 participants were recruited from the general population , giving a response rate of 66.2%. Of the 2,895 participants, 2,440 participants were included in the current analysis—after removing 455 respondents with diabetes. The plot of eigenvalues of the initial 7-item social distance scale indicated that a single factor solution was plausible. The range of standardized loadings in the social distance factor was 0.51–0.91. To confirm this factor structure, CFA of the one-factor model resulted in an acceptable fit. The model fit indices were as follows: CFI = 0.97, RMSEA = 0.08, SRMR = 0.04, and TLI = 0.96 .The plot of eigenvalues for the initial 7-item scale indicated that one or two-factor solutions were plausible. Upon examination of each of the rotated solutions, including the pattern of factor loadings, i.e., cross-loading and loadings > 0.30, three items  were removed. A one-factor solution with four items was found to be optimal. The range of standardized loadings in the negative attitudes and stereotyping factor was 0.36–0.64, respectively. To confirm this factor structure, CFA of the one-factor model using the final four items resulted in an acceptable fit. The model fit indices were as follows: CFI = 0.98, RMSEA = 0.04, SRMR = 0.02, and TLI = 0.95. Factor loadings and goodness of fit indices of the final model are presented in Two separate diabetes stigma scores related to social distance and negative attitudes and stereotyping were generated by summing up the relevant items of the scales. The Cronbach's α coefficient for the social distance and negative attitudes and stereotyping scales were 0.81 and 0.49, respectively.Those with pre-university/junior college education (vs. degree and above), divorced/separated (vs. married/cohabiting), having a personal income of SG$2,000 to 3,999 and SGD $6,000 and above (vs. < SGD2000), and those with close friends or family members diagnosed with diabetes were significantly associated with lower negative attitudes and stereotyping scores. In contrast those aged 35 years and above (vs. those aged 18–35 years), those with primary education and below (vs. degree and above), and those of Malay ethnicity (vs. Chinese) were significantly associated with higher negative attitudes and stereotyping scores.This is the first study on stigma toward diabetes in an Asian general population to the best of our knowledge. The item-wise endorsement of social distancing ranged from less than one in ten of the population being unwilling to be friends with someone with diabetes to about three in ten unwilling to have someone with diabetes marry into their family. This contrasts with the results from a previous study in Singapore that examined stigma toward those with mental illness using a similar methodology. The study found that three in ten of those who were presented with a vignette of a person with schizophrenia stated that they would be unwilling to be friends with the person, while about one in ten were unwilling to be friends with a person having depression. Almost eight in ten were unwilling to have someone with schizophrenia marry into their family, and six in ten felt similarly about someone with depression getting married into their family , discrimination and loss of status of the stigmatized group, and lastly, the exercise of power to exploit or control the stigmatized group  expressed significantly more desire for social distancing toward those with diabetes. Similarly, those aged 35 years and above (vs. those aged 18–34 years) had higher negative attitudes and stereotyping toward diabetes and those with diabetes. It is possible that people belonging to younger age groups may have more access to diabetes-related information and hence may have better knowledge and understanding of diabetes. However, knowledge alone does not influence stigmatization. Those belonging to the younger age group may be more inclusive and open-minded due to exposure to diverse cultures, especially in educational and workplace settings , under certain conditions, can promote tolerance and reduce prejudice Allport, . HoweverParticipants of Indian ethnicity had significantly lower social distancing scores than those of Chinese ethnicity. Several factors may have contributed to the lower social distancing observed in the Indian ethnic group. Diabetes prevalence among ethnic Indians in Singapore is higher than for other ethnic groups  was adopted in Singapore. While we adjusted for non-response bias, those refusing to do the study may be inherently different from those willing to participate, affecting our results. Social desirability bias could have impacted participants' self-reported responses to the social stigma instrument, given that social stigma, in general, has a negative connotation, and many of the items required explicit endorsement of one's rejection or unwillingness to associate with persons with diabetes. While the sample is multi-ethnic, the findings might not be generalizable to other Asian populations with its diversity of cultures, literacy, and economic development.In conclusion, while our study found a relatively low level of stigma toward diabetes in the general population of Singapore, some stigmatizing beliefs emerged. The authors believe that while greater knowledge of diabetes could reduce stigma, anti-stigma messaging should be incorporated into the “War on Diabetes” programme in Singapore. In line with an integrated care perspective, stigma should be viewed as a crucial element of chronic disease management so that all the different stakeholders involved in a person with diabetes's care journey  can be more mindful of their own stigmatizing attitudes or language. Multiple stakeholders should be involved in co-creating and implementing multi-level stigma reduction interventions, thereafter sustaining it through community engagement (Nyblade et al., 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 National Healthcare Group Domain Specific Review Board, Singapore. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.MS, EA, JV, RD, EL, CS, and SC contributed to the study conception and design. SC was the PI of the study and was awarded the funding. Questionnaires were developed by MS, JV, PA, ES, RD, EL, CS, and SC. Literature review was done by SB, MS, PW, KR, and FD. Translation of questionnaires, cognitive testing, interviewer training, data check, and field management was done by PA, SS, FD, PW, KR, ES, and MS. Data analysis was done by EA. The first draft of the manuscript was written by MS and all authors commented on previous versions of the manuscript. All authors read and approved the final 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.


To extract texture features from magnetic resonance imaging (MRI) scans of patients with brain tumors and use them to train a classification model for supporting an early diagnosis.Two groups of regions (control and tumor) were selected from MRI scans of 40 patients with meningioma or glioma. These regions were analyzed to obtain texture features. Statistical analysis was conducted using SPSS (version 20.0), including the Shapiro–Wilk test and Wilcoxon signed-rank test, which were used to test significant differences in each feature between the tumor and healthy regions. T-distributed stochastic neighbor embedding (t-SNE) was used to visualize the data distribution so as to avoid tumor selection bias. The Gini impurity index in random forests (RFs) was used to select the top five out of all features. Based on the five features, three classification models were built respectively with three machine learning classifiers: RF, support vector machine (SVM), and back propagation (BP) neural network.Sixteen of the 25 features were significantly different between the tumor and healthy areas. Through the Gini impurity index in RFs, standard deviation, first-order moment, variance, third-order absolute moment, and third-order central moment were selected to build the classification model. The classification model trained using the SVM classifier achieved the best performance, with sensitivity, specificity, and area under the curve of 94.04%, 92.3%, and 0.932, respectively.Texture analysis with an SVM classifier can help differentiate between brain tumor and healthy areas with high speed and accuracy, which would facilitate its clinical application. Brain cancer remains a diagnostic challenge for clinicians and radiologists because malignant brain tumor cells can invade into the neighboring cells in the brain and spinal cord with fuzzy borders and have a high progression rate . TreatmeTo increase the diagnostic precision and efficiency, many computer-assisted methods have been developed and introduced, including machine learning (ML) and deep learning (DL) . TextureWe hypothesized that some texture features acquired from MRI scans would serve as classification features and markedly improve classification efficiency. To test our hypothesis, the Gini impurity index in the random forests (RFs) was applied to select features, which were then used to develop classification models. Finally, the performance of the features and the models in confirming our hypothesis was assessed.The data used were collected from the Affiliated Nanjing Brain Hospital of Nanjing Medical University. Patients in whom meningioma or glioma was histopathologically confirmed between January 2014 and December 2014 were selected. In all, 40 patients (average age: 51.10 years) comprising 22 men (average age: 52.36 years) and 18 women (average age: 47.33 years) were included. The exclusion criteria were as follows: (1) presence of other organic mental disorders and nervous system diseases and (2) a history of major physical illnesses. All of the patients met the above criteria. The study was approved by the medical ethics committee of Nanjing Medical University. All patients provided signed written informed consent.All images were acquired using a 3T Siemens MRI system. The patients were instructed to relax, keep their eyes closed, stay awake, and remain still. Patient compliance was confirmed after scanning was completed. The images were recorded axially for 6 min by using an echo-planar imaging sequence with the following parameters: TR = 1900 ms, TE = 2.49 ms, slice thickness = 1 mm, flip angle = 90°, and matrix size = 256 × 256. All patients underwent MRI without reporting discomfort during or after the procedure.For the experimental preparation, the raw sample image format was changed from DICOM to JPG. In the texture analysis, the tumor region in the coronal MRI image was selected as the experimental group, and the symmetrical healthy region on the other side of the brain was selected as the control group. There were 40 tumor regions in the experimental group and 40 healthy regions in the control group. In each group, 25 texture features (belonging to three categories) were calculated, as shown in The 25 texture features were recorded as mean ± SD. Statistical analysis was performed using SPSS (version 20.0), including the Shapiro–Wilk test and Wilcoxon signed-rank test, which was used for testing significant differences in each feature between tumors and healthy areas. Meanwhile, an RF model was employed to predict whether each sample was a tumor or a healthy area and for importance rankings of 25 texture features according to the Gini impurity index in the RF . All texThe samples were randomly divided into training (70%) and test sets (30%). This was iterated five times to provide five unique training and testing groups. The training set was used to generate classification models with three different classifiers: RF, BP, and SVM.The RF is fast, is flexible, and has become a standard tool in biomedical informatics. Each classifier in the ensemble is a decision tree classifier and is generated using random selection of attributes at each node to determine the split. During classification, each tree votes, and the most popular class is returned.The BP iteratively processes a set of training tuples and compares the network’s prediction with the actual known target value. For each training tuple, the weights are modified to minimize the mean squared error between the network’s prediction and the actual target value. Modifications are made in the backwards direction. The process will reach the terminating condition when the error is very small.The SVM is a classification method for both linear and nonlinear data. It uses nonlinear mapping to transform the original training data into a higher dimension. With the new dimension, it searches for the linear optimal separating hyperplane. With an appropriate nonlinear mapping to a sufficiently high dimension, data from two classes can always be separated by a hyperplane. SVM finds this hyperplane using support vectors and margins.Four indexes were used to evaluate each model, including the area under the curve (AUC), error rate, sensitivity, and specificity. Moreover, the receiver operating characteristic (ROC) curve was constructed for each model.Using the Wilcoxon signed-rank test, 25 texture features could reveal regions with higher and lower texture values when comparing the experimental (tumor region) and control groups , as shown in t-test was used to examine 40 samples to determine whether their features were relatively different between the tumor and healthy regions. We found that the mean P-value was 0.2390645. The P-values of seven samples—1, 9, 10, 19, 23, 30, and 35—were greater than the mean P-value, and these samples were also mistakenly distributed in the t-SNE picture and were deleted.The t-SNE test results are shown in On the basis of the results obtained above, we selected the five features  identified in the RF to set up classifiers, which helped save calculation time and resources. Three classification models  were applied, and five features were used to train each classifier. A detailed summary of the model’s performance is presented in All three models showed satisfactory AUCs of 0.85–0.95. The RF and the BP shared a similar performance based on the AUC, error rate, sensitivity, and specificity. The model trained by the SVM classifier demonstrated the best performance among the three models, with markedly better AUC, error rate, sensitivity, and specificity, indicating that this model could correctly classify the tumor and healthy regions. Receiver operating characteristic (ROC) curves were constructed for the three models to compare their performance directly, as shown in Some studies have reported the same methods to select features, and the validity of this approach has been proven. t-test was applied to generally examine whether the healthy and tumor regions showed significant differences in the 25 texture features for each sample. To determine the modified number of samples that would be deleted, the mean P-value was set as the deletion standard, and seven samples were excluded on the basis of this standard. Since the samples were marked manually and these samples were likely to be marked mistakenly, this was a limitation that has been mentioned in many previous studies.The images for the t-SNE test results showed some seemingly noisy dots. Considering the possibility that all mistakenly distributed samples may be deleted incorrectly, the On the basis of the five features, three class-action models were built by training three ML classifiers, namely, RF, SVM, and BP. The SVM classifier was superior to the RF and BP classifiers, as shown in This study had some limitations. First, the dataset was modified, since the model was trained with only 80 samples. Its robustness needs further examination. Second, some degree of selection bias may exist. Different categories of brain tumors have different texture features. Some unique features were excluded, which may have influenced the results of our analysis. Third, a manual approach was adopted to segment tumors in this study. Although manual segmentation generally works better than automatic methods, segmentation errors could still exist. Some noise dots may have been mistakenly marked manually, negatively influencing the formation of our model.In conclusion, we hypothesized that a few of the textures acquired from the MRI images could serve the role of classification features, thereby significantly improving the classification efficiency. The Gini impurity index in the RF was applied to select features. On the basis of the five features, three class-action models were built by training three ML classifiers, including RF, SVM, and BP. The classifier model in this article was superior to the previous models, since it depended on only five features. On the basis of our initial findings, tumor regions characterized on the basis of MRI-based texture analysis may have clinical usefulness in differentiating brain tumors.med.info@njmu.edu.cn.The datasets presented in this article are not readily available because the data cannot be used out of the hospital. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Nanjing Medical University. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


A new coronavirus causes COVID-19, a developing respiratory illness. Unfortunately, there is little information assessing healthcare workers' understanding of technology and preventative strategies during the Nepalese epidemic. Researchers from other subspecialties uncovered some mythical thoughts. As a result, we decided to put it to the test with healthcare personnel on the front lines. The research also looked at the problems experienced by frontline health care personnel (HCP) because of the COVID-19 strategic shift in work policy.Nepalese healthcare workers participated in web-based cross-sectional research. A pre-tested, structured questionnaire utilizing a Google form was used to get self-informed, digitally typed consent, and examine critical perspectives and problems with current technology and COVID-19 prevention efforts.n = 27), health assistants (n = 2), medical intern doctors (n = 1), paramedical (n = 139), pharmacy (n = 1), and paramedical interns (n = 73) in this study. The calculated mean percentage score of knowledge on instruments and tools was 73.64 (SD ± 10.43) %, and perception on COVID-19 transmission and control was 70.06 (SD ± 18.30) %. At various levels, frontline health workers faced significant challenges, including the adoption of digital health technology.In total, 243 participants with mean age of 29.66 ± 7.61 years agreed to participate and were doctors (Frontline HCPs are anticipated to have updated knowledge from what the study has outlined. It is recommended to follow national guidelines. Policies should be put in place so that every frontline worker can demonstrate high standards in prevention, control, and equipment use that do not create misinformation among HCPs. Throughout, support for digital health materials and disease control methods for HCPs is essential. COVID-19, a coronavirus, is a pandemic globally. There seems to be no other way for the virus to stop its spread other than to prevent it. Proper use of personal protective equipment (PPE) is the key to stopping the spread of the virus from the patient to the caring personnel. The Centers for Disease Control and Prevention (CDC) has given health care personnel (HCP) guidelines for working at health centers and isolation centers . The latDigital technologies and protective instruments used in testing, treatment, and management of COVID-19 are the pillars for protecting and restricting the spread of diseases among people, especially for the frontline HCPs . AlthougA pilot test of the same tool revealed poor knowledge of the HCP. Hence, this study was conducted to access the knowledge of current critical technology and understand the perceptions of health professionals toward the spread and control of the pandemic. In addition, we looked at the challenges faced in treating the patients and adapting the digital health material to prevent COVID-19 among frontline HCP in Nepal with the help of a comprehensive yet straightforward questionnaire tool.A web-based qualitative descriptive cross-sectional study was carried out from August 10 to December 23, 2020, among frontline healthcare workers. The Nepal Health Research Council (NHRC) granted permission to conduct the study with mandatory written consent as the criterion. Each participant was asked to sign a digitally written and informed consent form. The research tool and design were adopted and streamlined from Sanyam's et al.  for statistical analysis was used. Finally, the data were presented in percentage, mean, standard deviations (SD), and frequency using bar diagrams and tables.n = 27), health assistants , medical intern doctors (n = 1), paramedical (n = 139), pharmacy (n = 1), and paramedical interns (n = 73) in this study. The remaining 496 did not turn up even after the second reminder. The calculated response rate was 32.74%.The survey questionnaire was sent to 742 people, of whom 243 , mean age of 29.66 (SD ± 7.61) years, agreed to participate, whereas three did not consent from the list of overall respondents. Participants were doctors (The details of socio-demographics are presented in n = 127) felt that PCR is mandatory for everyone, whereas a similar (n = 116) number of responses were noted for temperature screening, which was not helpful in screening for COVID-19. A limited yet considerable  number of participants were unsure about the importance of teleconsultation in contagious diseases like COVID-19. The obtained detailed perception responses are tabulated in There is a scarcity of protective equipment, exacerbated in low- and middle-income countries due to limited resources. Health workers were self-motivated to know and be updated about this pandemic using government websites, awareness messages, and social media. That means a well-associated positive attitude toward obtaining the information. In this study, we asked about the instruments, the virus transmission, and control. About 50% , at a satisfactory level.The calculated mean percentage score of perception on instruments and tools was 73.64% (SD ± 10.43), at a satisfactory level.n = 4) who did not encounter any problems adapting to COVID-19 made variations in health strategies. In contrast, the majority  agreed on challenges faced at personal, institutional, technological, and policy levels.There was a significant issue with adapting and using the protective measures during the pandemic, and this had a drastic impact on the lifestyle and working habits of the health professionals. In n = 82) challenge faced was lack of appropriate training to use digital health and educational materials. Only 8.2% (n = 20) of health professionals did not have any sort of difficulties in adapting to and using digital devices to make the health system more effective. The overall challenge of using digital health materials by frontline health workers during COVID-19 is shown in the bar diagram . All those factors can impact the body temperature; thus, it may not be adequate to declare the thermal gun report as standard care , but it'PCR is considered the gold standard in the diagnosis of COVID-19. However, the understanding of PCR seemed insufficient in this survey, as 20.59% of the participants could not interpret the PCR result and seemed to have poor knowledge. Similarly, 19.33% believed that chest X-ray is superior to PCR in the COVID-19 suspects. However, roughly half of the participants, 52.10%, said that everyone must get a PCR test done with or without symptoms. This is not the fact; the reality is that it is mandatory to have knowledge about PCR and get it done if the patient has symptoms or is asymptomatic but exposed to COVID-19 aerosols , 32. Varn = 176) of the participants said they faced challenges at all levels  in adopting the change in health strategy amended due to COVID-19. The government (MOHP) should take this as a matter of seriousness and support the frontline HCPs in a more effective implementation model  sampling method was chosen. The COVID-19 pandemic is still evolving, and there might be a change in perception throughout the data collection until the publication of the report. Although the sampling technique was non-probability-based, the overall sample of this study is sufficient to draw the required conclusion. This study has the potential to be useful in highlighting some of the public health concerns and implementation issues that are mandatory for the Nepal government to consider. Also, there is critical public interest in understanding health workforce capacity and strain during the COVID pandemic. The government should carry out more robust training and awareness for frontline healthcare workers to recompense any misinformation. Also, it is recommended that MOHP carry out a similar but detailed study at the policy level, making it mandatory for all HCPs to analyze the gap and develop a strategic work plan to overcome the challenges and update knowledge.Although the perception of instruments and tools and disease transmission and control scores seemed satisfactory in HCP, it cannot be considered acceptable for public health concerns like COVID-19. Inadequate information about disease control, communication, and tools employed are indicators of poor health outcomes. Some of the perceptions were so based on fiction that they may have implications for hospitals, COVID centers, and respective government bodies. HCPs must seek out relevant information on disease management and continue to upgrade their skills following MOHP regulations. The difficulties encountered by HCPs in this study are expected to obstruct the result. So, the challenges faced by HCP should be addressed with the appropriate strategy regularly. Any form of training given to HCP must have 24/7 support in terms of tech or monitoring.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Nepal Health Research Council. The patients/participants provided their written informed consent to participate in this study.SDS, KP, TG, and BB designed the study. KP, SDS, JH, and BB reviewed the design. SDS, SKS, KP, SP, TG, and PB collected and cleaned the data. KP and BB oversaw the study. SDS drafted the manuscript. KP, JH, and SI crucially evaluated the manuscript. SDS, KP, and JH revised the reviewers' comments extensively. All authors analyzed the data and have authorized the final manuscript for publication.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.


Adolescents were classified as 82.4% responders for %Fat, 70.6% for WC, 88.2% for WHR, and 70.6% for CRF. Further, there was an association between changes in %Fat (p = 0.033), WC (p = 0.032), and WHR (p = 0.033) between responders and non-responders with CRF in the IG. There was a positive effect on body composition, physical fitness, and leptin. In addition, reductions in body composition parameters were explained by CRF improvements.Physical exercise reduces the biochemical markers of obesity, but the effects of multicomponent interventions on these markers should be explored. The present study aimed to elucidate how overweight/obese adolescents respond to a multicomponent program approach on body composition, physical fitness, and inflammatory markers, using a quasi-experimental study with 33 overweight/obesity adolescents (control group (CG) = 16; intervention group (IG) = 17). The intervention consisted of 24 weeks with physical exercises and nutritional and psychological guidance. Both groups were evaluated at the pre/post-intervention moments on body mass index (BMI); body fat (%Fat); waist circumference (WC); waist/hip ratio (WHR); waist-to-height ratio (WHtR), cardiorespiratory fitness (CRF); abdominal strength, flexibility; leptin; interleukin 6; interleukin 10; and tumor necrosis factor-alpha. Mixed-analysis of variance and generalized estimation equations were used for statistical analysis. There was an interaction effect between groups and time on %Fat ( Child and youth obesity currently has alarming proportions worldwide . PhysicaAdolescence is a period of physical, cognitive, and social development, and at this time, the behaviors developed can last into adulthood. It is in this phase of increasing autonomy that health-related behaviors may be more susceptible to change. Therefore, preventive and rehabilitation interventions applied in this “window of opportunity” can be more effective in promoting changes to healthy behavior and, thus, in improving health throughout life . In thisThe current literature highlights that programs that include regular physical training, in the treatment of excess weight and its comorbidities, demonstrate improvements in physical fitness and body fat reduction, which may induce physiological, endocrine, and cardiovascular adaptations ,12. In aHowever, most of the results based on obesity intervention programs are highlighted by comparing the groups using mean values. Few studies report an individual prevalence of responses, especially in children and adolescents. Additionally, although some studies have reported such prevalence of responders, they highlight results on cardiometabolic risk factors including adiposity, glycemic and lipid profile ,10, leveLikewise, it is not yet clear what are the characteristics of an intervention program that must be taken into consideration for the treatment of obesity in adolescents, including the type of exercise, duration, and intensity, to exert a beneficial effect on the individual responsiveness. Therefore, this study aims to elucidate how overweight and obese adolescents respond to a multicomponent program, including different types of physical exercises , nutrition and psychological approach on body composition, physical fitness, and circulating inflammatory markers, as well as to determine the individual prevalence of responsiveness on these parameters and the main mediators associated with the positive effects.This quasi-experimental study was part of a larger study called: “Obesity in elementary school students: an interdisciplinary intervention study-Phase III”, developed with overweight and obese adolescents of both sexes, aged between 10 and 17 years. The research was approved by the Research Ethics Committee of the University of Santa Cruz do Sul (UNISC), under the number 1,498,338. In addition, it is registered as a clinical trial under Protocol ID: 54985316.0.0000.5343. All the participants were informed about the research procedures, parents or legal guardians of the adolescents signed free and informed consent forms, and the adolescent signed the assent form.The initial sample of this study was obtained from the cross-sectional research “Health of students-Phase III”, carried out at the University of Santa Cruz do Sul, in which overweight and obese adolescents were identified through body mass index (BMI) assessments, classified according to the World Health Organization percentile curves . Of thesAs inclusion criteria, adolescents needed to present the signed free and informed consent form and informed consent form for the underage child; be aged between 10 to 17 years; perform blood collection; not have participated in another physical exercise program simultaneously with the intervention project and in the last six months and be able to participate only in regular physical education classes. The exclusion criteria were a frequency of participation in the intervention program below 60%, or presenting incomplete data in physical tests or blood tests. The sample size calculation was performed in G*Power 3.1.9.7  Anova: rn = 48) and Control Group . The multicomponent intervention program had an initial participation of 48 members in the IG. However, over the 24 weeks of intervention, there was a sample loss of 25 adolescents, 22 of them due to excessive absences; 3 because they presented some type of contraindication to performing physical activity during the program, and another 6 adolescents were excluded because they did not present complete data on blood tests or physical tests. In the CG, 42 adolescents participated in the initial evaluation, but at the end of the intervention program, only 23 performed the post-test evaluation. Afterward, seven adolescents were excluded for not presenting complete data on physical tests or blood tests. The sample flow diagram can be seen in Initially, 90 adolescents agreed to participate and were allocated by convenience criteria into two groups: Intervention Group  and relaxation/stretching activities. Monday’s sessions consisted of warming up, stretching, pedagogical processes and sports activities, and the classes were programmed with sport variation . On Wednesday, the session covered activities with a functional and resistance exercise circuit, respiratory re-education, and postural correction exercises. On Fridays, varied water activities were offered in a heated pool, which included swimming initiation, aqua aerobics, and recreational games.®, Finland) and the training intensity was defined to induce HR between 50% and 70% of maximum HR, considering a Karvonen equation (HR maximum = 220-age). Mandatory requirements and requirements were gradually increased.The intensity of the activity developed was controlled by heart rate (HR) monitors , which was used to verify body weight. BMI was determined by the formula BMI = weight/height² (kg/m²) and the results were subsequently classified by the WHO percentile curves [The height of the adolescents was measured using a stadiometer coupled to a properly calibrated scale  by the outsourced laboratory.For blood analysis, 10 mL of blood was collected from the brachial vein after a 12-h overnight fast and 72 h after the last training session or evaluation. 5 mL was used in the vacant tube without anticoagulant  and 5 mL of whole blood for the EDTA vacutainer tube (for blood count). All samples were collected, processed, divided into serum or plasma aliquots for analysis or stored at −80 °C. The blood was collected by a trained professional from the Exercise Biochemistry Laboratory, at UNISC. To determine leptin, interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-alpha (TNF-α) were studied in a serum sample . The categorical variables were presented with absolute and percentage frequency to characterize the sample, and the difference between groups was determined through chi-square test. To compare the baseline variables between IG and GC, the one-way ANOVA test was used. The effect of the intervention was analyzed using generalized estimation equations (GEE), adjusted for maturation and sex, testing the main effects of group and times, as well as the respective interaction effects. Additionally, analyses were performed to derive mean relevant differences between groups. The effect size between pre and post-intervention was also calculated using the means and standard deviation of the groups through the Cohen’s e effect .12 + SD22)/2), where SD1 is the base value and SD2 is the post-test value. The cutoff point was considered to be the one that presents an effect size (≥0.20 or ≤−0.20) after the intervention period. The difference in prevalence between groups was determined through logistic regression. The differences between CRF responders and non-responders for the results considered showed a difference in responsiveness between the CG and IG , which were examined by univariate linear models (ANCOVA) adjusted for baseline. All analyzes were performed using the Statistical Package for the Social Sciences, version 23.0  and the level of significance was set at α = 0.05 for all analysis.The prevalence of the responders was defined according to the magnitude of the size of the individual effect of each group (intervention and control), calculated by the calculation: Δ/SDpooled, where changes (Δ) were calculated as Post-intervention minus Pre-intervention values dividing by SDpooled. To define SDpooled, an equation was used: √((SDp = 0.04), WHR (p = 0.01) and IL-6 (p = 0.04), compared to CG.p = 0.001; d = −1.03), WC , WHR , WHtR , CRF  and leptin , in which IG presented an improvement on these parameters from the pre- to post-measures, compared to the CG.p < 0.001), WC , WHR  and CRF . The other variables did not show differences in the prevalence of responders.For the variables that showed a difference in responsiveness between CG and IG  we intend to understand the influence of CRF. Thus, differences in changes in body fat, WC, and WHR between responders and non-responders in CRF are presented in The main findings of the present study indicate that: (1) there was an interaction effect between groups in body fat, WC, WHR, WHtR, CRF and leptin, in which IG presented an improvement on these parameters from the pre- to post-measures, compared to the CG; (2) The individual prevalence of responders showed that 82.4% of the adolescents were classified as responders on body fat, 70.6% for WC, 88.2% for WHR, and 70.6% for CRF in the IG. For those variables there was a significant difference in the prevalence of responders between IG and CG; (3) There was an association between the change in body fat, WC, and WHR between responders and non-responders for CRF in the IG.Our data are aligned with previous studies namely on body composition, reporting decreased body fat, BMI, WC, WHtR, and WHR after physical exercise interventions, with durations ranging from three to six months and different intensities (moderate to vigorous) ,15,26,27Although we have found important results in the aforementioned variables, there were no significant changes in the levels of IL-6, IL-10, and TNF-α between IG and CG after the intervention program. In this sense, a meta-analysis identified that although there was a tendency to decrease IL-6, no significant reductions in IL-6 and TNF-α were observed in overweight/obese children or adolescents after a physical training program . On the The analysis of the individual response showed that the number of responders regarding body fat, WC, and WHR were significantly higher in the IG than in the CG. Walsh et al.  reportedAs far as is known, there is no evidence on the prevalence of responders in inflammatory markers after a multicomponent intervention consisting of exercise, nutritional, and psychological counseling with overweight/obese adolescents. Indeed, our data indicated unexpected results, in which the prevalence of responders was high for IL-6 and TNF-α in both CG and IG. The lack of previous studies that indicate the interindividual response to lifestyle intervention programs on inflammatory parameters makes difficult comparisons and assertions about the results found in this study, especially regarding the variables of IL-6, IL-10, and TNF-α. Furthermore, the presence of genetic polymorphisms may be associated with different responses found in the literature about these parameters .Considering that there is wide inter-individual variability in the effects of interventions with physical training on health outcomes, it is important to note that genetic and environmental factors can contribute to this variability ,43. In aThe literature is clear about the positive influence of CRF on body composition parameters and as a strong predictor for cardiovascular diseases and total mortality. In addition, an improvement in CRF is a potential mediator of the metabolic effects of exercise on adiposity and related comorbidities . A higheThus, seeking to understand the results obtained so far and the effects of this multi-component intervention aimed at improving physical fitness and body composition of overweight and obese adolescents, we verified the influence of the response of CRF on the other variables that showed a higher prevalence in the IG after the intervention. It was possible to identify that the changes in body composition variables  in the IG were associated with the CRF responders. Adolescents who were classified as responders to CRF showed a reduction in body fat (6.83%), WC 9.67 cm), and WHR (0.08 cm) compared to the non-responder’s peers. No studies were found comparing fitness changes between responders and non-responders after an intervention, which makes comparisons with our results difficult. In this regard, it is speculated that a frequency of three sessions of moderate to high intensity aerobic or combined physical exercise is sufficient to improve the CRF of overweight and obese adolescents . In addi cm, and Multidisciplinary programs are considered the gold standard treatment for young people with obesity because interventions that propose behavioral changes, increased physical activity, and dietary education can be beneficial and effective in changing their lifestyle in a short time . BesidesIn addition, these findings may have important implications in the design of interventions focused on the prevention/treatment of pediatric obesity and related comorbidities, such as low-grade inflammation, since the regular practice of moderate-intensity exercises direct the immune response to an anti-inflammatory state, such as the reduction of leptin levels promoted by this program, which is believed to be the main molecular mechanism desired to improve health outcomes .Our study has some strengths. Indeed, we have highlighted the implementation of this multicomponent intervention program, which offered sports and physical activities, contributing not only to the physical health of adolescents but also in all dimensions of quality of life . In addition, as far as we are aware, this is one of the first studies that report the effects of the intervention in “mean terms” and the interindividual variability of inflammatory markers, as well as the influence of changes in CRF on body composition in a sample of overweight/obese adolescents. However, some limitations must be mentioned, such as the relatively small sample size due to the large number of dropouts during the intervention period, so that we can only detect the moderate effects and the quasi-experimental study design that requires caution regarding the extrapolation of these results. Besides, genetic factors or energy metabolism, which may be determinants of inter-individual variability, were not measured in the present study.The results from this multicomponent intervention program, which went for 24 weeks and included physical exercise, nutritional guidance, and psychological support had a positive effect on body composition, physical fitness, and leptin reduction in overweight/obese adolescents. Furthermore, there was a higher prevalence of responders in the IG for body fat, WC, WHR, and CRF than in the CG, and reductions in some parameters of body composition were explained by CRF improvements. These findings reinforce the effectiveness of this program, however, studies with a larger sample size should be developed in order to establish that this intervention model can be adapted to school reality or social programs contributing to health promotion among overweight/obese adolescents.


Undernutrition is one of the leading causes of morbidity and mortality among under-five children, particularly in low-and-middle-income countries. Since women, including mothers, are the primary caregivers of their children, their empowerment status can inherently influence children's nutritional status. Empowerment is, mainly, an intrinsic agency developed as an affective domain trajectory or attitude that guides the skill or behavior. This study aimed to assess the association between women's empowerment and nutritional status of their children.A cross-sectional study was carried out among 300 mothers having children aged 6–59 month in rural municipalities of Kaski district in Nepal. Face to face interview and various anthropometric measurements were used to collect data. Chi-square test was performed to assess the association between women's empowerment and children's nutritional status, and multivariable logistic regression was used to assess the strength of association.Of 300 mothers having 6–59 months' children, nearly half (49%) were highly empowered while around 38% children were in poor nutritional status. More than one-fourth (26.7%) children were stunted, 7% were wasted, 17.7% were underweight, and in overall, nearly 38% were in poor nutrition. There was a five-fold increase in odds of wasting, thirty-fold increase in odds of stunting, and twenty-nine-fold increase in odds of underweight among children whose mothers had low empowerment status compared to their counterparts.Overall, this study exhibited that maternal empowerment strongly affected children's nutritional status, especially stunting and underweight. Thus, intrinsic factor, mainly education and community membership are suggested to empower them for making their own decisions. Interventions aiming to improve nutritional status of children should include women empowerment incorporating dimensions of material resources. Further empirical evidence is required from trials and cohort studies. Health, physical growth and development, academic performance, and progress in life are determined by the nutritional status of children . UndernuAlthough the global trend of child nutritional status in LMICs has improved in the last few decades, still 28% of under-five children are stunted. One of the core causes for child undernutrition is the lack of appropriate care for women and children , 10. It By 2030, ending preventable deaths of newborns and under-five children, ensuring women's full and effective participation and equal opportunities for leadership at all levels of decision making in political, economic, and public life in all countries were the established target of Goal 3 and Goal 5 of the sustainable development goals (SDG)  of stunting as 28.9% (that yielded higher sample size than wasting (5.8%) and underweight (14.9%)  with a 9From a list of 6,023 eligible children in rural municipalities, sample size for each of the 25 clusters have been calculated by probability proportional to size (PPS) technique. In order to select the first sample in each cluster, we used WHO EPI method .Face to face interview and anthropometric measurements were used as data collection techniques. Women's empowerment was assessed using a women empowerment index (WEI) which includes five indicators, i.e., women's involvement in household decision-making, women's membership in community groups, women's cash earning, women's ownership of house/land and women's education . Tools wp < 0.05) two socio-demographic variables-maternal age (p = 0.025), and number of children (p = 0.003); from the seven variables included in primary analysis. We also checked autocorrelation of these two variables with maternal empowerment where the highest correlation, among all, was observed as r = 0.18 (p = 0.002) between the number of children and maternal empowerment score. Since it was low (r = 0.18), so, we proceeded for the second step for adjustment and calculated the adjusted odds ratios.We included socio-demographic variables as background variables in the study and dummied as confounders. Sociodemographic variables included age of mother and child, religion, ethnicity, type of family, number of U5 children, the women had, household economic status and the sex of child. The independent variable was women's empowerment and included five indicators- decision-making; involvement in community groups; independent cash earing; house/land ownership; and educational status. Empowerment level was categorized as low, moderate, and high. The dependent variable of the study was the nutritional status and assessed as stunting, wasting, and underweight. Socio-demographic variables, mother's empowerment, and nutritional status of 6–59 months children were described per protocol. In the first analysis, the mother's empowerment status was associated to children's nutritional status using chi-square and unadjusted odds ratio. For the adjustment, then, we filtered out and selected only the significant , Pokhara University. Written informed consent were taken from selected rural municipalities for conduction of study in those areas. Participants were not subjected to any sort of harm and they were informed about their autonomy to withdraw from the study at any time during the study. Confidentiality of their information was fully maintained. Children identified as malnourished were referred to the nearest health facility and information was provided to the respective municipalities about the number of malnourished children.Among the 300 mothers interviewed, majority (87.3%) were from the age group of 24–34 years and followed Hindu religion (84.7%). The proportion of Dalit participants among the ethnic group was the highest (32.7%). Richer group as per IWI (fourth quintile), consisted the majority (57%), followed by third quintile (18%). The majority children (70.3%) were aged above 24 months. More than half (53.7%) of the children were male .Around 60% of women had completed secondary level and above whereas few (3.3%) had never been to school. Almost every nine out of 10 women themselves took the decisions related to healthcare and household goods purchasing. More than 80% reported having freedom to visit their relatives whereas 62% were members of any community groups. More than one-third of women earned cash income independently and one-fourth were the owners of a house or land. In aggregate, nearly half of the mothers had a high empowerment level followed by moderate and low .Among 300 children, more than half (53.5%) were found to be stunted. The proportion of stunting among male and female children was almost similar at 25.5 and 27%, respectively. Similarly, severe and moderate stunting was noted among 5 and 21.7%, respectively. Around 14% were found wasted. Wasting among male child (9.4%) was almost two-fold as compared to female child (4.3%). Similarly, more than one third (34.7%) of the children were found underweight. The proportion of underweight among male children was slightly greater than the female child . Overall, 60.3% children were felled under the normal category  whereas remaining was categorized as having poor nutritional status (37.7%) .In preliminary analysis, only two background variables, maternal age  and number of children in a family , were found significant with children's nutritional status, so entered as confounders in the multivariate models. Mothers with low empowerment were almost 30  times; nearly 5  times; nearly 29  times; and 37  times more likely to have their children being stunted, wasted, underweight, and in poor  nutritional status in reference to highly empowered mothers. Moderate empowerment level among women was also associated with children's stunting, underweight, wasting, and overall nutritional status but with lower strengths .The results show that all the dimensions of the women's empowerment index were significantly associated with children's nutritional status. The decision making in health care, decision making in household good purchasing, having membership in the community, earning cash independently, ownership of house/land, and education status showed a strong association with children's nutritional status .Children's nutritional status and the maternal empowerment level are analyzed and the findings are compared with that of the NDHS reports, other similar studies, and further discussed. Seminal literature has confirmed strong relationship between early childhood undernourishment and lowest income groups . This cap < 0.05). These findings are consistent with another study in Nepal, which found women's empowerment positively associated with nutritional status of their children (The study showed that low and moderate level of empowerment (with reference to high) were moderate to strongly associated with undernutrition of the children: Stunting , wasting , and underweight   was statistically significant with the nutritional status of children. These verdicts were accord with another study from Northern Benin, which showed positive correlation between women's empowerment and leadership while decision making was correlated with wasting and underweight among children . An RCT Our study showed that women's engagement in a community group was associated with child nutrition. The result is coinciding with the cross-sectional study from Andhra Pradesh, which showed that larger and more literate social networks are associated with better length-for-age of 1-year-old children . AnotherIn this study, the cash earning that leads to higher women's empowerment level was strongly associated with child nutrition. The finding concurred with the study from rural Karnataka, which showed a strong association with maternal employment and children's underweight .In this study, although ownership of house or land that comprised a part of women's empowerment, was associated with children's nutrition, the findings are consistent with the study from Nepal which found that women who own land are significantly more likely to have the final say in household decisions (OR = 1.48), a measure of empowerment  but a stIn this study, the level of education, which is a factor for high women's empowerment, was strongly associated with a child's nutrition. The finding is accordant with the study from Nairobi that found mother who passed the primary level have high (43%) stunted children compared to the mothers who passed the secondary level of education . Our stuHowever, it is not clear from the literature that how women's empowerment is associated with children's nutritional status. A systematic review summed up (from 62 quantitative studies) as 82 and 84 percent of the weighted cases, stunting and wasting, respectively, were not found significant with women empowerment. For this, the authors have blamed the study designs rather than the embedded underlying associations .To sum up, education , 41, incOur results demonstrate that 7%, more than one in every four, and more than one in every six children were wasted, stunted and underweight, respectively. Similarly, almost half of the mothers were highly empowered. There was nearly a five-fold increase in odds of wasting, thirty-fold increase in odds of stunting and twenty-nine-fold increase in underweight, among children whose mother had low empowerment status compared to their counterparts. Empowerment dimensions like women's education and their community membership are cautiously warranted so as to impact on their decision making, thereby positively contributing to children's nutritional status. Dimensions of material resources like independent cash earning and house/land ownership need further empirical evidences from stronger study designs.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 Pokhara University Research Center (PURC), Pokhara University, Nepal. The patients/participants provided their written informed consent to participate in this study.SP and CA conceptualized the research and analyzed the data. SP collected the data. SP, CA, RKY, and MJ prepared the first draft. SP, CA, DKY, and DKT prepared the second draft by addressing the comments from the reviewers. All authors reviewed the first draft, contributed for improvement, reviewed the final draft, read, and agreed to the final version of 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.


Older age was related to greater mediolateral displacements of the center of pressure with eyes open and closed . There were no associations between the menopausal symptoms’ severity and functional mobility. We can conclude that a greater severity of psychological menopausal symptoms was independently associated with worse postural balance in middle-aged postmenopausal women.The aim of the present study was to determine the associations between the severity of the menopausal symptoms and postural balance and functional mobility in middle-aged postmenopausal women. A cross-sectional study was performed . Severity of the menopausal symptoms , postural balance (stabilometric platform) with eyes open and closed, and functional mobility (timed up and go test) were determined. A multivariate linear regression was performed, with body mass index, waist to hip ratio, age and fall history as possible confounders. Our findings showed that a greater severity of the menopausal symptoms at a psychological level was associated, under both eyes open and closed conditions, with worse postural control assessed by the length of the stabilogram (adjusted R Menopause is defined as the permanent cessation of menstruation, confirmed after twelve consecutive months of amenorrhea. Menopause is characterized by physiological, psychosocial, and sociological changes associated with the reduction in ovarian function . MenopauFalls are a major public health problem, being the second leading cause of unintentional injury deaths worldwide , thus, iAltered balance and gait have been recognized as important fall risk factors . It has The goal of the present study was to determine the possible associations between the impact of the menopausal symptoms and postural balance and functional mobility in middle-aged postmenopausal women. We hypothesized that a greater impact of the menopausal symptoms is associated with worse stabilometric parameters and longer times in performing the TUG test. An analytical cross-sectional study was conducted on 171 postmenopausal women. Participants were recruited by contacting the staff of several associations of postmenopausal women from Granada and Jaén (Spain). This study was approved by the Research Ethics Committee of the University of Jaén, Spain (OCT.18/4.PRY). All participants gave their written informed consent to participate in this study, which was conducted in accordance with the Declaration of Helsinki, good clinical practices, and all applicable laws and regulations. Inclusion criteria were: 45–65 years old, at least 12 months of amenorrhea, being able to understand the instructions and complete the questionnaires, and willing to provide their written informed consent to participate in the study. Exclusion criteria were being under hormonal replacement therapy, taking vestibular sedatives or other central nervous system depressants, suffering from any chronic and/or severe medical diseases or any neuropsychiatric disorder that could limit balance and physical activity .2) calculated with an adult height scale (Asimed). A 1.5 m flexible tape was used to evaluate waist and hip circumferences. Waist to hip ratio (WHR) was calculated by dividing waist circumference (cm) by hip circumference (cm). As for BMI, values <25 indicated normal weight, between 25 and <30 overweight, and ≥30 obesity [All women were questioned by well-trained interviewers, who collected demographic and clinical data such as age, occupational status, education and marital status, and the number of falls experienced in the previous 12 months . Women were classified as fallers if they experienced one or more falls in the last year. A fall was defined as unintentionally coming to rest on the ground, floor, or other lower levels . Body ma obesity . Regardi obesity .In order to assess postural balance, we used a FreeMED resistive multisensor platform  and the Free-Step Standard 3.0 software . The Romberg test was performed under eyes-open (EO) and eyes-closed (EC) conditions. Participants stood barefoot, with their feet at a 30° angle, heels 2 cm apart, with their arms at their sides. Each session lasted 30 s, with a 1-min interval between sessions. The following parameters related to the center of pressure (CoP) under each condition were obtained: velocity of CoP displacements , length of the stabilogram , and the root mean square amplitude of CoP in the mediolateral (RMSX) and anteroposterior (RMSY) directions (mm). These stabilometric variables were obtained under both EO and EC conditions.In order to assess functional mobility, the TUG test was used . This teThe Menopause Rating Scale (MRS) was used to assess the severity and the impact of menopausal symptoms on quality of life ,26. ThisAccording to Concato et al. , in a mut-test was performed to analyze differences regarding the history of falls. In order to study the multivariate independent associations between variables, a multivariate linear regression model was used, with the postural control parameters as dependent variables. Those independent variables and confounders exhibiting significant results (p < 0.05) in the bivariate analysis and the Student’s t-test were included in the multivariate linear regression. In order to calculate the effect size coefficient of multiple determination in the linear models, we used adjusted-R2. According to Cohen [2 can be classified as insignificant when <0.02, small if between 0.02 and 0.15, medium if between 0.15 and 0.35, and large if >0.35. A 95% confidence level was used (p < 0.05).Data management and analysis were performed with the SPSS statistical package for the social sciences for Windows . Categorical variables were presented as frequencies and percentages, whereas continuous variables were described using means and standard deviations. The Kolmogorov–Smirnov test was used to evaluate normality. To evaluate the individual associations between stabilometric variables with MRS domains and total scores, as well as other confounders such as age, BMI, WHR and the history of falls, a bivariate correlation analysis was employed. A Student’s to Cohen , adjusteSociodemographic and clinical characteristics of the participants are presented in p < 0.01), as well as with the psychological MRS domain or subscale , which was also related to RMSYEC (p < 0.05). A bigger impact of the symptoms at a somatic level was linked to elevated VEO (p < 0.01), LEO, VEC, LEC and RMSYEO (p < 0.05). No association between postural control and the MRS urogenital domain was found. As for the functional mobility assessed by the TUG test, the analysis did not show any statistical correlation with the severity of the menopausal symptoms.In the analysis of the individual associations between postural control and the severity of menopause-related symptoms and hot flashes, , higher p < 0.01). There were no differences regarding the history of falls for postural control or functional mobility.As for the possible confounders , older a2 = 0.093 and 0.91 respectively), the velocity of the CoP displacements with eyes open and closed (adjusted R2 = 0.065 for both conditions), as well as with the anteroposterior displacements of the CoP under eyes open (adjusted R2 = 0.051) and closed (adjusted R2 = 0.031). Finally, older age was independently related to worse postural control regarding mediolateral displacements of the CoP both with eyes open and closed .The analysis of the independent associations performed by the linear regression  showed tThe objective of the present study was to assess the associations between the severity of the menopausal symptoms and postural control and functional mobility in Spanish middle-aged postmenopausal women. Our findings suggest that, taking into account possible confounders such as age, BMI, WHR, and the history of falls, the impact of the menopausal symptoms at a psychological level was independently associated with worse postural balance. There were no associations between the severity of the menopausal symptoms and functional mobility.Menopausal symptoms significantly affect the quality of life of middle-aged women . It has It has been reported that physical and mental fatigue may influence postural control in older adults . BesidesDuring the menopause transition, women are predisposed to experience musculoskeletal pain , which iObesity is considered as a fall risk factor in people aged 60 years and older . It has The history of falls has been described as an important fall risk factor. Older adults who experienced one or more falls are more likely to fall again, and it is considered an essential part in the screening for falls . MoreoveSome limitations to our study should be noted. The cross-sectional nature of the study design does not allow establishing causal relationships. Moreover, this study was carried out in postmenopausal women recruited from a specific geographical area, and thus, any generalization of the results should be limited to people with similar characteristics to those of our sample. Although the validity and reliability of the TUG test has been shown in different populations regardless of age , the parA greater severity of menopausal symptoms at a psychological level was associated, under both eyes open and closed conditions, with (i) longer length of the stabilogram, (ii) greater velocity of the CoP displacements, and (iii) larger anteroposterior displacements of the CoP.Older age was linked to worse postural control regarding mediolateral displacements of the CoP.Functional mobility was not related to the impact of menopausal symptoms on the quality of life.The results of this cross-sectional study indicated that, considering possible confounders, a higher impact of menopause-related psychological symptoms was a significant predictor of poorer postural control. More specifically:


Background: Pilonidal sinus (PS) disease frequently occurs in adolescents and young adults, and in many cases involves wide excision or local flaps as treatment. These treatments are associated with a significant recurrence rate, a long healing time, and thus absence from school or work. The hybrid technique, which is a combination of side-swing plasty with negative-pressure wound therapy (NPWT) may improve these outcomes. The aim of the study was to compare the latter with other current methods.Methods: Children presenting with a pilonidal sinus to two referral centers for pediatric surgery from January 2017 till June 2019 and subsequent (1) slide-swing plasty, (2) open excision, or (3) slide-swing plasty in combination with NPWT were included in this retrospective study. Type of therapy, number of interventions, duration of hospitalization, complications, and recurrence rate were recorded. In addition, data was retrieved from the national diagnosis-related group for inpatient statistics, for all patients who underwent surgery for pilonidal sinus in 2015 and 2016.Results: In total, 85 children were included, with a mean age of 15 years and a near equal gender distribution . The minimum follow-up was 1 year. In 56% open resection was performed, while 18% underwent a slide-swing plasty and 26% a slide-swing plasty in combination with NPWT. While the hybrid technique was superior regarding recurrence rate in comparison to open excision , it had significantly longer hospital stay  and number of interventions .Conclusions: Management of PS disease using slide-swing plasty in combination with NPWT is an effective treatment and is associated with low recurrence rate and minimal morbidity. However, this type of treatment is accompanied by an elongated hospitalization time and more frequent interventions. A diligent case by case evaluation and thorough patient counseling is thus necessary when choosing the right technique for the treatment of PS disease. Pilonidal sinus (PS) disease was first described by Mayo in 1833 as a hair-containing cyst located just above the coccyx . SymptomPathogenesis of PS cysts is still not fully understood. As such, one main theory is known as the theory of follicular occlusion tetrad, which believes that the underlying pathophysiology of PS disease involves an occlusion of the infundibular hair follicle on account of follicular hyperkeratosis as the first step. As a consequence, the clogged follicle ignites and subsequently bursts, leading to inflammation of the surrounding subcutaneous tissue . HoweverManagement of PS disease should ideally be simple, attaining low recurrence rates with the least possible tissue trauma. While surgery is considered to be the most successful treatment for chronic PS disease, it still leads to a recurrence rate of 10% . The mosRetrospective analysis of all children and adolescents treated with pilonidal sinus abscess formation at two large departments for pediatric surgery between January 2017 and June 2019, who met the following inclusion criteria: side-swing plasty (Schrudde-Olivari flap) with or without primary NPWT or open excision without NPWT. Demographic data was obtained on age and gender, as well as disease-related data, namely (1) immunodepression, (2) diabetes, (3) previous excision of the pilonidal sinus cyst, (4) complications, (5) recurrence, (6) duration of hospital stay, and (7) number of interventions.Moreover, a controlled remote analysis of the nationwide Diagnosis Related Group (DRG) database from 2016 to 2017 was undertaken to evaluate inpatient data provided by the Research Data Centers of the German Federal Statistical Office and the Statistical Offices of the Länder. The German adaptation of the International Classification of Diseases (ICD) Tenth Revision and the procedure coding system  were used to identify diagnoses and procedures. Every inpatient case with a procedure code for surgical treatment of pilonidal sinus abscess formation was included. The diagnosis codes L050 and L059 and the procedure code 5-897 were applied.t-test and ANOVA, whenever applicable. Data are presented as mean ± standard deviation (SD). The level of significance was set at 0.05.All data were analyzed with SPSS Statistics 26  and GraphPad Prism 8 . Differences between groups were calculated using the In total 85 children with PS disease presented at the department of pediatric surgery of the University Medical Center Hamburg-Eppendorf and the Children's Hospital Altonaer Kinderkrankenhaus between January 2017 and June 2019. One patient was excluded in which open excision with primary NPWT was performed. The minimum follow-up time was 1 year, while the mean age of the enrolled patients was 14.72 (1.90) years. Unlike other studies, which show that PS disease is more prevalent in males, 52.9% of the study participants in our study were female. With regards to demographics, no significant differences between all groups were found for average age and gender distribution. Moreover, the number of previous resections, immunosuppression, and diabetes did not differ among the three groups .Overall, 48 (56%) open excisions were performed and compared to 15 (18%) side-swing plasties (Schrudde-Olivari flap) and 22 (26%) side-swing plasties with primary NPWT (hybrid technique).p < 0.001), whereas only non-significant differences were found when compared to the flap only group (p = 0.007). (3) The number of interventions necessary in order for complete wound closure to occur differed between groups. In the hybrid group four interventions were needed compared to one in the open excision (p = 0.001) and two and a half in the side-swing plasty group (p > 0.05). (4) Lastly, while there were no cases of death, bleeding, peritonitis, or rectal fistula in the current study, the hospitalization length in days was significantly shorter for patients assigned to the non-hybrid groups compared to the hybrid group (p = 0.004).Regarding perioperative outcome significant differences between groups were found: (1) Seroma formation was rarer in the open excision group, as well as the group that underwent side-swing plasty without NPWT; As such, patients in the hydride group suffered significantly more from seroma formation in comparison to patients with open excision (ly group . (2) Whily group , differeThe nationwide database analysis showed that in 2 years 10,528 procedures for PS disease were performed in patients aged 0–18 in Germany. Of these, 59.3% were male. Mean age was 16.08 (2.48), which is more in line with the known gender distribution for the disease. The mean hospitalization time was 2.48 (3.07) days and no patient died during the duration examined for this study. Moreover, no patients developed peritonitis, while 24 cases (0.2%) did develop a rectal fistula. No bleeding complications were documented.The nationwide database underlines the relevance of PS disease in children, recording more than 5,000 procedures annually. As such, it is one of the most frequently performed procedures in children. Nevertheless, optimal treatment of PS disease remains controversial and the existing techniques are far from perfect. Therapy for PS cysts should not only be effective but also simple. Procedures should aim to reduce hospitalization time to a minimum, furthermore attaining quick recovery for patients and resumption of normal activities . While tData obtained from the nationwide analysis indicates that the average length of hospitalization lies at 2.48 days – a very short period of time compared to data acquired in our study. It is therefore to be presumed, that most patients were treated with the open excision technique, which was evaluated to have the shortest hospitalization rate in days in our study. However, in the absence of exact information from the database, a detailed comparison with our data cannot be conducted.Due to the very promising results of the hybrid technique with respect to relapse and infection rate on the one hand, but the substantial costs and long hospitalization time on the other hand, we believe that a diligent case by case consideration is necessary when choosing the right procedure for each individual presenting with a symptomatic PS cyst. Thus, when deciding which procedure to perform, evaluation should not only focus on objective criteria, such as the extend of the abscess, the exact anatomical location, or the medical history of the patient , but also subjective criteria, such as the patient's preferences, compliance, and domestic support for aftercare. Thorough patient counseling therefore is indispensable. Furthermore, we believe that in certain cases when high patient compliance and home care support are available, maintaining NPWT as an outpatient procedure could be advantageous for the patient, as hospitalization time could be reduced to a minimum. However, at the moment implementation of this option is difficult in Germany due to bureaucratic reasons.A limitation of this study is the relatively short-term follow-up period of only 1 year (longer in some cases), which might not provide enough time in order to properly assess recurrence and complication rates. Thus, additional studies with longer follow-up periods are necessary as to ascertain the efficacy of this hybrid technique.Management of symptomatic PS cysts using slide-swing plasty in combination with NPWT is an effective and simple treatment that is associated with low recurrence rate and minimal morbidity. Despite being expensive and resulting in numerous interventions. Additionally, the currently employed wide open excisional or local flap treatments for PS disease pose a heavy burden on the patient, since these interventions are often accompanied by a lengthy recovery time. As the patient population is quite young, lengthy hospitalization is thus often associated with an absence from normal everyday activities resulting in a decreased quality of life . In ordeIn conclusion management of symptomatic PS cysts using slide-swing plasty in combination with NPWT is an effective treatment that is associated with low recurrence rate and minimal morbidity. However, this type of treatment is accompanied by a very long hospitalization time and frequent interventions. As such, we recommend a diligent case by case evaluation and thorough patient counseling when choosing the right surgical technique for treatment of PS disease. Hence, future studies should compare the hybrid technique with other promising interventions like the GIPS procedure or endoscopic treatment.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.DD, IK, and JE designed the study, collected data, analyzed the data, and drafted and revised the paper. TG collected data, analyzed the data, and revised the paper. KR collected data, and revised the paper. MB designed the study, collected data, analyzed the data, performed statistics and drafted and revised the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.