The are several therapies available for OA. According to current knowledge, the combination of Platelet-Rich Plasma (PRP) and Pulsed Radiofrequency (PRF) can be applied in the treatment of pain of nociceptive origin due to peripheral tissue damage. (2) Methods: We performed a narrative review identifying the articles by searching electronic databases. A retrospective analysis of patients with OA treated with PRF and PRP in “Vito Fazzi” Hospital  was performed. (3) Results: A total of four publications on the use of PRP and PRF in degenerative joint arthritis were included in our review. In our experience, two patients with OA were treated with PRP and PRF after unsuccessful conservative treatment. Patient pain score, daily activity ability, active range of activity, and muscle strength improved after treatment. Patients reported a higher level of satisfaction. No major adverse events were reported. (4) Conclusions: The goal of the combined application of the two treatments is to make full use of the analgesic effect of PRF and the repairing effect of PRP. At present, the therapeutic potential of PRP and PRF in OA remains unmet. Osteoarthritis (OA) is a debilitating joint disease that causes the destruction of the articular cartilage and underlying bone; the etiopathogenesis is multifactorial and includes the gradual disappearance of articular cartilage, osteophyte formation, subchondral bone change, and aseptic synovitis .Worldwide, OA is the most common joint disorder. Approximately 85% of persons more than 75 years of age have symptomatic OA; 40% of them have significant difficulties in daily activities interfering with work or social activities. OA is characterized by joint pain, which worsens with activity, especially after a period of rest, the so-called “gelation phenomenon” . The joi3, usually five times higher than normal [Platelet-Rich Plasma (PRP) is defined as a volume of plasma with a higher-than-normal concentration of platelets. This concentration is at least 1,000,000 platelets/mmn normal . Traditin normal . Patientn normal ,6. PRP cThe use of radiofrequency (RF), conventional or pulsed, is a technique commonly used for the treatment of chronic pain in various musculoskeletal disorders, such as low back pain . Pulsed According to current knowledge, the combination of PRF and PRP can be used in the treatment of nociceptive pain due to peripheral tissue damage . Michno Aims. The aim of our article is to focus on the available relevant evidence that supports the use of PRP and PRF in osteoarthritis, firstly performing a narrative review and then reporting a case series of patients with OA treated with PRP and PRF after unsuccessful conservative treatment in our hospital.We performed a narrative review identifying the articles by searching electronic databases . Other relevant publications were identified from the bibliography. The search terms used were “Osteoarthritis”, “Platelet-Rich Plasma”, and “Radiofrequency Therapy”. The titles and abstracts were screened by two researchers (L.G.G. and F.C.) to identify the keywords. The selected papers were read in full by two of the authors independently, and, in case of disagreement, a third reviewer (P.S.) was consulted. The first search was conducted on 1 February 2023. All publications up to the end of January 2023 were included in this review. This review is based on previously conducted studies. We applied no language restrictions in searches.The inclusion criteria were as follows: (1) the full study was published; (2) the study described clinical use of PRF and PRP in degenerative joint arthritis; (3) the study reported the clinical outcome of the patient(s) treated with PRF and PRP. Exclusions criteria were as follows: (1) the study did not report clinical outcome; (2) the study had duplicate data with others ; (3) the study presented pooled data that did not allow for extrapolation of useful information.In addition to evaluating study characteristics, we analyzed the visual analog scale (VAS) at various time points, parameters to measure articular motility, and any adverse reactions. Possible adverse effects include PRP incompatibility reactions, surgery site swelling, tissue necrosis, bleeding, local inflammation, infection, or local pain.t-test with a statistical significance level of p < 0.05.The data were analyzed using standard computer programs . Results are reported as mean ± standard deviation (SD). Data consistency was assessed using the Chi-squared test with a 95% confidence level. Comparison was performed using Student’s A retrospective analysis of patients with OA treated with PRF and PRP in the Pain Clinic of the “Vito Fazzi” Hospital  was performed since January 2020.A total of four publications on the use of PRP and PRF in degenerative joint arthritis were included in our review. Three case reports ,18,19 anIn the studies included, 39 patients  were treated first with PRF and thereafter with autologous PRP injection in the same session. The mean age was 55.73 ± 3.82 years. Thirty-four patients were diagnosed with knee osteoarthritis. Four patients reported supraspinatus injury. Avascular necrosis of the femoral head was diagnosed in a case.In all studies, PRF was carried out at 42 °C for 120–240 s. PRP was prepared according to the local protocol. After local anesthetic infiltration, 4–20 mL of autologous PRP was injected.Patients were followed up at 1, 3, and 6 months post-procedure see . Pre-proA comprehensive evaluation of the patient’s pain, daily activity ability, active range of activity, and muscle strength improved 6 months after treatment. No adverse events were reported, such as wound swelling, exudation, fever, nerve injury, and vascular injury. No antibiotics were used.We report two cases  treated at the Pain Clinic of the “Vito Fazzi” Hospital in Lecce . The patients were informed prior to the publication of this article, and they provided written informed consent to data use.Case 1. A 67-year-old patient presented with severe pain (VAS score 8/10) in the left knee. About 10 years ago, they reported a fracture of the right lateral tibial condyle; several traumas to the left knee were reported, but no documentation was available. For some years, they suffered from minor pains that increased in recent months. No history of surgery or any other treatment was reported. On examination, a limping gait was observed. Tenderness around the left knee joint, moderate swelling, increased pain on weight-bearing, and decreased ROM were observed. The X-ray of the left knee was grossly normal. They underwent an MRI of the bilateral knee joint with evidence of marked tricompartmental gonarthrosis with the osteophytotic reaction on the left. No history of steroid use was reported. The patient reported the use of nonsteroidal anti-inflammatory drugs, tramadol, vitamin D, and calcium supplements.Case 2. A 76-year-old patient presented with severe pain  in the right knee. No past traumas to the right knee were reported. The patient reported the onset of mild pain for some years, which had increased in recent months. On examination, a limping gait was observed. Tenderness around the right knee joint, moderate swelling, increased pain on weight-bearing, and decreased ROM were observed. X-ray of the right knee showed marked tricompartmental gonarthrosis with slightly greater changes in the medial femorotibial compartment. No history of steroid use was reported. The patient reported the use of nonsteroidal anti-inflammatory drugs, vitamin D, and calcium supplements.–Pain lasting more than 3–6 months with VAS > 4;–Clinical data, images, and diagnostic procedures confirming the presence of OA;–Symptoms resistant to conservative therapies such as NSAIDs and physiotherapy;–The patient’s goal was to avoid surgery.Both patients were treated first with PRF and then with an injection of autologous PRP in the same session. The combined use of PRP and PRF was proposed when the following criteria were met:Informed consent was obtained by providing information on risks , benefits, and possible alternative therapies.–Active infections;–Use anticoagulants and antiplatelet agents;–Blood dyscrasias;–Use systemic immunosuppressive drugs.PRP and PRF were contraindicated in the presence of the following:All procedures were performed after local anesthesia was obtained in the operating room. After palpating the anterior patella region with the knee angled at 30–45 degrees, the patella was visualized with the aid of a 5–10 MHz linear probe. The transducer was then moved proximally until the patella disappeared. After acquiring the best ultrasound image at this location, the skin was marked according to the location of the probe. After disinfection, local anesthesia was performed using 1% lidocaine. Then, a 22-gauge Quincke needle was inserted into the knee joint under ultrasound guidance. A total of 2 mL of 1% lidocaine was injected into the joint while observing the filling of the suprapatellar bursa in real time. Once proper placement was confirmed, the stylet was withdrawn, and the RF probe was inserted through the introducer needle. PRF was administered for 15 minutes at 42 °C and a pulse span of 20 ms at 2 Hz.After drawing 60–120 mL of blood from the patient into tubes containing an anticoagulant, we used the Z206A Compact Centrifuge . Our protocol was based on double centrifugation at 1000 rpm for 10 min, followed by 4000 rpm for 10 min. This protocol produced a five-fold increase in platelet concentration above the baseline level and preserved platelet integrity. Then, approximately 20 mL of intra-articular PRP was injected using another entry site under ultrasound guidance.Patients had to rest for 48 h and inform the physician of any joint abnormalities, especially signs of inflammation. They were advised of the possibility of more pain during the first few days after the procedure and encouraged to practice physical therapy before and after treatment to improve their prognosis.Patients were followed up 1, 4, and 12 weeks after the procedure see . At baseNo adverse events were reported.OA is a serious chronic disease that affects one in seven adults in the United States, about 32.5 million people. OA causes pain, stiffness, and swelling, which cause limitations that interfere with the ability to perform routine daily living activities. In addition to traditional treatments, others are being developed, especially in the field of regenerative medicine. There are several clinical studies that showed good results in treating joints arthritis with PRP or PRF. Very few reports in the literature in which PRF and PRP combination are reported. The clinical studies published to date are publications with a limited number of patients.In 2018, Kothari et al. treated a 53-year-old patient with avascular necrosis of the femoral head with PRF of articular branches of the femoral and obturator nerve and intraarticular injection of PRP . After 1Sixty patients with chronic OA of the knee were enrolled in a randomized study by El-Tamboly et al. . The autIn 2021, Jin et al. combined PRF with four injections of PRP into the knee joint to treat OA . Pain reThe combination of PRF and PRP has also been used for the treatment of supraspinatus lesions by the same authors. Jin et al. treated four patients with a single injection of PRP after the PRF procedure . PatientIn our experience, we used PRP and PRF as both work via different mechanisms, and thereby, we have a synergistic effect of regeneration and pain relief. Two patients with OA were treated with PRP and PRF after unsuccessful conservative treatment. Patients refused surgery for various reasons, particularly the need to return to normal activity quickly and the desire not to undergo surgery. VAS pain score, daily activity ability, active range of activity, and muscle strength improved 12 weeks after treatment. Patients reported a higher level of satisfaction. No major AEs were reported.Management of OA may include educational, behavioral, psychosocial, and physical interventions, as well as topical, oral, and intra-articular medications. Therapeutic decisions must be made considering the personal beliefs and preferences of the patient, as well as his medical condition. In the current guidelines for the management of osteoarthritis , PRP treDespite the many options available, some patients continue to be symptomatic or experience negative effects from available interventions.Recent studies suggest that PRP could be a promising therapy for OA ,23. CurrAll these data indicate that a combination of both PRF and PRP applications may be useful in controlling pain and accelerating healing in OA.Limitations. First, our review includes a few studies (3 case reports and 1 RCT), and most of these involve a few patients. Due to the greater potential for bias, case series and observational studies are often excluded from reviews. In a typical review of developing technology, that is, the combination of PRF and PRP for the treatment of OA, case series, and observational studies contribute substantially to the available evidence, and their results supplement the limited evidence available from other studies. Second, the preparation method of PRP in these studies is not standardized. The different existing protocols for the preparation of PRP are one of the reasons that can explain the variability of the results obtained in the different studies conducted. Third, the PRP and PRF therapy protocol is not uniform in the analyzed studies. Finally, we reported only two cases treated with PRP and PRF therapy in our pain clinic. In Italy, treatment with PRP is still reserved for only a few extremely selected cases.In this work, we have reviewed currently available evidence supporting the use of PRP and PRF to treat OA. The goal of the combined application of the two treatments is to make full use of the analgesic effect of PRF and the repairing effect of PRP in order to maximize the advantages of these treatment methods. This approach could be promising in unresponsive patients to conservative therapies and where surgical treatment is contraindicated.In conclusion, at present, the therapeutic potential of PRP and PRF in OA remains unmet, and in the absence of standardization, its clinical efficacy will still remain an open debate. Randomized trials with larger numbers of patients need to be conducted.


Methamphetamine (MA) use disorder is associated with a large public health burden. Despite the therapeutic effects of psychosocial interventions based on current evidence, finding an approach to retain patients in treatment remains a real-world challenge. The rapid development of mobile health  systems suggests the potential to provide real-time personalized care at any time and from any location, minimize barriers to treatment, maximize use, and promote the dissemination of accessible therapeutic tools in at-risk populations. Our study aimed to investigate the feasibility and effectiveness of chatbots for the treatment of MA use disorder.The inclusion criteria were (a) a diagnosis of MA use disorder as defined by the DSM-5, (b) age between 18 and 65 years, (c) no acute exacerbation of severe mental illness during the initial assessment, such as schizophrenia or bipolar I disorder, (d) willingness to participate in standard outpatient treatment for ≥ 6 months, and (e) an Android phone. Participants were randomly allocated to either a chatbot-assisted therapy via smartphone (CAT) group or a control group following simple randomization procedures (computerized random numbers) without blinding. All participants were followed up for 6 months. Treatment retention and monthly urine test results were analyzed as outcome measures. Participants' satisfaction with CAT was also assessed.df = 1, p = 0.099). The CAT group had fewer MA-positive urine samples than the control group . The proportion of MA-positive urine samples was positively correlated with the frequency of MA use , severity of MA use disorder , and polysubstance use , and negatively correlated with readiness to change . Totally 55 participants completed the study at the 6-month follow-up and 60% reported relative satisfaction.In total, 50 and 49 participants were allocated to the CAT and control groups, respectively. There were no significant differences in retention time between the two treatment groups (Participants in this study had favorable acceptance and generally positive outcomes, which indicates that chatbot is feasible for treating people who use MA. Methamphetamine (MA), a psychostimulant with high abuse potential, can result in physical and psychological harm , 2. AcutCurrent evidence supports the efficacy of face-to-face psychosocial interventions, such as the Matrix Model program , cognitiCompleting treatment and undergoing more intensive interventions are important for reducing MA use and improving psychiatric symptoms . NeverthSmartphones have become ubiquitous, and most individuals own and use them daily. As smartphones have evolved, they have become a platform for mental health support through mobile health  systems in the form of various applications and services that can assist individuals in managing their mental wellbeing. Delivering interventions through mHealth offers several benefits, including continuous therapeutic support regardless of time and location, low barriers to access due to geographic isolation, and convenient dissemination to at-risk populations , 32. Thip = 0.01 and 0.003), cravings (p = 0.03 and.02), frequency (p = 0.01 and.004), and expenditure (p = 0.04 and 0.003) of gambling problems at postintervention and follow-up (p = 0.039)  . Overallp < 0.01), an increase in abstinence , and an increase in MA-free periods (p < 0.01). Additionally, Kioleian et al. developed a text messaging intervention as an adjunct to cognitive behavioral group therapy for MA users and demonstrated its feasibility and potential (p < 0.01) and reduce MA use  among individuals with MA use disorder . The study population was recruited from outpatients of the Addiction Unit at Jianan Psychiatric Center from January 2018 to July 2019.We performed a randomized, placebo-controlled, parallel-group study without blinding , according to the CONSORT Statement 2010. The experimental group received CAT, and both groups received standard treatment provided by the facility. No interim analyses for efficacy or futility were performed. This study was registered at The inclusion criteria for this study were as follows: (a) a diagnosis of MA use disorder as defined by the DSM-5, (b) age 18–65 years, (c) no acute exacerbation of severe physical or mental illnesses, such as schizophrenia or bipolar I disorder during the initial assessment, (d) a willingness to participate in standard outpatient treatment for a minimum of 6 months, and (e) possession of an Android phone for the app assessment. Participants were provided an explanation of the study and an opportunity to provide informed consent. Those who were unwilling to participate were incarcerated during the study period or hospitalized due to physical or mental illnesses and were considered to have dropped out of the study. The CAT was introduced as an adjuvant treatment for MA use disorder and promoted through flyers, email, and via our case managers to attract users. Users could download the Line app and add our chatbot on it. After informed consent was obtained, the participants who agreed to enroll were given an information sheet and asked to provide their contact details. Case managers then scheduled further visits for the study. The patient screening and recruitment process is shown in Eligible patients were randomly assigned via computerized randomization to one of the two groups (1:1 ratio) on the day of enrollment after baseline measurements were taken. The randomization was prepared by an investigator who was not involved in the trial, and the allocation sequence was concealed from the researcher until after the participants completed their baseline assessments. The allocation was revealed by a contact independent of the recruitment process when they opened the corresponding number concealed in an envelope.Participants attended outpatient visits at the time of randomization and monthly intervals. Treatment retention and results from monthly urine tests were used as primary outcome measurements. The readiness to change was assessed using the University of Rhode Island Change Assessment (URICA) scale before randomization and the end of the study . The parMBRP is an evidence-based treatment approach that combines mindfulness practices with traditional relapse prevention strategies to help individuals who struggle with substance abuse, including MA abuse –59. MBRPStudies have investigated the effectiveness of MBRP for MA abuse and found that it may be an effective treatment approach. For example, an 8-week MBRP program was found to improve mindfulness, self-compassion, and psychological wellbeing, and reduce MA use in individuals who completed the program . AnotherThe chatbot application was meticulously developed by our research team following a collaborative and iterative design process. The initial stage of development involved identifying and defining the specific intervention problem that the chatbot was to address. This process was undertaken by a diverse focus group composed of mental healthcare professionals  and two technical experts. Utilizing the valuable insights gathered from these discussions, our development team proceeded to create a prototype of the chatbot. The design integrated crucial features such as natural language processing and machine learning capabilities, which were harmoniously interfaced with the Line chatbot platform. Following the development phase, the chatbot was deployed on the Line platform, which was deemed a suitable medium for access by our focus group and anticipated user population. During this preliminary deployment stage, both members of the focus group and case managers from Jianan Psychiatric Centers were invited to interact with the chatbot in a realistic setting, thus closely mimicking the user experience of the eventual participants. Throughout this process, data pertaining to user interaction patterns and general feedback were systematically gathered and meticulously analyzed. Following this preliminary testing phase, the gathered insights were presented to the focus group for further discussion and feedback. Based on this invaluable feedback, the chatbot underwent necessary adjustments and refinements, ensuring optimal functionality and user interaction. Subsequently, the refined chatbot was officially deployed for use within the study. The chatbot used in our study was tailored to the audience's level of familiarity with the subject matter and was based on artificial intelligence in the communication software, LINE. The MBRP sessions consisted of eight components:  automatiIndividuals in the experimental group were reminded of their MBRP sessions with the message, “We have an MBRP session to attend this week. It will help your recovery”, and were encouraged to continue with positive feedback, such as “Keep going” and “Good job”, after completing a session. The chatbot also assessed the participants' mood daily using the-5 Brief Symptom Rating Scale-5 (BSRS-5) questionnaire  and prov*Power software. The computations were based on a two-sided hypothesis test with a significance level of 0.005 and a power of 80% to detect an odds ratio of 1.0 for the outcome variables. The estimated proportion of 60% versus 30% in each group was based on previous studies investigating the effectiveness of psychosocial interventions for individuals with MA use disorder  and a chi-squared test. The data were analyzed using an intention-to-treat approach, and missing data were assumed to be missing completely at random. The criterion for significance was set at t-test was performed to compare the response rates of the two groups regarding psychotherapy appointment attendance and drug urine test results. Pearson's correlation test was applied to evaluate significant trends. The cumulative retention in treatment was calculated using the Kaplan–Meier method with a log-rank test, based on the number of days in treatment from initiation until the patient quit or the end of the 6-month follow-up period. Variables that were significantly associated with retention were included in the multivariate Cox regression analysis and presented as odds ratios with 95% confidence intervals. Logistic and linear regression analyses were used to analyze the differences between potential predictor variables  and the proportion of negative urine samples. Subgroup analyses according to addiction severity or polysubstance use were performed using Cox hazards models, and a p < 0.05 was considered statistically significant.The differences in the objectively measured adherence values of clinical data gathered at follow-up were examined using a one-way ANOVA. A matched paired n = 6, control group n = 11), hospitalization (control group n = 2), and lack of contact . No deviations from the protocol were noted, and all data were synthesized for further analysis. The mean age was 37.00 ± 10.40 years (range: 20–69 years), and most patients were between 31 and 40 years of age . As for comorbidities among our participants, the most common psychiatric diagnoses were major depressive disorder (n = 12), alcohol use disorder (n = 10), and anxiety disorder (n = 3). Six participants were diagnosed with at least two comorbid mental disorders. No significant differences were observed between the two groups in terms of categorical or continuous variables (p>0.05). The overall retention rate was 58.6% (58/99).Of the 99 participants, 81 were men (81.8%) and 18 were women (18.2%). All participants underwent a survey, treatment intervention, and follow-up observation. Moreover, 16 participants in the experimental group and 18 participants in the control group were assigned to our OPD (outpatient department) for prosecution and addiction treatment, and no significant distribution was observed between the groups. Additionally, 17 participants from the experimental group and 24 from the control group dropped out, resulting in data from 41 participants being available for the intention-to-treat analysis. The reasons for dropout included incarceration . However, a significant positive correlation was found between the participants' age and duration of MA use . Additionally, a significant positive correlation was found between the severity of MA use and the duration of MA use  and weekly expenditure .The participants' drug use history is summarized in df = 1, p = 0.099). However, participants with more severe MA use disorder , low readiness to change , and polysubstance use  tended to have shorter treatment retention periods .The average retention time was 142.42 ± 60.54 days in the experimental group and 118.12 ± 73.41 days in the control group. The 6-month completion rates for the experimental and control groups were 66% and 51%, respectively.  periods . The mulF = 9.116, p = 0.003). The proportion of MA-positive urine samples was positively correlated with the frequency of MA use , severity of MA use disorder , and polysubstance use , and was negatively correlated with readiness to change . When the pretest scores were used as covariates, an ANOVA revealed that the intervention group only had higher posttest scores in the contemplation subscale of the URICA . No significant differences in scores for readiness to change and the URICA subscale were observed between the experimental and control groups. The average attendance rate for MBRP was 75.1% in the experimental group and 60.8% in the control group. No significant differences in treatment attendance, completion, or retention were observed between patients referred for prosecution treatment and those who were not. No harm or unintended effects were reported in either group.A total of 378 urine samples were collected: 209 in the CAT group and 169 in the control group. The experimental group had fewer MA-positive urine samples than the control group , “Receiving CAT helped me to deal with addiction problems” 85%), “Felt someone cared by receiving CAT” (76%), and “Would suggest that other patients receive CAT” (67%) . Only tw%, “Felt F = 9.116, p = 0.003). Similarly, in the original study investigating the Matrix Model, which followed 183 people who used MA, 19.3% of urine samples tested positive for MA after treatment  , 66. Furreatment . In anotreatment . Our finreatment , 50, 68.reatment , 70. FurDespite the potential benefits of the use of chatbots in addiction treatment, several limitations of the study must be considered. First, CAT provided 24-h unlimited access to treatment materials and regular reminders, while the control group received limited contact. This may have resulted in a difference in the number of contacts received by the experimental and control groups over the 6-month period, which could have masked the therapeutic effects in both groups. Therefore, the mechanism of the therapeutic effects, such as the dose–response relationship and the influence of in-person or virtual contact should be further investigated. Second, the study sample was predominantly male, single, and employed, and the results may not be generalizable to populations with different demographic characteristics. The study population was limited to individuals with MA use disorder who were more accepting of technology-assisted treatment, motivated to participate in research, and willing to complete weekly assessments compared with the overall population of individuals with substance use disorder. The study participants may also have been underrepresented by individuals who are uncomfortable with using mobile phones or who use phones that run on the Android operating system, leading to unintentional selection bias. Therefore, our findings may not be generalizable to the entire population of patients with MA use disorder. By excluding individuals with acute exacerbation of mental illness, our sample may not be fully representative of the broader population of individuals struggling with methamphetamine use, who often have concurrent mental health issues or heavy alcohol consumption which could potentially impede their ability to participate fully in the study. This could potentially limit the generalizability of our findings. Third, the satisfaction survey was conducted only among the participants who completed the 6-month treatment and remained in the study until its end. Thus, the satisfaction of those who dropped out of the study before the end of treatment could not be evaluated. Furthermore, satisfaction with different treatments and components of the treatments were not evaluated. Moreover, the detection window for methamphetamine metabolites in urine typically ranges between 3 and 5 days post-consumption but can extend to a week for heavy or chronic users, contingent on factors such as the individual's metabolic rate, the drug's dosage, and the frequency of use. It is essential to note potential limitations tied to this monthly testing schedule. Specifically, sporadic or infrequent methamphetamine use may not be captured if usage does not coincide with the testing window. Furthermore, while immunoassay tests are highly dependable, they can occasionally yield false-positive results due to cross-reactivity with certain over-the-counter medications and other substances. Finally, although the present study was a longitudinal intervention study, the follow-up period of 6 months is relatively short compared with the DSM-5 criteria for full remission of 12 months.Notably, this study recruited participants who were mandated addiction treatment. Despite the absence of significant differences in outcome variables among participants who were or were not referred for mandatory addiction treatment, our results revealed similar results among this population compared with those of other mandatory treatments for MA use disorder . HoweverThis study had several strengths, despite its limitations. We observed a significant reduction in MA use, according to urine test results, and identified potential factors related to the retention of treatment. Moreover, this is one of the few studies to investigate the use of chatbots for the treatment of individuals with MA use disorder, and it contributes to the growing body of knowledge related to mHealth. There is potential for a large-scale RCT in the future to further validate the effectiveness of CAT for methamphetamine use disorder. In an ideal scenario, the design of such a study should address several key factors. First, expanding the sample size would allow for greater statistical power and generalizability of the results. Including a diverse range of participants in terms of demographic characteristics , the severity of methamphetamine use disorder, and comorbid mental health conditions would also be beneficial to determine the effectiveness of the intervention in various subgroups. Second, the future RCT should consider a stratified randomization process to account for potential confounders such as the severity of substance use disorder, readiness to change, and other comorbidities. This would ensure balanced groups and increase the validity of the findings. Third, to comprehensively assess the efficacy of the CAT, a multifaceted evaluation approach should be adopted. Apart from urine tests, other measurements such as self-reported drug use, psychosocial functioning, quality of life, and participant satisfaction should be included. A longer follow-up period, ideally at 12 months, would also help to ascertain the long-term effects of the intervention. Furthermore, the issue of participant engagement with the chatbot should be addressed. Future trials could include strategies to promote regular interaction with the CAT, such as push notifications or rewards for consistent use. It would also be insightful to explore user experiences and preferences through qualitative methods to continually improve the chatbot design and functionality. Finally, given the potential for contamination between groups in digital interventions, it would be prudent to ensure that the control group receives a standardized level of care or alternative digital intervention to accurately determine the added benefit of the CAT. The design and implementation of chatbot-related interventions, including the type of therapy  and the use of biosignals  to reflect an individual's craving status, could also be investigated. While no harmful or unintentional results of these interventions have been observed, studies regarding the privacy, ethics, and cost analysis associated with CAT are needed , 73. MorIn this study, participants diagnosed with MA use disorder exhibited greater adherence to CAT, experienced favorable treatment outcomes, and reported favorable results in terms of treatment acceptance, indicating that CAT is feasible for individuals with MA use disorder. The use of chatbots holds promise as a method of providing immediate help and collecting valuable clinical information that can inform treatment decisions and monitor outcomes without imposing a significant burden on patients or providers. Moreover, the participants indicated that they were generally satisfied with receiving CAT.The implementation of effective treatments for stimulant use disorder faces numerous barriers. For example, patients may experience a chaotic lifestyle, financial difficulties, a lack of social support, and stigmatization. These challenges hinder adherence to care, requiring innovative solutions. This study provides evidence of the effectiveness of using chatbots as a tool in the treatment of individuals with stimulant use disorder. However, a comprehensive understanding of the strengths and limitations of this technology in addiction treatment is warranted.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 IRB in Jianan Psychiatric Center (IRB-18-017). The patients/participants provided their written informed consent to participate in this study.LC-H: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing-original draft, writing-review and editing, project administration, and funding acquisition. LG-H and YW-C: conceptualization, methodology, software, resources, and data curation. LY-H: formal analysis, investigation, and writing—review and editing.


P < 0.05). In fact, cows with an intermediate BCS/muscularity were more likely to stay in the herd after the third lactation (STAY3-4), compared to those presenting a lower BCS/muscularity (P < 0.01). However, cows whose muscularity was high were generally less likely to start the third lactation compared to the others. A potential explanation for this could be the willing to market cows with good conformation for meat purpose. Simmental is in fact a dual-purpose breed known for the good carcass yield and meat quality. This study demonstrates how muscularity and BCS available early in life can be associated with the ability of Simmental cows to stay in the herd.The present study aimed to investigate the association between stayability (STAY) traits, muscularity, and body condition score (BCS) in the Italian Simmental dual-purpose cows. Data were collected from 2,656 cows linearly scored in their first lactation from 2002 to 2020 and reared in 324 herds. The binary trait STAY, which is the ability of a cow to stay in the herd, was obtained for each cow-lactation available up to parity 5 (from STAY1-2 to STAY4-5). Analysis of STAY was carried out using logistic regression, considering the fixed effect of energy corrected milk, conception rate, somatic cell score, and muscularity or BCS predicted at different time points. The herd of linear classification and residual error were the random effects. Primiparous cows with a medium BCS and muscularity in early lactation presented a more favorable STAY across life compared to thinner ones ( Herd-testing for daily milk yield and composition is one of the major sources of information for the genetic evaluation of dairy cows and quantification of herd productivity and profitability . For sevIn dairy cows, productive lifetime is defined as the period during which the animal is in production in the herd . InsteadConformation traits, or type traits, have been used for indirect selection to improve productive life due to their correlation with survival . AlthougTherefore, the aim of the present study was to retrospectively explore the variability of STAY in Italian Simmental cows and quantify its association with muscularity and BCS.The present study was conducted using data retrieved from the National Association of Italian Simmental Cattle Breeders  database that were collected between January 2002 and December 2020. Data was recorded on 2656 Italian Simmental dual-purpose cows reared in 324 dairy herds located in Emilia Romagna region, in North-eastern Italy. This region has a large number of dairy farms . The maData provided by ANAPRI included information regarding the cows' lactations estimated by the Italian Breeders Association , namely whole lactation milk and solids yield, and test-day milk records with the daily milk yield, gross composition, and somatic cell count . Linear type traits scores, measured once in life (in primiparous cows) by trained personnel were also present.This trait was calculated in the lactation set, and it was defined for each cow-lactation up to the fifth, based on the presence or absence of the subsequent calving date . BrieflyThe energy corrected milk (ECM) was obtained from the actual lactation data according to the formula proposed by Dairy Records Management Systems :MY, FY, and PY indicate the kg of milk, fat, and protein produced within the lactation.where Milk SCC was converted to somatic cell score (SCS) according to the formula proposed by Ali and Shook  to achieTest-day SCS values were then averaged within each lactation, in order to be merged with STAY phenotypes and be used as an indicator of the cow's udder health.Linear-type traits can be scored on any days in milk (DIM) in primiparous cows. However, the morphological traits considered in the present study (muscularity and BCS) are known to vary within lactation, suggesting that observed differences among cows can be due also to the moment in which they were scored, i.e., stage of lactation. For this reason, following Buonaiuto et al. , individBTx and BTy are the predicted muscularity or BCS at xth and yth DIM, tx is the initial age of the cow (in days), and ty is the final age (in days) (where in days) .For further statistical analysis, only muscularity and BCS data predicted at four specific moments during the lactation were considered :i. at the onset of lactation , i.e., the moment where the uptake from body reserves stops in Simmental ;iii. at the maximum AGR, i.e., when the greatest recovery of muscle/fat reserves is observed in Simmental ;iv. at the second null AGR, representing the moment from which cows start to lose again muscle/fat reserves (280 DIM in both traits);Subsequently, cow-specific predictions of muscularity and BCS were merged to the lactation data.Muscularity, BCS, ECM, and SCS (lactation average) were grouped into 5 classes based on quintile distribution for each individual variable, as: low, medium-low, medium, medium-high, and high. Records belonging to different lactations were analyzed separately, meaning that the effect of parity was not accounted for in the statistical models. Muscularity and BCS predicted at each given time point during the first lactation were included. Therefore, STAY1-2, STAY2-3, STAY3-4, and STAY4-5 were analyzed 4 times, by considering at each run classes of muscularity and BCS predicted at one out of the four different time points considered.A logistic regression model was fitted with the GLIMMIX procedure using SAS software, version 9.4 :y is STAY1-2, STAY2-3, STAY3-4, or STAY4-5; μ is the overall intercept of the model; MUl is the fixed effect of the lth class (n = 5) of muscularity predicted at each specific aforementioned time point; BCSm is the fixed effect of the mth class  of BCS predicted at each specific aforementioned time point; ECMn is the fixed effect of the nth class (n = 5) of ECM; CRn is the fixed effect of the nth class (0 vs. 1) of conception rate at first insemination, where 1 indicates that only a single insemination is needed to achieve pregnancy and 0 otherwise; SCSo is the fixed effect of the 0th class  of milk SCS; Herdp is the random effect of the pth herd (n = 324) of linear classification, assumed to be distributed as e is the random residual term, assumed to be distributed as where The Italian Simmental cows included in the present research presented relatively high production levels compared to those reported by Cziszter et al.  for FlecAlong with the high productivity, the population studied was characterized by a composition comparable to that of specialized dairy breeds, with an average fat and protein content of 3.79 and 3.48%, respectively (data not shown). Parity-specific descriptive statistics of fat and protein yield, both used to calculate ECM, are reported in The cows' productive level and milk quality can be evaluated simultaneously by the means of ECM. The ECM can be considered as a key parameter for STAY in dairy cows as it directly affects the farm profit and, consequently, may have an effect on culling decisions . The culIn the present research the highest and the lowest CI value were observed in 1st (410.73 ± 76.70 d) and 4th lactation (399.19 ± 68.07 d) and, overall, the mean CI is similar to that reported in previous research in Italian Simmental cows . Dry perAn overview of the investigated STAY traits and their definition is reported in According to Padilla et al. , a graduP < 0.001; Results from the analysis of variance for STAY traits are summarized in P < 0.05). STAY3-4 was significantly (P < 0.05) affected by cow's BCS during the max (around 160 DIM), and the second null AGR (around 280 DIM).Muscularity was significant for STAY1-2 at the onset of lactation and for STAY3-4 in second null AGR and in late lactation. On the other hand, BCS was significant during all the phases considered for STAY2-3  to complete the lactation compared to those with lower condition . From thth week after parturition. Also Schäff et al.  that commonly occurs in the periparturient period . Grummerf et al.  observedf et al. . Findingf et al.  are in af et al.  reportedf et al.  and thatf et al.  reportedf et al. . It is wf et al. , the oddf et al. , who sugf et al. , dairy cf et al. –70. In af et al. , 72. Bahf et al.  reportedf et al. , 75. A tf et al. . Furtherf et al. .In the present study data of Italian Simmental cows were used to investigated the relationship between STAY and type traits, namely muscularity and BCS. The results indicate that cows characterized by a medium BCS/muscularity are more likely to stay in the herd compared to those with extreme body conditions, i.e., they are more likely to close the lactation and then start the subsequent one. Results of this study provide new insights into the survival and culling of Italian Simmental cattle population. Apart from productivity, in dual-purpose cows type traits and STAY are connected, being indicators of direct voluntary culling with a direct effect on farm's profitability. Further studies should disclose genetic architecture of STAY taking into account muscularity, BCS, and productive performance.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study did not require manipulation or modification of the usual handling of the animals, since we have worked directly with the routine records provided by the breeders' associations.Conceptualization: AF, LD, and GV. Methodology: GV and LD. Software: AC and GV. Formal analysis and writing—original draft preparation: GB, GV, and AC. Data curation: LD, AC, GB, and GV. Writing—review and editing: GV, GN, AC, and NL-V. Visualization: AF, DC, AP, and LM. Supervision: GV, AF, and NL-V. Project administration: GV and AF. All authors have read and agreed to the published version of the manuscript.


Speleomantes strinatii and Salamandrina perspicillata. Our results suggested the presence of an interference/interaction occurring between the two species and affecting the foraging activity of the smaller one . This competitive interaction is size mediated and configured as interference competition rather than exploitative competition.Organisms compete for resources, such as food and space, and competition can occur in two ways: exploitative competition or interference competition. In exploitative competition, organisms consume the same limited resources, directly reducing the availability of those resources for other individuals, while in the case of interference competition, organisms actively prevent others from accessing resources, independently of resource availability. We tested for the presence and type of foraging competition in two species of forest-dwelling salamanders in Italy: Speleomantes strinatii and Salamandrina perspicillata. We also aim at testing for size-mediated competition. We obtained stomach contents from 191 sampled individuals by means of stomach flushing at 8 sampling sites where both species occur. We focused our analysis on the core prey taxa shared by both species: Collembola and Acarina. We found that the foraging activity of S. perspicillata is positively affected by body size and negatively affected by potential competitor’s activity on the forest floor during the sampling, which also significantly weakened the positive relationship with body size. These results suggest the presence of an interference/interaction occurring between the two species and affecting the foraging activity of S. perspicillata. This competitive interaction is size mediated and configured as interference competition rather than exploitative competition.Exploitative competition and interference competition differ in the way they affect re-source availability for competitors: in the former, organisms reduce resource availability for the competitors; in the latter, one organism actively prevents the competitor from accessing resources, independently of their availability. Our aim is to test for the presence of foraging competition in two forest-dwelling salamanders in Italy:  Competition is a fundamental aspect of ecological systems, shaping the distribution and abundance of organisms, and it plays a crucial role in determining which species will survive and thrive in a particular environment ,2. Two tForaging, i.e., the way in which food and energy are actively obtained and maximized from a pool of resources available in the environment, is one of the most important activities carried out by animals and has multiple ecological and life history drawbacks . Indeed,Amphibians represent the most endangered vertebrate group worldwide, with habitat loss and alteration being one of the main drivers of their global decline . StudyinSpeleomantes strinatii, and the Northern spectacled salamander, Salamandrina perspicillata. Within the study area, the two species are largely sintopic and inhabit the same forest microhabitats, but differ in body size, population trophic strategy [The principal aim of this paper is to test for the presence of foraging competition in two forest-dwelling salamanders inhabiting the Northern Apennine Mountain chain of Italy: the Strinati’s cave salamander, strategy ,34, and strategy . In this2. The study area is characterized by a sub-Mediterranean climate, with annual rainfall comprising between 1600 and 2100 mm and usually displaying two rainfall peaks per year: the first in spring (April–May) and the second in autumn (October–November) [Speleomantes strinatii and Salamandrina perspicillata are present, but are active on the forest floor and forage under different climatic conditions [Salamanders were sampled in eight sampling sites across a homogenous area of the Northern Apennines of Italy , coverinovember) . In all nditions .Speleomantes strinatii is a fully terrestrial species capable of establishing stable populations both in surface and underground environments [Salamandrina perspicillata, despite having a generally terrestrial activity for the majority of the year [S. strinatii and S. perspicillata has been extensively described, both in the spring and autumn seasons, by means of stomach flushing [S. strinatii behaves as a generalist while S. perspicillata is more specialized on smaller taxa, such as springtails and mites [S. perspicillata being more active with higher air temperatures and requiring higher levels of moisture in the forest floor [Strinati’s cave salamander, belonging to the family Plethodontidae, has a maximum length of about 125 mm, while the Northern spectacled salamander, belonging to the family Salamandridae, does not exceed 100 mm in total length . Speleomronments ,38,39 anthe year , displaythe year . Adults the year ,40,41. Iflushing ,42,43, aflushing . Both spnd mites ,43. Althnd mites ,43. The st floor .S. perspicillata [Speleomantes [Salamanders were captured at eight sites, during the day, immediately after rainfall, while active on the forest floor. Sampling occurred in the spring of 2021, from April 22nd to May 20th , a perioicillata  and Speleomantes .S. strinatii and S. perspicillata, we focused on the shared prey items that constitute the core diet of the two species, i.e., the prey categories that are consumed by an f fraction of the individuals (sensu [f) and retained for subsequent analyses only the prey items, shared by both predator species, that accounted for f > 0.1, i.e., prey items that were present in the diet of >10% of both Strinati’s cave salamanders and spectacled salamanders. Therefore, the dataset used for the analysis consists, for each individual salamander, of the number of prey items for each of the shared prey taxa with f > 0.1 for both predators, the SVL of each individual salamander, and a categorical variable  describing if the potential competitor salamander was active on the forest floor when sampling occurred. We built a series of generalized linear models (GLMs) for both S. perspicillata and S. strinatii; one model was built for each shared prey category in the core diet, accounting for a Poisson error distribution and log-link function, assuming the number of prey items per stomach as the response variable, and SVL and competitor presence as predictors. Moreover, in order to test if resource use for a given prey taxon is mediated by a size-dependent interaction between the two species, we also included an interaction term between SVL and competitor presence. Prior to model building, we scaled continuous predictors (SVL) by means of R function scale , which subtracts the sample mean from each value and divides it by the SD. Model adequacy was assessed through visual inspection of the residuals, and significance levels for the analysis were set at alpha = 0.05. All analyses were conducted within the R (R Core team) environment.In order to evaluate the potential presence of behavioral interactions between s (sensu ). Thus, S. perspicillata active on the forest floor in five out of eight sampling sites and S. strinatii active in six out of eight sampling sites, while we found both species simultaneously foraging in three out of eight sampling sites. From sampling, we obtained stomach contents from 191 individual salamanders: 85 S. perspicillata and 106 S. strinatii, and the sample size for each species at each sampling site is reported in f > 0.1) of the two sampled species consisted of four taxa for S. strinatii  and two taxa for S. perspicillata (Acarina and Collembola). Only 2 prey categories with f > 0.1 were shared by the 2 species: Springtails (Collembola) and Mites (Acarina); therefore, we built models for each species based on these 2 prey taxa.During sampling, we found Number = number of items for a given prey category; n of stomachs = number of individual salamanders in which a given prey category has been found; f = frequency of occurrence for a given prey taxon.S. perpsicillata’s consumption of both Collembola and Acarina is negatively affected by potential competitor’s activity on the forest floor during the sampling .From the results of the GLMs , while the interaction between competitor’s presence and body size resulted negative and significant for both prey categories , but not on Acarina , while neither competitor’s activity nor the interaction between body size and competitor’s presence had a significant effect on prey use ..f > 0.1,f > 0.1) of both species: Acarina and Collembola. Indeed, our study showed that the foraging activity of the spectacled salamander is negatively affected by the concurrent activity of the Strinatii’s cave salamander on the forest floor, and not vice versa. This pattern suggests the existence of some sort of competitive interaction between the two study species. Indeed, S. perspicillata consumed more prey items of the two core diet categories when S. strinatii was not actively foraging. Moreover, we found body size to positively affect the consumption of both prey categories only in S. perspicillata, in particular when S. strinatii was not active on the forest floor. This latter result suggests a size-mediated interaction between the two species. In this respect, Salvidio et al. [S. strinatii and S. perspicillata, found a weak overlap among adults of the two species; however, some sort of overlap exists between S. strinatii subadults and S. perspicillata adults, which have similar body size. In addition, we also observed that, while for S. perpicillata the two considered prey categories with f > 0.1 are numerically predominant in the realized trophic niche  has a direct effect on the resource use of another species (S. perspicillata), but not by reducing resource availability, is consistent with the theoretical framework of interference competition, rather than with exploitative competition .S. strinatii and S. perspicillata in relation to local weather conditions. In the light of our new findings, the different foraging activity of these species in relation to precipitation and temperature [With the present study, we provided evidence about an interference/interaction occurring between the spectacled salamander and Strinati’s cave salamander and affecting their foraging activity. As we can ascertain from the present study, this competitive interaction is, at least to some extent, size-mediated, and is configured as interference competition rather than exploitative competition, at least concerning trophic resources. The results of the present study also corroborate the observations of Rosa et al.  about thperature  could alperature ,51. FutuFinally, although the foraging strategy of the two study species is known to be consistent across seasons ,43, our


To investigate the therapeutic effect of transcranial direct current stimulation (TDCS) combined with donepezil on stroke patients with memory impairment.The subjects of the study were 120 stroke patients with memory impairment admitted to the Rehabilitation Department of Tianjin Medical University General Hospital from July 2017 to March 2020. Enrolled patients were divided into Group-A (58 cases) and Group-B (62 cases) according to different treatment intervention methods. Patients in Group-A were treated with TDCS and those in Group-B received donepezil on the basis of TDCS. The changes in Montreal Cognitive Assessment (MoCA) memory index score, Barthel Index (MBI) score, cognitive function and cognitive potential were observed and compared between the two groups before and after treatment.p<0.05).The improvement of total MoCA score, a single score of memory, MBI score, cognitive function and P300 potential index in Group-B was significantly better than that in Group-A (TDCS combined with donepezil can reduce or delay the cognitive impairment of stroke patients, improve their delayed memory ability, increase the neurotransmitter acetylcholine in the cerebral cortex, and further enhance their neural function. Findings in our study support that the proposed therapeutic method is worthy of clinical application. Stroke, commonly known as “apoplexy”, has been the leading cause of disability in Chinese adults due to its incidence rate, mortality and disability rate. Memory dysfunction in stroke patients is mainly manifested in short-term memory impairment, such as time and spatial memory errors, decreased understanding ability, decreased learning ability, etc., which has a great impact on the quality of life and social adaptability of patients.Transcranial direct current stimulation (TDCS) is a non-invasive brain stimulation technique that can directly stimulate cortical neurons. Meanwhile, donepezil can effectively improve the cognitive function of patients with Alzheimer’s disease and has a significant inhibitory effect on cerebral cholinesterase.p>0.05).This study was approved by the Institutional Ethics Committee of Tianjin Medical University General Hospital , and written informed consent was obtained from all participants.The subjects of the study were 120 stroke patients with memory impairment treated in Tianjin Medical University General Hospital from June 2017 to March 2020. Enrolled patients were divided into two groups according to different treatment and intervention methods, including 58 cases in Group-A and 62 cases in Group-B. There were no significant differences in gender composition ratio, age and underlying diseases between the two groups   Edition8Patients with memory impairment complained by the patient themselves or insiders;Patients with total score ≤26 points and memory score ≤4 points according to the Montreal Cognitive Assessment (MoCA) scalePatients without communication disorder;Patients and family members who knew and were willing to participate in the study.Patients allergic to the studied drug;Patients with a history of mental illness;Patients taking memory-enhancing drugs;Patients with severe liver and kidney dysfunction.Blood glucose, blood pressure, blood lipids and other indicators were controlled in all patients in both groups after enrollment. Besides, patients were provided targeted cerebral nerve protection. For example, patients with cerebral hemorrhage were given treatment such as prevention and treatment of cerebral edema and prevention of cerebral vasospasm, and patients with cerebral ischemia were given anti-platelet aggregation treatment. On this basis, patients in Group-A were treated with Donepezil Hydrochloride  orally  for four weeks.Patients in Group-B were given Donepezil Hydrochloride in the same dosage as above combined with TDCS. In terms of the therapeutic method of TDCS, patients were instructed to take a sitting position and use an electric stimulator . The coil diameter was set to 12 cm to stimulate the affected frontal lobe of patients. The peak stimulation intensity was 1.2 T, the pulse time was 100 s, and the stimulation frequency was 20 Hz. One sequence of stimulation was 30 times (5 d/week), and patients were treated for four weeks.Memory score: The seven indexes of attention and calculation, linguistic competence, abstract thinking, naming, delayed memory, and orientation were evaluated according to the MoCA test.Activity ability: The improved Barthel Index (MBI) scaleCognitive function: The Mini-Mental State Scale (MMSE)Cognitive potential P30012: P300 was used to detect the event-related potentials of patients. P300 amplitude and latency could effectively reflect the changes in patients’ psychological activities such as perception, comparison, memory, judgment and thinking before and after treatment.χ̅±S) and examined by the t-test, and the counting data was expressed as n (%) and detected by the x2 test. P<0.05 was used to indicate the existence of statistical differences.Data processing used SPSS23.0 software. The measurement data was represented by (p<0.05). After treatment, the ability of orientation, attention and calculation, memory and linguistic competence in Group-B were higher than those in Group-A . After treatment, P300 amplitude was longer and P300 latency was significantly shorter in both groups than those before treatment; meanwhile, the improvement of the P300 index in Group-B was significantly better than that in Group-A , increase the content of acetylcholine, and improve the cognitive function and activity of daily life of patients.Stroke is cerebral ischemia caused by vascular stenosis or occlusion, and cerebral hemorrhage is caused by vascular rupture. Chronic cerebral dysfunction caused by long-term ischemia will lead to cognitive decline, including impairment in attention, memory, emotion, thinking, intelligence, etc.26However, and importantly, the nervous system has plasticity to a certain extent, which can increase the dendritic branches of neurons under continuous external stimulation. Subsequently, there will be new axons and cell bodies that can facilitate the formation of new connections between neurons. Consequently, it can help to rebuild the neural network and brain function, so as to achieve the purpose of restoring cognition and memory.28However, this study was conducted in a single hospital with a small sample size. There is a need to further increase the sample size to improve the accuracy of results in our study.TDCS combined with donepezil can promote the recovery of cognitive function of stroke patients, improve their visuospatial skill and executive ability, enhance brain cell vitality, and promote the recovery of functional activities of cerebral cortex.WHandQW: Designed this study, prepared this manuscript, are responsible and accountable for the accuracy and integrity of the work.XW: Collected and analyzed clinical data.XL: Data analysis, significantly revised this manuscript.


Although the association between maternal exposure to antibiotics and the risk of atopic dermatitis (AD) in childhood has been studied extensively, there still is a lack of clarity on the topic. The aim of this study was to summarize the published data and to examine if maternal exposure to antibiotics increases the risk of AD in childhood.Systematic search was performed in PubMed, Scopus, Web of Science, and Embase for all types of studies on the review subject independent of any language restrictions and published up to 28th December 2022. Data was analyzed using random-effects model and presented as pooled odds ratio (OR) with 95% confidence intervals (CI).I2 = 85%, p = 0.0003). The significance of the results was not affected by the location of the study (Asia or Europe). While subgroup analysis based on exposure assessment or diagnosis of AD demonstrated a tendency of increased risk of AD, the association was not statistically significant in multiple subgroups. Segregating data based on the timing of exposure did not affect the significance of the results for studies on all trimesters. However, there was no association between antibiotic exposure in the third trimester or just before delivery and the risk of childhood AD.A total of 18 studies  were included. Maternal exposure to antibiotics was associated with an increased risk of AD in childhood (OR: 1.14, 95% CI: 1.06, 1.22, The results of this meta-analysis suggest that maternal exposure to antibiotics may lead to a modestly increased risk of AD in offspring. The evidence is limited by high interstudy heterogeneity and bias in exposure and outcome assessment. Future studies are needed to explore if the timing of exposure, the dose, the number of prescriptions, and the type of antibiotic affect this association.https://www.crd.york.ac.uk/prospero/, identifier CRD42023387233. Atopic dermatitis (AD) is a common, chronic, and recurring inflammatory skin disease of childhood. It is characterized by intense itching, dryness, and eczematous lesions . StudiesDuring the last decade, clinicians focused on identifying risk factors for AD which can be modified to reduce disease prevalence. One such factor is maternal exposure to antibiotics which has been linked with several allergic diseases –8. WomenThe relationship between maternal exposure to antibiotics and the risk of AD has been a subject of research in multiple studies –8 but wiThe PROSPERO registration (No. CRD42023387233) of the review was completed before the beginning of the study. The review conformed to the standard instructions of the PRISMA statement .The search strategy was completed independently by two reviewers. Systematic electronic literature search of PubMed, Scopus, Web of Science, and, Embase was done. Since these databases are not comprehensive, a Google Scholar search was also conducted for gray literature. The search was independent of any language restrictions and publication dates, and was completed on 28th December 2022. The terms “eczema”; “atopic dermatitis”; “pregnancy”; “maternal”; “prenatal”; “antimicrobials”; and “antibiotics” formed the various search strings used for the literature search . The seaPopulation- Mother-child pairsExposure- Exposure to antibiotics before birthComparison- No exposure to antibioticsOutcome- AD in childhood (<18 years of age) [Outcome was to be reported as adjusted effect size with 95% confidence intervals (CI)]Study type- All typesExclusion criteria were: (1) studies not specifically on AD and reporting data on all allergic diseases combined (2) studies not reporting adjusted outcomes (3) studies not reporting exclusively on AD in childhood (4) studies with overlapping or duplicate data. In such cases, the study with the largest sample or the most comprehensive data was selected.The standardized PECOS inclusion criteria were used to select eligible studies. The criteria for each domain were as follows:Two authors extracted the following data in separate forms: author's last name, database of the study, country of origin, study type, sample size, children's age range, method of antibiotic exposure assessment, the timing of exposure, diagnosis of AD, factors adjusted in the data analysis, and effect size. If studies reported multiple ratios of the association for different subgroups, these were combined using the meta-analysis software to generate a single combined ratio. No restrictions were placed on the method of exposure assessment, the timing of exposure, or the diagnosis of AD. All methods reported by the studies were acceptable.Quality assessment was conducted using the Newcastle-Ottawa scale (NOS) . Every sI2 statistic tool was used for inter-study heterogeneity. Values of >50% indicated high heterogeneity. Funnel plots were used for publication bias. The robustness of the results was checked by excluding one study at a time in a sensitivity analysis. P-values <0.05 were considered statistically significant. Subgroup analyses were conducted based on study location, study type, sample size, exposure assessment, diagnosis of AD, and timing of exposure.The meta-analysis was performed using “Review Manager” . Effect ratios from the studies were combined in a random-effects model to calculate pooled odds ratio (OR) with 95% confidence intervals (CI). The κ = 0.9).Systematic literature search across all databases resulted in 1,238 studies. Of them, 844 were removed as duplicates. Of 394 articles, 31 studies were selected for complete text review. Thirteen studies failed to meet the eligibility criteria. Finally, 18 studies were included in the review , 20–31 . The intAll 18 studies were from Asian or European countries . Most ofI2 = 85%, p = 0.0003)  . The fun 0.0003) . There wThe results of subgroup analyses are shown in Lactobaccillus and Bifidobacterium  heterogeneity. This inter-study heterogeneity may be explained by the varied study populations and methodological differences in the included studies. Multiple subgroup analysis that was performed to assess the source of heterogeneity showed that the results were not affected by the study location and sample size. A slightly increased risk of AD was noted in Asian vs. European studies (53% vs. 12%) but this could be due to a smaller proportion of Asian studies in the review. Also, most of the studies included in the review were predominantly prospective cohort studies. The risk of AD was increased in both study types but just lost statistical significance in the case of only prospective studies.Assessment of exposure and outcomes can also be a major source of bias. Assessment of antibiotic exposure from medical records and clinical diagnosis of AD is more reliable that self-reported data which can be a subject of recall bias. There is always a possibility of mistaken reporting of drugs used by the women, or reporting other symptoms for AD. However, no marked difference was noted in the subgroup analyses, and all results remained statistically significant or showing a tendency of increased risk of AD.According to the altered gut microbiota theory, the timing of maternal antibiotic exposure should be an important variable influencing the risk of AD. Theoretically, very early exposure to antibiotics should have minimal impact as there is still enough to restore the maternal microbiota. However, research shows that certain classes of microorganisms, eliminated by antibiotics, are not restored even after nine months . LiteratThis review should be interpreted with the following limitations. The pathophysiology of AD is complex with a number of confounding factors such as maternal smoking, socioeconomic status, parental history of allergy, infant gender, birth weight, delivery mode, breastfeeding, pet contact, etc., . While oIn terms of the clinical significance, our review demonstrated that while maternal exposure to antibiotics led to a higher risk of AD in offspring, the increased risk was modest at 14% (6%–22%). Given the high inter-study heterogeneity and bias in the included studies, our results do not recommend avoiding antibiotics in pregnancy. The prescription of antibiotics in pregnancy should be carefully considered after evaluating the risk vs. benefit ratio. Most of the times antibiotics are needed for improving the overall health of the female and prevent any adverse effects of the infectious disease on the fetus. However, mothers should be advised that any intake of antibiotics during pregnancy may lead to a small risk of AD in the child who needs to be closely monitored for early diagnosis and treatment.The results of this meta-analysis suggest that maternal exposure to antibiotics may lead to a modestly increased risk of AD in childhood. The evidence is limited by high interstudy heterogeneity and bias in exposure and outcome assessment. Future studies are needed to explore if the timing of exposure, the dose, the number of prescriptions, and the type of antibiotic affect this association.


The contamination of air, water and soil by heavy metal ions is one of the most serious problems plaguing the environment. These metal ions are characterized by a low biodegradability and high chemical stability and can affect humans and animals, causing severe diseases. In addition to the typical analysis methods, i.e., liquid chromatography (LC) or spectrometric methods , there is a need for the development of inexpensive, easy-to-use, sensitive and portable devices for the detection of heavy metal ions at the point of interest. To this direction, microfluidic and lab-on-chip (LOC) devices fabricated with novel materials and scalable microfabrication methods have been proposed as a promising approach to realize such systems. This review focuses on the recent advances of such devices used for the detection of the most important toxic metal ions, namely, lead (Pb), mercury (Hg), arsenic (As), cadmium (Cd) and chromium (Cr) ions. Particular emphasis is given to the materials, the fabrication methods and the detection methods proposed for the realization of such devices in order to provide a complete overview of the existing technology advances as well as the limitations and the challenges that should be addressed in order to improve the commercial uptake of microfluidic and LOC devices in environmental monitoring applications. The environment and human health are threatened by heavy metal ions, such as lead (Pb), mercury (Hg), arsenic (As), cadmium (Cd) and chromium (Cr), which are present in water, air and soil. Heavy metals ions can be categorized into those required by living organisms in small amounts , which only cause toxic effects in high concentrations, and those  that are highly toxic even in small amounts ,2,3,4,5.These contaminants are entering the aquatic and food chains of humans and animals through both human-related activities and natural phenomena. Some examples that result in the release of heavy metal ions include industry activities, urbanization, mining and metals discharges from natural resources, volcanic activities, soil erosion, rainwater and other physical phenomena ,3,5,6.3 (five times higher than water density) and also exhibits a low biodegradability and high chemical stability, resulting in the pollutants staying present in the environment for a long time. Such heavy metals are detrimental for fauna and flora, catastrophic to animal and plant habitats and can eventually be lethal to living organisms, including humans ..38].2, Fe3O4, SNO2, TiO2 and ZrO2) . T. T2+. Thg et al.  have fabk et al.  have fabetection   is achieved. This portable device is controlled by a smartphone and the LOD of Pb2+ in river water is 0.00498 μg L−1. Finally, a microfluidic channel was combined with a wireless sensor in a low-temperature cofired ceramic substrate among the capacitor plates for the detection of various metals ions, like Pb(NO3)2 and Cd(NO3)2 (A novel autonomous robotic system for Pbeveloped . More sp4 µg L−1 C. M. Zhaap water D. This pCd(NO3)2 E 81]. T. T2+ detMercury (Hg) is another harmful pollutant that affects the environment, and it is produced by various industries, such as the paper, pharmaceuticals and horticulture industries. It can be absorbed by fish or shellfish and enter to human body via the food chain or by drinking water, affecting in this way cardiovascular, gastrointestinal, urinary and neurological systems. The toxicity of Hg and its compounds differs according to the method of inhalation or ingestion or the amount. The provisional tolerable weekly intake of Hg in foods proposed by the Food and Agriculture Organization of the United Nations and the WHO is 0.3 mg. No detectable negative effects are caused to the human body below this limit, but this high safety standard stresses the need for accurate Hg detection ,46.2+, many efforts have been made for the detection of Hg using microfluidics devices and optical detection systems. For example, Hg2+ was detected via an optical microfluidic device with ionophore modified gold nanoparticles . T. T−1 of 2+ using an electrochemical detection method based on a microfabricated planar bismuth electrode on the chip, while the system was also tested for the on-site detection of Cd2+ in soil pore and ground water samples. A. Jang et al. . . 2+ and Chromium (Cr) is used in electroplating, chrome plating, leather tanning, dye and pigment production, wood preservation and metallurgy. It can further be found in water, sediments, soils, rocks, biota and volcanic emissions. Trivalent (Cr (III)) and hexavalent (Cr (VI)) chromium are the most stable forms of chromium in aqueous solutions. Although Cr (III) is essential for living organisms in a high dose, it can cause digestive problems and affect the kidneys and liver. Furthermore, Cr (VI) is considered highly toxic and carcinogenic for humans. These kinds of metal ions are probably released in the environment through waste water due to industrial activities but also from other human activities . Drinking water is also polluted by Cr (III) and Cr (VI) as a result of the utilization of corrosion inhibitors in water pipes and containers or by the pollution of underground water ,125,126.−16 mol L−1 is detected, while total Cr can be defined using the same strategy as Cr (III). W. Alahmad et al. . . 124]. T−1 and 4 μg L−1 for Cr (III) and Cr (VI), respectively, can be detected. M. Manachino et al. [An easy-to-use and low-cost PMMA lab-on-disk, which is combined with an optical detection system, was presented for Cr (III) and Cr (VI) detection in water samples . By combo et al.  tried to−1 and 0.06 mg L−1 detected for Cr (VI) and total Cr, respectively. Finally, an LOC device was fabricated and proposed for Cr (VI) detection [Compared to optical-based microfluidic devices for Cr detection, microfluidics devices with electrochemical sensors are limited. For example, a novel paper-based microfluidic device where colorimetric and electrochemical detection methods are used in a single device is described in . In thisetection . In the The WHO  has alre−1 (up to 50 μg L−1 in some countries) for As, 3 μg L−1 for Cd, 50 μg L−1 for Cr, 10 μg L−1 for Pb and 6 μg L−1 for Hg.In The food and water safety markets are highly regulated and, therefore, in order for new methods to proceed to the commercialization phase, specific legislations and directives should include them as accepted analysis methods. Otherwise, new methods will never be tested under real conditions because there will be no market interest. A representative example in order to better understand the reason for the slow uptake of new methods in the food and water safety market work is the following: Regarding the quality of water intended for human consumption, only recently the EU Directive  has inclDuring the pandemic, in an effort to limit the spread of the SARS-CoV-2 virus, several methods were rapidly developed and accredited, thus opening a favorable environment in the post-COVID era for new methods and innovative devices to find their way to the health, food and water safety markets.One of the scientific sectors in which microfluidic and LOC devices are widely used is that of environmental monitoring. One of the most important targets in environmental monitoring is water pollution by heavy metal ions as they can easily pass to drinking water. Miniaturized systems that take advantage of microfluidic devices equipped with appropriate detection schemes seem to be a very promising tools for water safety and the detection of heavy metals. The main reason is that such devices can offer sensitivity, specificity, portability and multiplexing in terms of multiple targets’ detection in a single device, specifications which are essential in water and environmental monitoring.This review paper reports the most common microfluidic-based devices with a particular focus on the LOC approaches together with details on their fabrication methods, the materials used, their detection schemes and their performance capabilities. It is clear that state-of-the-art examples, which can meet the legislation limit values, have already been reported. However, despite this great progress in the field, several challenges still exist. According to our point of view, one of the biggest is the device integration, i.e., the incorporation of all the necessary parts . Additionally, on their way towards possible commercialization, performance and detection repeatability is another aspect which could be improved along with an extensive industrially relevant evaluation of these devices, which is also missing. It is therefore evident that, further to the technology advancements that are required, it is also important to develop collaboration frameworks to address these shortcomings. In this way, important feedback can be provided by the end users, which can help the research community to work on the drawbacks and improve the performance and repeatability of LOC devices. To date, conditions are in favor of new technologies and methods and it is expected that during the next years more and more LOC and microfluidic devices in general will reach the commercialization level.


A limited number of studies have evaluated the masticatory indices of individuals with obesity who only chew their food a few times and for shorter duration or who were provided with an instructional intervention. This study aimed to examine the effects of a 6-month instructional mastication intervention on the body composition and biochemical indices in female patients with obesity.Female patients with obesity were randomly classified into a conventional treatment group , which only received normal nutritional and exercise guidance, and a mastication intervention group , which received an additional mastication guidance. The MIG received guidance on foods requiring increased number of chews and chewing duration, eating techniques, and the proper method of cutting foods.Changes in the masticatory, body composition, and biochemical indices were compared before and after the 6-month intervention. The values of body composition indices decreased significantly in both groups; however, the rate of change in body mass index significantly decreased in the MIG. In addition, the values of biochemical indices were significantly decreased in the MIG compared with that in the CTG, which is attributed to the addition of mastication instruction to female patients with obesity.Increasing the number of chews and duration of chewing times for carbohydrates, which are staple foods, possibly contributed to weight loss and improvement of glucose metabolism.UMIN, UMIN000025875. Registered on 27 Jan 2017. Obesity is a well-established risk factor for many lifestyle-related conditions, including hypertension, diabetes, dyslipidemia, and cardiovascular disease . PreventRecently, the importance of mastication has received increasing research attention. Eating speed, number of chews, and other eating behaviors and habits are also associated with obesity. Traditionally and supported by numerous studies, “fast eating,” with fewer chews and shorter meal duration, is one of the factors contributing to obesity. For example, college students who eat quickly are 4.4 times more likely to become obese, and men have a 2.8-fold higher risk of developing obesity than women , 6, and Li et al. compared the masticatory behavior of lean male patients with obesity. The obese group exhibited a significantly lower number of chews per gram of food and a higher rate of ingestion and energy intake per gram of food . RegardlWe have previously conducted a cross-sectional study to examine the relationship between mastication characteristics and obesity indices in patients with obesity. This relationship was established by comparing the number of chews and chewing duration for each food item in the obese and non-obese groups using a device with optical sensors plugged into the external auditory canal for measurement . PatientIn this study, we aimed to conduct a 6-month instructional mastication intervention in female patients with obesity and examine its effects on their body composition and biochemical indices.2 who visited an obesity outpatient clinic were enrolled in the study. After medical examination by a physician, the patients provided written informed consent to participate in this study. The preliminary measurements of body composition, biochemical indices, and masticatory indices were obtained. Subsequently, the patients were randomly classified into the conventional treatment group (CTG), which only received normal nutritional and exercise guidance, and the mastication intervention group (MIG), which received masticatory guidance in addition to nutritional and exercise guidance. The patients were randomly assigned to groups using envelopes. Medical personnel, who were not involved in the study designing, were assigned by drawing lots. Using G power, the number of cases was calculated by setting an effect size of 0.5, an α-error of 0.05, and a power of 0.80. Six patients with chewing disorders, with oral diseases, and under medication treatment were excluded. Of the 34 enrolled patients, three dropouts were identified from each group. Therefore, only 28 patients   were included in the final analysis.Forty female obese patients with a body mass index (BMI) of ≥ 30 kg/m2 were included. Moreover, an understanding of the description of this study and provision of voluntary written consent were required. Individuals with masticatory problems due to a cranial nerve disorder and those with oral disease, otitis externa, or psychiatric disorders were deemed unsuitable for participation in the study by the principal investigator and were excluded. Participants who were diagnosed with diabetes only, but did not receive medication treatment were considered as having diabetes; meanwhile, those with non-alcoholic fatty liver were also considered as having fatty liver. Smoking, drinking, and exercise habits were defined according to the standards of the “National Health and Nutrition Survey” of the Ministry of Health, Labour and Welfare of Japan.Patients aged ≥ 20 years and women who were able to perform their daily living activities independently with a BMI of ≥ 30 kg/mJinrin-019).This study was approved by the Ethics Committee of Kansai Medical University  and the Ethics Committee of Osaka Sangyo University ). Furthermore, the visceral and subcutaneous fat areas were measured using computed tomography  to determine the cross-sectional area above the navel. CT and fat scan analysis software  were used to measure the visceral and subcutaneous fat areas at the navel level.Body composition was measured in a fasting state using InBody 720 . The indices measured were body weight, body fat, and BMI  by height in meter squared , alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), immunoreactive insulin (IRI), and homeostasis model assessment of insulin resistance (HOMA-R). HOMA-R was used to measure insulin resistance and was calculated using the following formula: resistance index = fasting insulin×fasting blood glucose/405.Mastication was evaluated by attaching an earphone-type masticatory meter called “earable”  to the outer ear opening. It is plugged into the opening of the external auditory canal and utilizes infrared light. In addition, an optical distance sensor (LED and phototransistor) was installed to determine the number of chews and chewing duration by measuring the minute changes in the external auditory canal. The measured changes are displayed as waveforms; a proprietary algorithm is used to detect mastication and displays the mastication data on a tablet screen in real-time. Since the user is only required to wear an earphone, the device can measure masticatory indices under conditions closer to those experienced in everyday life than the conventional masticatory meters that are worn on the chin Fig. .This device has a precision of at least 0.958 and a recall of at least 0.937; therefore, it can accurately measure the number of chews .For the evaluation of mastication, we used three food items . The num(1) A salad  contains ingredients, such as shredded cabbage, that are high in fiber. (2) Rice ball  is a staple food in Japanese. (3) Donuts  are readily available snacks.p value of < 0.05 was considered significant.The indices were expressed as the mean ± standard deviation or the median (1st–3rd quartiles). The Shapiro–Wilk test was used to test for normality. The pre-post-intervention comparison of the CTG and MIG was performed using the paired t-test or Wilcoxon signed-rank test. The pre-intervention values and changes in each indicator were compared using a two-sample t-test or Mann–Whitney U test. The analyses were performed using the Statistical Package for the Social Sciences version 25. A As regards the baseline patient background, the incidence of dyslipidemia was significantly higher in the MIG; however, no significant difference was observed in the other indices Table .p = 0.035) (Table p = 0.040) and number of chews  for rice ball and a significant increase in the number of chews for donuts . However, these significant changes were not observed in the CTG. No significant difference was observed in the rate of change of each index between the two groups.Among the masticatory and biochemical indices measured at baseline, the chewing duration was significantly different between the two groups only for salad  in the CTG and body fat percentage  in the MIG significantly decreased. Among the biochemical indices, the HbA1c, AST, ALT, and GGT levels in both groups significantly decreased, while the LDL and HDL levels significantly increased.The changes in body composition and biochemical indices after the 6-month intervention provided in both groups are presented in Table p = 0.002) in the CTG and FPG  in the MIG significantly decreased. When the rates of change in body composition and biochemical indices were compared, the BMI , FPG , IRI , and HOMA-R values  significantly improved in the MIG compared with that in the CTG (Fig. Furthermore, the levels of TG (from 110.5 82.5–162.3] to 91.5 [73.5–131.0] mg/dL,  to 91.5 The masticatory indices for salad improved in both groups. By contrast, the number of chews and chewing duration for rice ball and number of chews for donuts also improved in the MIG. With regard to the body composition indices, the body weight, BMI, skeletal muscle mass, and body fat mass improved, and the HDL and LDL levels increased in both groups after 6 months of intervention. Meanwhile, the body fat percentage and FPG significantly decreased in the MIG. Among the biochemical indices, the HbA1c, AST, ALT, and GGT values improved significantly in both groups. Based on the rates of change between the two groups, the BMI, FPG, IRI, and HOMA-R values in the MIG were significantly lower than those in the CTG. In both groups, the content of nutritional and exercise guidance provided was the same; this result is considered an additional effect when masticatory guidance was added.A previous study reported that chewing gum between meals alone did not promote weight loss . QuantifIn addition to regular nutritional guidance, the mastication intervention encouraged patients to recognize their masticatory behavior by measuring their masticatory indices in advance. Furthermore, the patients were encouraged to change their behavior by providing individual feedback and guidance on mastication. It is conceivable that because of this intervention, although chewing instruction was provided once a month by a registered dietician, changes in chewing behavior were observed after 6 months. This was expected to influence the three daily meals. Specifically, this study quantified the number of chews and chewing duration during nutritional guidance and provided valuable results regarding the usefulness of chewing guidance along with the results. The Japanese Ministry of Health, Labor and Welfare recommends chewing each mouthful of food 30 times, which has been implemented in many studies .After giving feedback on the number and duration of mastication before intervention, we instructed the participants to increase the number of mastications. Since the number and duration of mastications vary depending on the food item consumed, it is necessary to provide guidance on how to select food, how to cook it, and how to reduce the size of each bite. The recommended number and duration of mastications for each ingredient have not been reported in this study and should be investigated in future studies.This study has some limitations. First, only female patients with obesity were included in this study. Therefore, whether the same results would be observed in male patients with obesity remains unknown. Previous studies have reported sex-related differences in mastication characteristics , 20. A sWe quantified the number of chewing times and chewing duration for obese women, and found that providing chewing guidance significantly improved the BMI, glucose metabolism, and insulin resistance than the regular nutritional guidance. In particular, the chewing instructions for carbohydrates such as rice balls and donuts may contribute to the improvement of sugar metabolism. Notably, increasing the number of chews and chewing duration while consuming carbohydrates, such as rice balls and donuts, may contribute to the improvement of glucose metabolism.