Osteosarcomas (OSs) are a group of neoplasms originating from bone cells, usually presenting in three specific age groups: children, young adults, and the elderly. High-grade OS is an extremely malignant tumor mainly due to evolution into metastatic disease, usually in the lungs. Survival of these patients has improved since the 1980s thanks to close cooperation between oncologists, oncological surgeons and orthopedic surgeons. Unfortunately, no progress has been made in the last 30 years and new, more effective drugs are needed. This article reviews the biological and pharmacological basis of the treatment of OS. Models of clinical pharmacology of the active drugs, toxic effects and reasons for primary and secondary resistance to old and new drugs are discussed. Osteosarcoma (OS) is the most common primary bone sarcoma in the context of rare tumors. It represents 0.2% of malignant tumors with about 1000 cases per year in the USA [OS arises from mesenchymal cells of the bone with osteoblastic phenotype and osteoid production. The tumor is more often localized in long bones .High-grade OS is an extremely malignant tumor: following the surgical treatment alone the tumor is responsible for the death of the patient in about 70% of cases, mainly because of the presence of micrometastatic disease, even in seemingly localized cases .The multidisciplinary approach and the association between chemotherapy (pre- and postoperative) and surgery, increases the event free survival at five years to 60–70% .Neoadjuvant and adjuvant chemotherapy presents several advantages: elimination of micrometastases, better control of the primary tumor, assessment of the effect of chemotherapy, improvement of the prognosis.Despite these results 30–40% of patients with localized OS treated with chemotherapy and surgery will develop local or distant recurrence during the five years follow up .Resection of lung metastasis can improve long term survival (20% at five years); nonetheless, radical resection can only be carried out in 40% of cases .Consequently, when the disease becomes metastatic and non-operable, the only medical treatment that can be provided is palliative in most cases.Very few active agents are available in metastatic OS and this is the main reason of the disappointing results.The aim of this paper is to analyze under a pharmacological point of view the mechanism of action of the drugs utilized as first and second line therapy in OS, focusing on the pharmacodynamic and pharmacokinetic aspects of the molecules.Special attention is paid to the reasons for the onset of resistance to chemotherapy in metastatic disease.Since the 1980s, few drugs have demonstrated effective activity against OS cells. The most active regimen in the neoadjuvant/adjuvant setting is MAP, a combination of High Dose Methotrexate (HDMTX), Adriamycin (ADM) and Cisplatinum (DDP).Ifosfamide (Ifo) was integrated into the protocols over the last 20 years  as the fA single agent regimen is less effective than combination therapy and many studies have utilized the MAP combination in the neoadjuvant/adjuvant setting as well as in non-pre-treated metastatic disease ,6.Methotrexate is an antifolate inhibiting Dihydrofolate Reductase (DHFR), a key enzyme in folate metabolism. Dihydrofolate reductase is an enzyme that reduces dihydrofolic acid to tetrahydrofolic acid, using NADPH as an electron donor, and it cooperates to maintain the folate pools in purine synthesis.DHFR gene [In humans, the DHFR enzyme is encoded by the HFR gene .The pharmacological effect of MTX is exerted when the drug is polyglutamated. In this intracellular form the antitumor activity is prolonged thereby inhibiting DHFR and thymidylate synthase. MTX can be administered orally or parenterally, however, since absorption in the gastrointestinal tract is highly variable, in oncology MTX is administered intravenously ,9.Standard doses range between 40 and 1500 mg/sqm. However, in an effort to improve MTX antitumor activity, doses of HDMTX ranging from 8000 to 15,000 mg/sqm are used in neoadjuvant/adjuvant therapy in OS in order to increase the concentration of the drug in the cells with passive inflow .(Cooperative German-Austrian-Swiss Osteosarcoma Study Group) [HDMTX was first administered to OS patients by Jaffe and Rosen in 1970. In 1982, Rosen reviewed the existing postoperative chemotherapy strategies in patients with OS . The samy Group)  and by ty Group) . HDMTX cy Group) .The mechanism of resistance to MTX can explain the scarce activity of this drug when rechallenged as second line chemotherapy in metastatic OS. The factors involved in resistance include decreased accumulation due to impaired transport, decreased retention as a consequence of lack of polyglutamate formation, increased DHFR, altered DHFR that binds MTX less avidly, and an increased level of a lysosomal enzyme, γ-glutamil hydrolase, that hydrolyses MTX polyglutamates ,14.On the contrary, after prolonged exposure to MTX a positive feedback effect can increase the level of DHFR and thymidylate synthase proteins in the cells. This translational effect represents a clinically relevant mechanism following repeated exposure with HDMTX and can play a positive role in case of drug rechallenge ,14.Pemetrexed is a multitargeted antifolate with a wider range of action than MTX. Its activity involves the inhibition of thymidylate synthase-dihydrofolate reductase (TS-DHFR) and glycinamide ribonucleotide formyltransferase (GRFT) ,16. An iNo other antifolate antipyrimidine agents, including 5-FU, Capecitabine, Cytarabine, 6 Thiopurine, are active against osteosarcoma cells, while marginal activity in second line treatment has been reported for Gemcitabine (see text).Doxorubicin, like all antitumor antibiotics, is a natural product of Streptomyces species with some chemical substitutions that yield a great array of similar compounds. The mechanism of action is broad and includes intercalation into the base pairs of DNA, production of toxic oxygen free radicals with DNA breaks, inhibition of RNA and protein synthesis, defective mitoses, and high mutation rates [on rates ,19.In the neoadjuvant/adjuvant setting Doxorubicin is actively combined with MTX and Platinum at doses of 45 mg/sqm in a bolus or in a 4-h infusion to reduce cardiotoxicity . As a siSeveral options have been put forth in order to increase the maximum tolerable dose: slow infusion of the drug over 4–24 h; in combination with dexrazoxane as an antioxidant agent; introduction of possibly less toxic analogs . Unfortunately, none of these analogs showed increased activity against OS .Moreover, we must also consider the rapid onset of resistance to Doxorubicin. The presence and genetics of the membrane glycoprotein GP170 product expression of ABC multidrug resistance genes that acts as a drug carrier to mediate efflux from neoplastic cells was first described in 1990 ,21.Other patterns of resistance to Doxorubicin include reduced binding affinity to topoisomerase II, an increase in the glutathione intracellular pool, and faster detoxification of oxidative species ,22.All these reasons prevent rechallenge of metastatic OS with anthracyclines.No other antitumor antibiotic agents are active in OS cells.PA represent a unique class of antineoplastic agents.Cisplatinum (DDP) is the first approved agent of this group and the only active agent in OS. Platinum has a 2+ or 4+ oxidation state, the ligands around the platinum atom assume a specific geometry. Platinum compounds form strong covalent bonds in the form of an interstrand cross link of DNA, in general between the guanine and adenine bases. DNA replication can be inhibited by platinum adducts .Cisplatinum as a single agent at dose ranging from 80 to 100 mg/sqm every 21 days shows moderate activity on OS cells and in clinical trials, with an objective response no higher than 10%.In MAP polichemotherapy in the neoadjuvant/adjuvant setting, cisplatinum is fundamental in order to achieve a 65% objective response of the combination .Nephrotoxicity is dose-limiting for cisplatinum resulting in glomerular and tubular damage and magnesium and potassium wasting. Nephrotoxicity is cumulative and can be worsened by the association with acid drugs .Neurotoxicity is another cumulative side effect. Paresthesias, loss of sensitivity in the extremities, pallesthesias and loss of motor function are the most common and irreversible toxicities .Ototoxicity is irreversible as well due to the sensitivity of cochlear hair cells to cisplatinum. No antidote is available for neurotoxic damage .Nausea and vomiting grades 3–4, alopecia and anemia are other very common side effects.The cumulative dose that is needed to induce irreversible toxicity is about 700 mg/sqm.Carboplatin, a dicarboxylate platinum, is less neuro- and nephrotoxic but more myelotoxic. Unfortunately, like oxaliplatin, it is inactive against OS cells.Cisplatinum induces rapid onset of resistance based on reduced cellular accumulation, intercellular detoxification through glutathione synthase, rapid DNA repair via ERCC1 gene expression, and the activation of autophagy .Antineoplastic activity can be determined by microenviroment conditions, hypoxia and DNA mutations.The rapid onset of resistance, together with irreversible toxicity make cisplatinum unfeasible as a second line agent in metastatic OS.2; N, S, thereby creating irreversible damage to the double strand.Alkylating agents contain reactive alkyl groups that form covalent bonds to DNA, and they include many groups of drugs. The mustard subfamily, which is active in OS, reacts with different atoms of DNA: OOf the nitrogen mustard group, cyclophosphamide and more specifically Ifosfamide are the only agents that are actively used. Both drugs are bifunctional agents and interfere with DNA and RNA throughout the whole cellular cycle, though mainly in the S phase .Both cyclophosphamide and Ifosfamide are pro-drugs with no antitumor activity prior to intracellular transformation into amide nitrogen mustard and acrolein (the latter as a toxic metabolite) .In the first studies that were carried out on OS in the 1970′s, cyclophosphamide was the only available agent, and a less than 5% response rate in monotherapy was reported at doses of 600 mg/sqm. Ifosfamide was introduced into the OS regimen when its natural antidote  was discovered .The Italian/Scandinavian Sarcoma Group tried to increase the response rate in the neoadjuvant/adjuvant setting by introducing etoposide and ifosfamide into the perioperative regimen but the results were disappointing: more than 40% of patients developed local or metastatic disease .Currently, Ifosfamide in OS is added to MAP in the postoperative setting in order to improve the clinical outcome when poor tumor necrosis is the result of neoadjuvant therapy ,25.A great variety of Ifosfamide doses are considered active: from 1200 mg/sqm over 5 days, to 3 g/sqm/day for three days, up to 15 g/sqm over several days in continuous infusion as second line treatment in metastatic disease.Ifosfamide toxicity is high , but unlike cisplatinum and adriamycin, there is no maximum dose, and the drug can be rechallenged in case of disease relapse . Patientchanges in drug uptake or transport,increased DNA damage repair,decreased prodrug activation activity,increased scavenging of drug species,increased enzymatic detoxification,altered apoptosis mechanism ,25,26.The mechanism of resistance can be partially overcome by increasing the dose of the drug. The reasons for incoming resistance are:In literature there are some encouraging reports regarding high dose ifosfamide as second line chemotherapy in metastatic OS.Verschoor et al. demonstrated that second line ifosfamide at a dose ranging from 5 g/sqm to 9 g/sqm resulted in an overall survival of 10.9 months and in 13 months of PFS in the 9 g/sqm arm .At the 2015 ASCO meeting the Italian Sarcoma Group presented a study on high dose ifosfamide as second line therapy in relapsed metastatic OS. Fifty-one heavily pre-treated patients  were administered Ifosfamide at doses of 15 mg/sqm over 5 days, and in some cases for up to 21 days, with the addition of G-CSF support in all cases. Eleven patients had partial response and 28 achieved stable disease, 6-month progression free survival was 53% and 1- and 2-year overall survival rates were 60% and 31%, respectively .Thus, high dose ifosfamide is now an approved drug for relapsing or metastatic, non-operable OS.No other alkylating agent has shown any activity in this disease.When metastatic OS progresses few other cytotoxic agents are available. Rechallenge, as stated above, is not feasible for most drugs, and other active chemotherapy agents should be used.The combination of Gemcitabine and Docetaxel is the only polychemotherapy approved as second line treatment.Gemcitabine is an anti-purine agent that blocks fluorination of the nucleoside and its conversion into an active di-and triphosphate drug. Gemcitabine acts as a fraudulent metabolite reacting as gem-triphosphate with DNA . The druGemcitabine triphosphates compete as fraudulent antimetabolic agents with deoxycytidine triphosphate for incorporation into the DNA. The final result is the inhibition of DNA synthesis. Gemcitabine has a long persistence into the cell and DNA polymerase cannot remove the drug and repair DNA .Neutropenia, thrombocytopenia, and renal and hepatic toxicity have to be taken into consideration .Gemcitabine resistance can be either primary or acquired. Resistance can result from molecular and cellular changes, including nucleotide metabolism enzymes, inactivation of the apoptosis pathway, high expression of MDR enzymes, activation of the cancer stem cells or enhanced epithelial-to-mesenchymal transition (EMT) pathway .Docetaxel inhibits both free microtubules and spindle separation, arresting cell mitosis in the G and M phases . The phaGemcitabine as single drug at doses of 1250 mg/sqm on day 1 and 8 in OS shows modest activity (<5% response rate), but in combination with docetaxel can determine a 23% rate of clinical control   and a me2 on days 1 and 8, and docetaxel 70 mg/m2 on Day 8 in 3-week cycles until disease progression or other evidence of treatment failure.As a consequence, gemcitabine-docetaxel combination is a well-recognized and approved second line chemotherapy. The patients received gemcitabine 900 mg/mIn experimental studies Gemcitabine was utilized in aerosol form in the treatment of lung metastases of OS, assuming that there is direct activity of the drug without metabolism, however, no definitive studies were carried out .No other combinations are considered to be active in second line therapy. Ifosfamide + etoposide, carboplatin + etoposide ± ifosfamide, and cyclophosphamide + topotecan were reported in small phase II studies but activity was not confirmed in larger studies ,34,35.High-dose chemotherapy and stem cell support was abandoned after a few studies due to inactivity .Unfortunately, none of the more recent cytotoxic drugs has demonstrated any activity on relapsing or pre-treated OS.Almost 100 children with pre-treated high-grade OS were included in a data set evaluating new generation drugs: Irinotecan, Topotecan, Imatinib, Ixabepilone and Rebeccamycin analog, but none of these agents were considered active according to conventional response criteria .Trabectedin, a marine derived cytotoxic drug is active in the L form of soft tissue sarcomas, and has been approved as second line therapy. On the contrary, at the same doses of 1.2–1.5 mg/sqm/24 h c-i. q 21 days, no activity was seen in pre-treated OS (no objective response) and the drug was not approved for this indication .2 i.v. twice or once weekly as compared to patients treated with CT alone. No further studies were published and the study in the neoadjuvant setting is still ongoing [Liposome encapsulated muramyl tripeptide-phosphatidylethanolamine (L-MTP-PE) is a liposomal encapsulated analog of muramyl dipeptide that activates macrophages and monocytes, stimulating the immune system in a specific manner.Mori reported a reduced incidence of lung metastases following surgery and an increased survival rate with. L-MTP-PE administered at 2 mg/m ongoing .Zoledronic acid (4 mg q 28 days) is a biphosphonate that inhibits osteoclastic bone resorption and is widely used to reduce cancer-therapy-induced bone loss and osteoporosis in metastatic breast cancer. In OS cell lines, the combination of zoledronate and ifosfamide seems to be synergistic. The results are not encouraging and zoledronic acid in metastatic OS is not recommended .While chemotherapy agents destroy cells inhibiting the replication of the tumor, recent advances in our knowledge of biochemical and biological pathways in OS as well as in many other tumors, have led to the recognition of novel mechanisms that could be potentially targeted with molecular drugs.Several possible OS targets have been identified, but unfortunately none of them are exclusive or easily druggable ,42.As a matter of fact, OS displays a great number of genetic, epigenetic and cellular pathway abnormalities with a high degree of intratumor heterogeneity ,42.Unfortunately, a widespread, stable genetic lesion among OS types has not been identified.The most common example of genetic alterations are changes in aploidy and in copy number of genes .Some genetic syndromes are well recognized: Li Fraumeni, Bloom, Werner but none have a specific target to be hit .Somatic syndromes are also represented, but the rarity of these events cannot guarantee they will be a useful target for these therapies.RB and p53 tumor suppressor genes are in most cases modified and some oncogenes are amplified in high-grade OS: MET, MDM2 (2–25% of cases) cMyc, MPK, PMP22, VEGF A, but none of them can be considered stable druggable targets ,42.Epigenetic changes are common with hypermethylation as is histone modification in OS cells, but presently no specific drugs are available ,42.As a consequence, targeting some intracellular pathways has become the principal area of investigation for new therapies in OS.Neoangiogenesis has been the main target of studies over the last ten years. The process of new blood vessel development is critical in tumor growth, normal tissue invasion and metastatic diffusion.There is a solid rationale for angiogenesis inhibition in OS: both the extent of disease and patient prognosis are correlated with VEGF and VEGFR expression.In response to hypoxia, tumor tissue releases angiogenetic growth factors such as VEGF, FGF alfa and beta, and PDECG 67 .The primary objective of antiangiogenic therapy is to prevent new vessel sprout and to inhibit tumor growth, invasion and metastatization. The final result is cell dormancy status and tumor regression .Nowadays, we recognize two classes of antiangiogenic drugs: small molecule tyrosine kinase inhibitors acting against different transmembrane receptors, and monoclonal antibodies which act either against circulating growth factors or the extramembrane part of their receptors .In OS therapy only the former category of drugs have been investigated.–Sunitinib  ;–Bevacizumab  ;–Pazopanib  ;–Sorafenib and Regorafenib provided some relevant benefits ,48.On this basis, various targeted agents were studied:Sorafenib, a multitarget tyrosine kinase against VEGF2, RAF 1, BRAF, ckit, FGFR1, FLT3, was investigated at the dose of 400 mg twice a day by Grignani in an Italian Sarcoma Group study . The resRegorafenib, another anti VEGFR 1,2,3, TIE 2, KIT, RET, RAF 1, BRAF, PDGFR and FGFR multikinase agent, was investigated by the French Sarcoma Group in a randomized study comparing Regorafenib at an initial dose of 160 mg taken orally on days 1 to 21 of a 28-day cycle with BSC . The stuUnfortunately, the results were not considered positive by the European Medicines Agency (EMA) and the drug was not approved for second line therapy of OS.The Italian Sarcoma Group evaluated the association between Sorafenib and the mTOR inhibitor Everolimus versus Sorafenib alone . PatientThe objective response rate was 10% in the Sorafenib arm and 14% in the combination arm.Sorafenib + Everolimus resulted in 5-month PFS compared to 4 months for the single agent Sorafenib.The results were considered unsatisfactory and the combination was not approved for OS treatment.Another negative study is the one by Schwartz  which coThe most common signs of toxicity of antiangiogenic agents are fatigue, diarrhea, anorexia, oral changes, hand-foot syndrome, thyroid dysfunction, myelotoxicity, and hypertension ,48,49,50The pharmacological reasons for tumor resistance to TKI are well known: VEGFR and PDGFR gene mutation, overexpression of targets, impaired membrane transport by the drug into the cell, accelerated drug clearances ,42,53.All the studies that have been published to date on this topic are disappointing.The SARC 028 trial reported only one partial response out of 22 patients who received Pembrolizumab as a single agent in second line therapy in progressing OS. All patients were treated with 200 mg intravenous pembrolizumab every 3 weeks. Median PFS was 24% eight weeks after the start of treatment . ImmunotOsteosarcoma therapy made a great deal of progress in the 1980′s following the discovery of MAP as an active combination of drugs for frontline treatment, both in primary and in metastatic disease.Ifosfamide came later and added some interesting results in the postoperative setting in poor responder patients.Perioperative chemotherapy improved the results and changed the prognosis in the majority of patients, increasing 5-year survival from 20% to 65%.Unfortunately, when the disease relapses, second line therapy provides far from satisfactory results.The MAP combination as second line is scarcely active because of the onset of secondary resistance, and the established maximum dose of Adriamycin and Platinum which hampers rechallenge.Few other chemotherapy drugs have shown much activity: Docetaxel and Gemcitabine, alone or in combination, provided an objective response of 23% and a PFS of 4–6 months.Targeted drugs have a good rationale because of the strong expression of intracellular pathways in OS cells, but the results are partial, erratic and short lasting.At present, immunotherapy shows no benefits.Forty years after the seminal study of Jaffe et al., the current standard therapy in OS is the combination of old cytotoxic drugs with surgery of both the primary tumor and of the resectable lung metastases. Integrated therapy has radically changed the prognosis in high-grade OS. Five-year survival is now 70% compared to 20–30% with surgery alone. Radiotherapy plays only a palliative role.Unfortunately, no new active agents have been identified in the last 30 years. Newer cytotoxic agents, as well as molecular targeted agents have shown no benefits and none of the targeted agents have been approved. Immunotherapy plays no role in OS.There is an urgent need for effective agents, especially to treat metastatic or relapsing disease.Basic research, active international cooperation, and a multidisciplinary approach are the key choices for future improvements in therapy.


The roles HPV plays in the host were gradually identified through the interaction between it (including its early genes) and host RNA. In recent years, increasing numbers of studies in HPV-related cancers have been published showing the relationship between HPV and host RNA. Here, we present a database named HRRD, which contains the regulatory relationship between HPV and RNA . The information was extracted from 10,761 papers in PubMed . In addition, the sequence map of HPV (198 genotypes) is also contained. HRRD was designed as a user-friendly web-based interface for data retrieval. It integrated the information of interaction between HPV and RNA, which reflects the relationship between HPV and host. We hope HRRD will further provide a comprehensive understanding of HPV in carcinogenesis and prognosis. HRRD is freely accessible at  After HPVs infect the basal cells of epithelia, they employ cellular machinery to replicate and survive in host cells2. With the persistent infection, HPV and the released viral genome will lead to squamous intraepithelial lesions, even cancers3, such as cervical cancer4 and head and neck cancer5. HPV not only plays an important role in carcinogenesis, but also participate in host tumor immunity, prognosis, drug resistance and so on. All these functions are achieved through the interaction between HPV and host RNA.Human papilloma viruses (HPVs) are a group of double-stranded circular DNA viruses with about 8000 nucleotides in size. More than 200 HPV types have been characterized to date, including some high-risk types . HPV genome is composed of six early gene  open reading frames (ORFs), two late gene (L1 and L2) ORFs and a non-coding long control region (LCR). Distinct genes perform different functions6. HPV activates miR-34 to participate in the cell apoptosis7. In addition, the expression of HOTAIR was significantly down-regulated by E7 to cause cervical cancer8. In cancer cells, HPV participates in cancer metastasis, prognosis, immune response and so on. For instance, HPV activates TGF-β and IL-10 expression to activate the host immunity9. HPV promotes tumor metastasis by affecting various miRNAs in HPV-related cancers10. Besides, there are many other RNA changes caused by HPV and its oncogenes in HPV-related cancers. By affecting the expression of host RNA, HPV can lead to the occurrence and development of cancers, and has a huge impact on the treatment, immunity and prognosis of cancers. Moreover, it has also been reported recently that host RNA can affect the expression of HPV in converse.Host RNA can be divided into coding RNA and non-coding RNA. mRNA is the main type of coding RNA, while miRNA and lncRNA are two kinds of non-coding RNA which are popular in the field of research. HPVs influence host cells  by regulating the expression of these RNAs Fig. . In norm11 is a database about papilloma virus (including HPV). HPVdb12 is a Human Papillomavirus T cell Antigen Database. HPVbase13 shows the integration information of HPV. However, these databases only focus on the biological characteristics of HPV itself, such as its type and sequence information, but do not collect any information about the HPV-infected host. Despite of numerous experimental studies in the field, there are no computational resources with a unique focus on the relationship between HPV and host RNA. Hence, it is important and necessary to establish a proper multi-comparative platform to show this mutual relationship. Here, we present HRRD, a database of the relationship between HPV and host RNA, which contains the existing studies on HPV and host RNA. It will contribute to providing a comprehensive web-based resource for HPV and host, and data support for HPV-related research.In the recent past, some databases about HPV have been published. PaVEhttps://www.eclipse.org), one of the open-source integrated development environment (IDE). The database manage system was MySQL (https://www.mysql.com) which stores the relationship data model. Java Server Pages (JSP) in the web tier was used to present dynamic responses to clients. The client tier was made up of static and dynamic html pages including forms, tables, charts, and embedded JavaScripts. The model-view-controller (MVC) model web application was managed by Struts (https://struts.apache.org). All plots and web crawler were generated with python (version 3.8.1). HRRD is implemented and hosted on a Windows operating system, with Tomcat and MySQL (version 5.6.19), for serving static and dynamic content and providing the features for data management, respectively , mRNA, lncRNA (long non-coding RNA), gene. Articles with the combination of keywords were searched on PubMed . Web crawler got the research literatures with the keywords above. After deleting the epidemiological survey, review and the duplications, there were 10,761 articles remaining . The whole genome information of HPV (198 genotypes with specific sequence information) was downloaded from NCBI in genbank format.The information of the relationship between HPV and host RNA was extracted from articles, containing the PMID number, cancer type, HPV genotype, HPV oncogene, RNA type and name, method, material and the regulatory relationship between HPV and host RNA (action direction & action type). The information is obtained by reading the literature manually. The collected data were checked and unified, and finally summarized into Excel form. There are totally 784 pieces of information extracted from the articles, including 13 pieces of lncRNA, 195 pieces of miRNA, and others are mRNA.The sequence information of different HPV was extracted from the genbank files, including the full-length genome of HPV and the location of its oncogenes. The information of HPV sequence was stored in the database in TXT format.The principal function of HRRD is query. The information about the relationship between HPV and host RNA is stored in the database. In the Relationship page, there are three input boxes with examples for users to search. Users can search by one to three conditions like HPV genotype, HPV gene or RNA name to get a list containing the relevant content of users searched. The list would contain following information: HPV genotype, HPV gene, RNA type and name, action direction and type, cancer type, PMID, method and material. Users can jump to the article summary in PubMed by clicking the PMID number. “HPV to host” means HPV affects host RNA expression, while “host to HPV” means host RNA influences HPV expression. “Activation” refers to up-regulated expression, while “Suppression” means down-regulated expression. The method shows whether this message was concluded from experimental verification or data analysis Fig. C. The reThe genome information of HPVs is stored in the database. In the Sequence page, the table shows all species of HPV stored in HRRD. Users can input different genotype of HPV in the search box and click the search button to search HPV in the table below. Users can go to the result page by the plot button or clicking the HPV ID in the table Fig. B. The reOther pages contain some other ancillary functions. A simple Home page was designed Fig. A with a To our knowledge, HRRD is the first database designed for the relationship between HPV and RNA specifically. To ensure the accuracy of data, the information was manually extracted from relevant literature. HRRD describes the sequence map of HPV and incorporates some links to HPV-related databases so that users can search and get relevant information quickly and easily. We chose RNA as our research object, because RNA is unstable and susceptible to changes and mutates by viruses, and it is the first step in protein synthesis. For example, if researchers detect HPV infection in cancer, HRRD can help to find out whether HPV affects the key RNA and causes the carcinogenesis. In addition, if researchers want to find some key RNA in HPV-related cancer, HRRD can help to do preliminary screening and query. With the plenty resources, it will provide candidate biomarkers for HPV-related carcinogenesis and prognosis and identify potential targets for molecular therapy. We anticipate it will facilitate an insight into HPV and host.Despite the database has contained data up to December 1st, 2019, a rapidly growing number of relevant researches are emerging from then. HRRD will be updated regularly by scanning newly published literatures. To ensure the timeliness of data, we plan to use data mining and machine learning to obtain information from the literatures. At the same time, we will update the software with modified function and expanded the scope of application. These updates will be implemented in the near future.


Background: Probiotics have been associated with the treatment of depression and anxiety. However, the results reported in the literature have been inconsistent, and no meta-analysis specifically reported probiotics used on participants with varying levels of emotional state.Methods: This meta-analysis aimed to study the effectiveness of probiotics on anxious or depressive symptomatology for participants under stress conditions or with a depressive or anxiety disorder diagnosis. Medline, PubMed, EMBASE, and the Cochrane Library were searched through December 2019 for randomized controlled trials (RCTs). The primary outcomes were depression and anxiety scores. Main inclusion criteria: RCTs of probiotics for participants with a mood or emotional disorder diagnosis or under stress situations; and all participants were adults (age ≥16 years); Assessed by the modified Jadad assessment scale found seven high-quality studies and three low-quality studies.Results: Ten clinical trials  were included based on the inclusion and exclusion criteria. All studies were assessed as low or moderate risk of bias. The meta-analysis showed that probiotics could significantly reduce the depression scale for patients with anxiety and depression, and healthy participants under stress. However, there was no significant difference between the probiotics and placebo groups in the reduction of patient anxiety scores, even if they are depressive or anxious patients or healthy participants under stress. Subgroup analysis revealed that probiotics had significant effect on depressive symptoms just in patients with depression, and no significant change in anxiety in patients, and no improvement in participant performance under stress.Conclusions: Probiotics could alleviate depressive symptoms in patients with a depression diagnosis or depression scores also in anxiety disorder diagnosis, and suggesting that probiotics may be adjunct therapies for mood or emotional disorders. Therefore, it is essential that probiotics could be more involved in the treatment of patients with depression in the future. The evidence of probiotics successfully treating depression is still insufficient, and more high-quality studies on patients with depression are still needed. Depression and anxiety disorders are the most common mental disorders in human health. Depression is the main clinical feature of low mood, loss of interest, often accompanied by guilt, hopelessness, loss of appetite and insomnia, and it is one of the main types of mood disorders. Anxiety is an emotional state where the main characteristics are tension, worry, fear, and physical changes such as palpitations, tremors, gastrointestinal tract, respiratory and circulatory disorders without obvious objective causes. The World Health Organization (WHO) estimated that the prevalence of depression in the global population was as high as 4.4% in 2015, and the prevalence of anxiety disorders was estimated to be 3.6%  AND (“probiotics” OR “lactobacillus” OR “bifidobacterium” OR “microbiota” OR “gut bacteria” OR “saccharomyces”). Electronic search supplemented by a manual search retrieved the search terms. Included articles are those published in English-language publications between January 1, 2015 and December 30, 2019. Cohen's kappa was used to assess auditors' consistency in the quality of randomized controlled trials. Statistical analysis was performed using RevMan 5.3  software and SPSS 20.0 . If there is a disagreement between the first two reviewers, a third reviewers participates in decision making.Eligible studies met the following inclusion criteria:RCT of probiotics for participants with depression, anxiety or under stress;Studies that compared the difference between probiotics and placebos. No limitations on dosage, strain, or form of probiotics;Reports that used similar methods and a scientific rating scale for depression and anxiety e.g., Hospital Anxiety and Depression Scale (HADS) or Beck Depression Inventory (BDI).All participants are adults (age ≥16 years).All participants had no medication history within the 3 months or during the study;Studies that met any one of the following criteria were excluded:No control group (placebo treatment) in the article;Did not report post-intervention scores on depression and anxiety;Participants who had other diseases.Research on pregnant women.Data related to the effects of probiotics on depression and anxiety were extracted from all included studies using a table designed by the two reviewers. This table includes the demographic information of included subjects, trial designs, probiotic regimens, rating scales for depression, and anxiety and dropout rate.2 and I2 statistics. When P < 0.05 for the χ2 statistic or I2 > 50%, the heterogeneity was considered high. Therefore, a random-effects model was chosen for meta-analysis. Conversely, in the absence of heterogeneity, a fixed-effect model was used. Due to the relatively high heterogeneity between the studies, a random-effects model was chosen for meta-analysis.The analysis was performed with RevMan 5.3. The primary outcome of the study was the standardized mean difference (SMD) of change from baseline in scores on the depression and anxiety rating scales between the probiotics and placebo groups. Statistical heterogeneity was determined by χA total of four databases were reviewed. After discarding the duplicates, 1,521 studies were remained. The title and abstract screening excluded 1,320 papers with 219 papers remained. The full-text screening further excluded 209 studies, with the remaining 10 studies included in the meta-analysis. Ten clinical trials (involving 344 participants in the probiotics group and 341 participants in the control group) were included based on the inclusion and exclusion criteria. The results of these search processes are described below . ConsensThe characteristics of the 10 studies are shown in The risk of deviation assessment is shown in I2 = 21%; P = 0.003 for χ2-test), the random-effects model was applied. The meta-analysis showed significant differences in the relief of depression scores between the probiotics and placebo groups , so the random-effects model was applied. Meta-analysis shows that there was no significant difference between the probiotics group and placebo group  individual subgroups of patients with a diagnosis of depression and anxiety disorder ; (b) heaFunnel plot was used to assess publication bias qualitatively. The funnel plot  shows thP = 0.27). However, there was no significant difference between the probiotics group and the placebo group  in alleviating anxiety scores. Subgroup analysis further found that probiotics could improve depression scores in patients with depression or anxiety diagnoses , but did not affect patients' anxiety scores . Furthermore, we have found that probiotics do not improve nor depression scores , nor anxiety scores  in participants under stress. These results were not exactly the same as those of the previous meta-analysis. A paper . There was no significant difference between the probiotic group and the placebo group in alleviating anxiety scores. The subgroup analyses found that probiotics had a significant effect on the scores of patients with depression and anxiety, suggesting that probiotics may be adjunct therapies for deep mental illness. Larger studies are needed in well-defined clinical populations to determine the clinical utility of this novel treatment, and to further investigate potential underlying mechanisms.In conclusion, the meta-analysis showed a significantly lower depression score in the probiotic group compared to the placebo group (SMD = −0.47, 95% CI: −0.67 to −0.27, All datasets generated for this study are included in the article/supplementary material.LC, CL, and SS contributed to the search strategy, data extraction, and preparation of the first draft of the manuscript. LC, YL, WL, WC, LY, JZ, AG, ZL, and SG contributed to writing, reviewing, or revising the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Several studies identified low subjective feelings of power in women with anorexia nervosa (AN). However, little is known about implicit power motives and the discrepancy between explicit feelings of power and implicit power motives in AN.The study investigated the discrepancy between explicit feelings of power and implicit power motives and its relationship to anxiety in patients with AN.Fifty-three outpatients and inpatients with AN and 48 participants without AN were compared regarding subjective feelings of power and anxiety. Explicit power [investigated with the Personal Sense of Power Scale (trait focus) and a visual analog scale (state focus)], implicit power motives [investigated with the Multi-Motive Grid (MMG)] and trait anxiety [measured with the State-Trait Anxiety Inventory (STAI)], were assessed.Explicit feelings of power (state and trait level) were lower in patients with AN compared to non-AN participants. No differences in implicit power motives were found when comparing the groups against each other. However, looking at the groups separately, women with AN had similar levels of implicit fear of losing power and hope for power, whereas woman without AN had significantly lower fear of losing power than hope for power. Focusing on discrepancies between powerful feelings and power motives, results were mixed, depending on the subscale of the MMG. Lastly, discrepancies between implicit power motives and explicit feelings of power were positively correlated with trait anxiety in AN patients.These findings underline that individuals with AN display significantly lower explicit feelings of power, however, they show similar implicit power motives compared to individuals without AN. The discrepancy between explicit feelings of power and implicit power motives is related to anxiety in AN and may represent a vulnerability factor to illness maintenance. All patients had to be diagnosed with AN as defined by the DSM-5 criteria, determined by a semi-structured interview [SKID-5 cv ] by a clSD = 4.12), and mean BMI was 21.89 kg/m2 (SD = 2.73). Inclusion criteria were (1) no present psychiatric or somatic disorder and age over 18 years. Groups did not differ in age  but, expectedly, differed in BMI . Further demographic information such as trait anxiety scores, illness duration, number of previous hospital admissions and scores of the Eating Disorder Inventory-2 are presented in The control sample consisted of 48 women without AN, recruited via advertisement at Ulm University. In the control group, mean age was 22.58 years  to high power (=100). The VAS for the power scales was embedded between a scale assessing current energy level and strength to avoid priming the participants with the focus of the study.To investigate participants’ explicit state power, they had to indicate how powerful they felt at the present moment on a visual analog scale. They had to mark their answer with a pen on a line, ranging from hope for power (HP) and fear of losing power (FP). The HP dimension primarily represents an individuals predisposition to influence other people or to gain power and status over others  to almost always (=4). Sum scores can range from 20 to 80, with higher scores indicating higher anxiety. In our study the McDonalds ω was excellent (ω = 0.920) indicating that the trait scale was as an internally reliable measurement.The State-Trait Anxiety Inventory  is a widThe study was conducted in accordance with the Declaration of Helsinki and ethical approval was obtained from the Institutional Review Board of Ulm University (Protocol Nr 109/15). In a first step, participants were informed about the study procedure and signed an informed consent to take part. The AN patient sample was assessed in a separate, quiet therapy room of the outpatient clinics ANAD e.V., and TCE in Munich, as well as Schoen Clinic Roseneck in Rosenheim. The non-AN sample was tested in the laboratories of the Clinical- and Health Psychology Department of Ulm University. The participants completed the different questionnaires in their own time with the experimenter present. At the end of the study, participants received either course credit or monetary compensation.t-tests. Homogeneity of variance was tested using Levene’s Test. When the assumption of homogeneity was violated, Welch’s t-test was used. Regarding hypothesis 3, MMG scores and SOPS scores were z-standardized and then absolute differences between the z-scores were calculated . Group differences (AN vs. non-AN) in implicit and explicit power variables (hypothesis 1–3) were investigated using independent samples lculated . PearsonM = 3.35; SD = 0.78) showed significantly lower Personal Sense of Power (SOPS) values than women without AN , [t(88.888) = 8.136, p < 0.001, d = 1.726, see M = 21.08, SD = 20.64) than women without AN , t(97) = 4.786, p < 0.001, d = 0.972  = -0.289, p = 0.773, d = 0.058, (see t(99) = -1.472, p = 0.144, d = 0.296. Thus, the implicit power motives did not differ between groups (hypothesis 2).As expected, there was no significant difference between groups regarding the MMG hope for power dimension, 058, see  and no sM = 1.43, SD = 0.97) displayed significantly higher discrepancies between the MMG fear of losing power dimension and the SOPS than women without AN , t(99) = -2.157, p = 0.033, d = 0.434. No differences between the groups regarding discrepancies between the MMG hope for power dimension and the SOPS were found, t(99) = -1.027, p = 0.307, d = 0.206)   for the anorexia nervosa group  and the MMG HP/SOPS discrepancy and trait anxiety .Regarding hypothesis 4, there was a significant positive correlation between the MMG FP/SOPS discrepancy and trait anxiety (= 0.050)  as well sa group . No signr = 0.29, p = 0.035). No significant positive correlation between the MMG HP/SOPS discrepancy and the EDI-2 was found . Regarding the MMG FP variable on its own, it significantly correlated with the EDI-2 in the AN group .Exploratory analysis also revealed a significant positive correlation between the MMG FP/SOPS discrepancy and the EDI-2 in the AN group,  than the non-AN sample. In comparison, no differences between implicit power were found when comparing the groups against each other. However, looking at the groups separately, women with AN had similar levels of implicit fear of losing power and hope for power, whereas woman without AN had significantly lower fear of losing power than hope for power. Regarding the explicit- and implicit power discrepancies, results were mixed. Whereas there was a higher discrepancy between the Personal Sense of Power Scale and the MMG fear of losing power dimension in patients with AN, no significant differences were found regarding the discrepancy between the Personal Sense of Power Scale and the MMG hope for power dimension. Lastly, higher discrepancies between implicit power motives and explicit feelings of power were associated with higher levels of anxiety in patients with AN. No correlations were found regarding the non-AN sample.The finding that individuals with AN displayed lower explicit feelings of power is in keeping with previous research findings highlighting that women with AN report feelings of powerlessness during their illness . It alsoFurthermore, our finding showed that no differences between both groups were found for the implicit power motives, indicating that women with AN have similar predisposition to approach power and fear of losing power, as women without AN. Although no previous study used the MMG in an AN sample, our finding is congruent with studies that employed the MMG in other clinical samples, such as individuals with remitted major depression- and bipolar disorder  that alsRegarding discrepancies between implicit power motives and explicit feelings of power in AN, the results were mixed. The finding that women with AN showed a significantly higher discrepancy between their explicit feelings of power and the fear of losing power dimension of the MMG, compared to women without AN, is in keeping with our expectation. This finding is concerning, as discrepancies in implicit- and explicit motives have been linked to psychopathology and stress . As the Considering the findings further, individuals with AN did not show a significantly higher discrepancy between explicit feelings of power and the hope for power dimension of the MMG than women without AN. In this context, we found that the hope for power was significantly higher than the fear of losing power in the non-AN group. On the other hand, implicit approach tendencies toward power and the fear of losing power were similar in the AN group. Having similarly high levels of fear of losing power and hope for power has been described as a vulnerability factor for an approach-avoidance conflict . TherefoIn keeping with our prediction, the discrepancy between implicit power motives and explicit feelings of power was linked to trait anxiety, only in the AN group. This finding is in line with previous research highlighting that the discrepancy between implicit- and explicit motives is associated with anxiety in women with AN . This obTo our knowledge, this is the first study investigating discrepancies between explicit feelings of power and implicit power motives and their relationship with anxiety in AN patients. However, our research needs to be interpreted, considering some limitations. Firstly, our AN sample was heterogeneous. For example, the participants differed regarding the AN subtype, comorbidities , as well as stages of recovery (in- and outpatients). Therefore, the study could be replicated and refined differentiating between the subtypes of AN and comparing participants during the acute illness and after recovery. Secondly, these data are cross-sectional. They should be extended by experimental and longitudinal data such as an ecological assessment to understand how subjective feelings of power and/or power motives fluctuate .Furthermore, the investigation of the implicit power motive was based on the Multi Motive Grid by Regarding clinical implications, our study has highlighted that low explicit feelings of power (on the state- and trait level) are present in AN patients. They should be explored in therapy, as they could represent a vulnerability factor regarding disordered eating and illness maintenance. In a therapeutic context, one could for example track explicit feelings of power (state level) using the visual analog scale at different points during the day or during episodes of disordered eating . Doing this could underline the connection between the individuals’ incentive to obtain power and avoid feelings of powerlessness through disordered eating. As our exploratory analysis also revealed a significant positive correlation between the MMG FP/SOPS discrepancy and the EDI-2, future studies should put a particular focus on how motive incongruence could be linked to eating pathology. Furthermore, one could assess individuals’ discrepancies between explicit feelings of power and power motives before, during and after treatment, to get a better understanding of possible inner conflicts and whether therapy is successful in reducing this incongruence.To sum up, our data provide evidence that explicit feelings of power are lower in women with AN than women without AN. However, there seems to be no significant difference regarding implicit power motives when comparing the groups against each other. Looking at the groups separately, women without AN display a significantly lower implicit fear of losing power than hope for power. In women with AN, the fear of losing power is similarly high as the hope for power. Moreover, the discrepancy between explicit feelings of power and implicit power motives is positively associated with anxiety in AN. It seems worthwhile to focus on the assessment of power in AN patients and to develop interventions that can address feelings of powerlessness.The data that support the findings of this study are available from the corresponding author, (FW), upon reasonable request.The studies involving human participants were reviewed and approved by the Institutional Review Board of Ulm University. The patients/participants provided their written informed consent to participate in this study.FW, DS, GH, KL, AS, and OP conceptualized the research idea and planned the experiments. FW carried out the experiments. FW, DS, and AM contributed to data analysis. FW, DS, GH, AM, UV, and OP contributed to the interpretation of the results. FW, DS, and FD wrote the manuscript. All authors provided critical feedback and helped shape manuscript.UV, AM, and MK were employed by Schön Klinik. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The prevalence of metabolic syndrome in adolescents is increasing. Recently, the relevance of grip strength as a factor of metabolic syndrome in this population has raised questions. This study investigated the prevalence of metabolic syndrome according to grip strength in children and adolescents using large-scale data from the Korean National Health and Nutrition Survey (KNHNS). From 2014 to 2018, 1527 boys and 1292 girls participated in the KNHNS. The participants were classified into three groups according to age: 10–12 years , 13–15 years , and 16–18 years . The participants were classified as having metabolic syndrome if they fulfilled three of the adolescent metabolic syndrome criteria. The grip strength was divided into groups with high and low grip strength, respectively, and the cutoff value for the prevalence was calculated using receiver operating characteristic curve analysis. There were significant differences in waist circumference, high-density lipoprotein cholesterol, and triglyceride levels based on grip strength in the ET, MT, and LT groups. Therefore, the prevalence of metabolic syndrome was lower when grip strength was higher. The cut-off values of the relative grip strength (kg/body weight) to predict metabolic syndrome among boys were 0.349, 0.466, and 0.485 for the ET, MT, and LT groups, respectively. The corresponding cut-off values for girls were 0.373, 0.383, and 0.382, respectively. In conclusion, there is a non-linear relationship between grip strength and metabolic syndrome in adolescents. Metabolic syndrome (MetS) refers to abnormal metabolic function and includes factors such as high blood pressure (BP), diabetes, low high-density lipoprotein cholesterol (HDL-C), and high triglyceride (TG) levels. MetS is closely related to the occurrence of cardiovascular disease . The incThe main causes of MetS are low physical activity, obesity, and low muscle mass and strength accompanied by high caloric intake ,8,9. Then = 382), did not measure waist circumference, height, and weight (n = 4), and could not obtain blood samples (n = 432) were excluded from this study. In addition, those with missing data (n = 45) that cannot be used for data such as 0 were also excluded. Therefore, the data of 2819 participants (1527 boys and 1292 girls) were analyzed. The participants were classified into three groups by age: individuals 10–12 years old were classified as early teenagers (ET), those 13–15 years old as middle teenagers (MT), and those 16–18 years old as late teenagers (LT). To comply with research ethics, the purpose of the test and the use of the results for research purposes were explained, and the data of those who agreed were used. This study was approved by the research ethics committee of the affiliated institution (2015-01-02-6C). To investigate the association between MetS and grip strength by age in children and adolescents, 3689 people aged 10–18 years who participated in the Korea National Health and Nutrition Survey (KNHNS), 2014–2018, were included in this study. The participants were physically healthy elementary to high school students, and data were collected from all regions of Korea. KNHNS is a health dataset supervised by the Korea Centers for Disease Control and Prevention, and it checks the health status of participants by collating the current status and trend of the people’s health and nutrition according to the National Health Promotion Act. It is an important tool for evaluating health outcomes in this population. The inclusion criteria for this study were participants who underwent testing for all factors related to MetS, underwent grip strength measurement, and agreed with both specimen and data collection for this study. Those who did not perform grip strength due to hand or arm injury or other reasons . The test method and procedure were performed according to the American College of Sports Medicine test method . The parThis study used the criteria proposed by Cook et al.  to diagnThe participants stood with the feet 25–30 cm apart and comfortably maintained breathing while the examiner measured the waist circumference. The thickest part of the lowest position of the ribs and the highest position of the pelvis (iliac crest) were measured to 0.1 cm precision with a tape measure not pressing the skin .BP measurements were performed using a mercury sphygmomanometer according to standard guidelines . The parThe Participants fasted for at least 8 h before blood collection, and excessive physical activity was prohibited until measurement. Blood was collected mainly through the median cubital vein, and the total amount of blood collected was about 25–30 mL . The varp < 0.05). Therefore, the non-parametric statistics method was applied to compare the variables of the continuous variables in p < 0.05. This study was conducted as a cross-sectional design study.SPSS 25.0  was used for statistical analyses. The data did not form a normal distribution as a result of performing a normality test using Kolmogorov–Smirnov (p = 0.031) and 0.373  in boys and girls, respectively, and the prevalence of MetS in the low-grip strength group increased 4.908 times in boys and 3.748 times in girls. The cut-off values of the relative grip strength in the MT group were 0.466  and 0.383  for boys and girls, respectively. The incidence of MetS increased 3.421 times in boys with low grip strength and 4.257 times in girls with low grip strength. The cut-off values of relative grip strength for MetS in the LT group were 0.485  for boys and 0.382  for girls. The prevalence of MetS in adolescents with low grip strength increased 3.933 times in boys and 4.465 times in girls. The characteristics of MetS factors in participants with high and low grip strength are shown in The purpose of this study was to investigate the relationship between grip strength and the prevalence of MetS in adolescents according to age and sex. This study selected and analyzed grip strength as a predictive factor. Grip strength analysis is a tool to evaluate upper body strength and is the most economical and simple strength test . The griIn this study, indicators related to MetS were significantly different between adolescents with high grip strength and adolescents with low grip strength. Specifically, this phenomenon was observed with regard to waist circumference, HDL-C, and TG in both boys and girls. This is likely the effect of exercise and physical activity. Exercise and physical activity have a positive effect on waist circumference, HDL-C, and TG in adolescence . Lopes eWe observed significant differences in the prevalence of MetS according to grip strength. Previous studies have investigated the relationship between the relative grip strength and MetS in adult men and found that a higher relative grip strength was associated with a lower risk of MetS ,31. SimiOne of the unique findings of this study is that we identified the cut-off value of grip strength to predict MetS. Adolescents with high grip strength showed a low prevalence of MetS. In a similar study, Bang et al. showed that the ORs for MetS in inactive adolescents compared to adolescents who regularly performed physical activity were 1.115 for boys and 1.198 for girls . Garcia-It is necessary to take measures to prevent adolescents from developing MetS because the time to onset of chronic diseases can be accelerated in their 20 s to 30 s and can cause many health problems. In particular, early management of childhood obesity has been suggested as a way to prevent metabolic syndrome after growing age ,39,40.There are relatively few studies on the relationship between grip strength and MetS in adolescents; therefore, this study is rare. However, it has several limitations. This study limited the examination of physical strength to grip strength. A previous study found that examining lower extremity muscle strength using isokinetic equipment and lower teeth resulted in a stronger association with MetS, although that study examined only elderly participants . While oThis study classified adolescents into three age groups and studied the prevalence of MetS according to grip strength. The prevalence of MetS was low when grip strength was high. In particular, waist circumference, HDL-C, and TG levels showed statistically significant differences according to grip strength among male and female adolescents in all three age groups. In addition, the blood glucose level of MT girls also showed a significant difference based on grip strength, and the systolic BP of LT boys was significantly different based on grip strength. Education on risk factor management and appropriate physical activity are recommended for the prevention and management of MetS in teenagers.


Introduction: Medication error is unintentional and can be reduced by reducing the risk factors. Patients suffering from chronic diseases are at an increased risk of medication errors.Objective: This work aims to assess the risk factors associated with medication errors among patients suffering from chronic disorders in hospitals of South Punjab, Pakistan.Methodology: Multiple logistic regression analysis was used to assess the impact of different risk factors on the prevalence of medication errors in patients suffering from chronic diseases.Results: A greater risk for the occurrence of medication errors was associated with age ≥60 years , overburdened healthcare system , number of prescribed drugs ≥5 , comorbidities , Charlson comorbidity index , and multiple prescribers to one patient .Conclusion: Older age, overburdened healthcare system, number of prescribed drugs, comorbidities, Charlson comorbidity index, and multiple prescribers to one patient are significant risk factors for the occurrence of medication errors. A medication error may be defined as “failure in drug therapy that may result in harmful effects to patients.” It is a serious concern especially in low- to middle-income countries and can result in an increased risk of drug–drug interactions, elevate the frequency of hospital admissions and outpatient visits, prolong the length of hospital stay, increase the management cost, and elevate the mortality risk –3. MedicMedication errors result in substantial economic burden on patients and the healthcare system due to an increase in the cost of treatment . The ecoDifferent studies reported 5.4 to 66% medication errors in prescribed therapy in outpatients and hospital-admitted patients –14. The Chronic diseases cause substantial economic burden and are major causes of morbidity and mortality –20. Two-Finding the factors associated with medication errors and effective strategies to prevent errors can help healthcare professionals to identify and manage medication errors. It can also reduce the economic and humanistic burden due to medication errors. Few studies assessed the relationship between medication errors and specific factors such as patient age, number of prescribers, frequency of hospitalization, length of hospital stay, cost of hospitalization, mortality rate, number of drugs prescribed, and review of prescription by a pharmacist or specialist –27. MoreThis study was a cross-sectional, observational, prospective one that included 803 patients from outpatient medical wards of 17 public and private hospitals  in different areas of South Punjab, Pakistan. The hospitals were included from all regions to obtain a representative sample. Purposeful sampling was done by including 45 patients from each hospital. Patients were included in the study if they had any disease listed in the Charlson comorbidity index (CCI), visiting outpatient for routine follow-up, prescribed with at least two drugs, age above 20 years, and with available medical records. Patients with diseases other than listed in CCI were excluded. Systematic random sampling method was used to avoid biases. Every third patient visiting the outpatient clinic was invited to participate in the study. The study protocol was approved by the Research and Ethics committee of the Faculty of Pharmacy, Bahauddin Zakariya University, and the concerned hospitals (registration no. Bzbp-18-4207). Written informed consent was obtained from all the participants.A self-developed questionnaire was used to collect the patients' demographic data, socioeconomic status, clinical condition, diagnosis, names, number and doses of prescribed medicines, self-medication, if any, route of administration, appropriate drug selection, drug–disease interaction, and drug–drug interactions. The data collection form was filled after physician consultation. Medication errors were defined as inappropriate dose (dosage too low or too high), invalid indication , drug duplication (multiple drugs for the same condition), inappropriate dosing frequency (too short or too long dosing frequency), longer duration of drug therapy than recommended, and drug–drug interactions (combination in the prescription which is prohibited or may cause harm to the patient) . A patieFor identification of medication errors, Pharmacotherapy: a pathophysiologic approach, 7th edition, Lexicomp Drug Information Handbook, 22nd edition, Harrison's principles of internal medicine, 17th edition, and Applied therapeutics: the clinical use of drugs, Uptodate®2009, were used. The possible potential hazardous combinations of drugs were evaluated using a drug interaction software, Micromedex®  . For fixp < 0.02 were included in the multiple regression model. Odd ratios were used to assess the influence of different risk factors. The Hosmer–Lemeshow test was used to check the goodness-of-fit of the model. A p-value of 0.05 or less was considered as statistically significant. All analyses were performed using SPSS version 24.0 .Frequencies and percentages were reported for categorical variables, and mean and standard deviation were reported for continuous variables. Normality of the data was checked using Shapiro–Wilk test of normality. To assess the face validity, a committee of experts including two academician, two medical practitioners, and a clinical pharmacist critically reviewed the questionnaire. Internal consistency of the questionnaire was assessed based on the value of Cronbach's alpha coefficient. Internal consistency is considered as excellent if Cronbach's α is ≥0.9, strong if Cronbach's α is ≥0.8, acceptable if Cronbach's α is ≥0.7, and reasonable if Cronbach's α is ≥0.6 . UnivariOut of 803 patients, 41.09% were male and 58.91% were females. The mean age was reported as 48.34 (9.4) years. The average number of medicines per encounter was 5.23 (2.8). More than five drugs were prescribed in almost 73.12% patients. The questionnaire showed good reliability with Cronbach's alpha coefficient value of 0.71. The most frequent diagnosis was diabetes mellitus (38.27%), followed by myocardial infarction (28.78%), peripheral vascular disease (22.54%), peptic ulcer disease (21.23%), liver disease (17.32%), congestive heart failure (13.43%), COPD (11.23%), hemiplegia (9.23%), moderate to severe chronic kidney disease (9.2%), connective tissue disease (6.3%), cerebrovascular disease (6.2%), dementia (3.9%), solid tumor (2.3%), malignant lymphoma (1.2%), and leukemia (0.12%). The demographic and clinical data of patients are shown in p < 0.1) were added in the multiple logistics regression. The odds ratio (OR), 95% confidence intervals, and p-value for the independent variables included in the multiple logistic regression are presented in p = 0.001), overburdened healthcare system , number of prescribed drugs ≥5 , number of comorbidities , CCI score , multiple prescribers to one patient , and trainee practitioner .Independent variables showing a significant relationship with medication errors in univariate analysis (p = 0.7), prescription by a specialist , presence of previous medical record , use of online software in prescription generation , and review of prescription by a clinical pharmacist .The association was not significant with the patients' gender  between observed and predicted probabilities in the Hosmer–Lemeshow test and a significant difference (p < 0.001) between observed and predicted probabilities in the goodness of fit model test.The logistic regression model showed an accuracy of 64.73%. The logistic regression model showed good model fit, as demonstrated by the non-significant difference  can overcome this issue. IT can be used to learn about potential drug-related events, to check a prescription for potential DDIs, and to get access to a patient's medical records . A previDue to the increasing cost of healthcare services, there is an urgent need to consider medication errors in routine clinical practice to reduce the burden on the healthcare system. Reduction of complexity in the act of prescribing by the introduction of automation improves a prescriber's knowledge by education, use of online aid, feedback control systems, and monitoring of the effects of interventions that can help in the reduction of medication errors. Most of the medication errors are preventable; medication review of the prescriptions by an experienced healthcare professional can detect these errors, and reconciliation can help remove such errors before these reach the patient.This study is the first to investigate the risk factors for medication errors in chronic disease patients visiting as outpatients for regular follow-up. Currently, there is no system in South Punjab to report medication errors. Therefore, policy makers and healthcare providers are encouraged to develop and implement medication error reporting forms. Despite several strengths, few limitations should be kept in mind before interpretation of the results. This study was conducted in a specific population (patients suffering from chronic diseases), so its results should be generalized with caution, but it can be assumed that the results found in this study can be generalized to chronic disease patients. Moreover, the frequency of potential medication errors was assessed, but their impact on other outcomes like outpatient visits, hospital admissions, and quality of life was not assessed. In a detailed study, the impact of medication errors on patient-relevant endpoints such as health status, quality of life, and hospital admissions should be assessed.A greater risk for the occurrence of medication errors was associated with older age, overburdened healthcare system (≥20 patients in 1 h), higher number of drugs in a prescription, comorbidities, multiple prescribers to one patient, and trainee practitioner. The risk was not significantly associated with a patient's gender, prescription by a specialist, presence of previous medical record, use of online software in prescription generation, and review of prescription by a clinical pharmacist.Due to the increasing cost of healthcare services, there is an urgent need to consider medication errors in routine clinical practice to reduce the burden on the healthcare system. Reduction of complexity in the act of prescribing by the introduction of automation, improving the prescriber's knowledge by education, use of online aid and feedback control systems, and monitoring the effects of interventions can help in the reduction of medication errors.Knowledge about the risk factors of potential drug–drug interactions and designing and implementing strategies to control them can reduce the economic and humanistic burden due to drug-related events.The datasets generated for this study are available on request to the corresponding author.The study protocol was approved by the Research and Ethics committee of Faculty of Pharmacy Bahauddin Zakariya University and the concerned hospitals (registration no. Bzbp-18-4207). The patients/participants provided their written informed consent to participate in this study.MR, AR, II, SA, IK, SShah, GA, SShak, MA, and KH made substantial contributions to the conception and design of the study and the analysis and interpretation of the data. MR and AR made substantial contributions to the analysis and interpretation of the data. All the authors drafted the work or revised it critically for important intellectual content, reviewed, critiqued, and approved the final version submitted for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Well-being in youth sport is a growing topic in literature. Practicing sports at a youth level is recognized as an important opportunity for growth and development but also an experience that conversely can prove to be tiring and cause discomfort. Sometimes expectations and pressures make it a risky experience. This is emphasized even more when looking at very popular and spectacular sports, such as football in some European Countries; practicing football often solicits the hope of becoming champions one day and thus being able living thanks to the beloved sport. How do young Italian football practitioners feel? What role do relationships with significant others belonging to the world of sport and extra-sport play on the well-being of young athletes? On which specific aspects of psychological well-being (PWB) are these relationships based? Are there any differences between elite and amateurs levels? These are the questions upon which this paper focuses, considering a sample of young Italian football practitioners. Analysis reveals a strong and positive influence of some dimensions of the relationships with significant others on PWB, specifically team effort, coach closeness, and parental learning climate. Moreover, elite players perceive significantly better relationships than sub-elite and amateurs and have significantly higher levels of PWB. Those results provide a first evidence for the importance of good relationships within and outside sport for an effective development of youth football players since they positively influence players’ PWB, which is higher in elite players. It emerges the necessity to further investigate different aspects of PWB and to deepen the knowledge about the meaning of relationship in developmental athletes according to a psychosocial approach. Practicing a sport, especially at a young age, can involve meetings and formative experiences or vice versa turn out to be a tiring experience and can sometimes also a cause of deep discomfort if not managed well —relationThe increasing demands from the sport setting during the developmental years of athletes challenge them with always increasing pressures, like more and more hours of training and competitions , along wFor this reason, deepening the theme maintaining a focus on the well-being of young athletes seems relevant in coherence with a holistic perspective, and specifically with the psychosocial approach, which emphasizes how the well-being or malaise of each person is influenced by his life context and in particular by the quality of relationships with people significant to him/her.How do young Italian football practitioners feel? What role do relationships with significant others belonging to the world of sport and extra-sport play on the well-being of young athletes? On which specific aspects of psychological well-being (PWB) are these relationships based? Are there any differences between elite and amateurs levels?Using a psychosocial approach , the preBefore presenting the empirical study, the state of the art of literature on the subject will be briefly presented.multidimensional model of PWB, which includes six dimensions  have been identified as one of the most important resources for young athletes’ development since In summary, literature highlights that the well-being of athletes is a dimension studied especially among elite athletes  and studThe proposed study aims to make a contribution to the understanding of the well-being of young players within the Italian context with the particular focus not so much on the influence of a specific relationship , but on the intertwining, the set of different relationships. In our study, we tested the influence of relationships with significant others on the PWB of youth football players, comparing players of different competitive level , to identify possible differences.N = 127), two semi-professional  and four amateur (N = 128) Italian youth soccer academies, aged between 14 and 20 years , mainly situated in the north of Italy , while a minority were foreign (8.4%) or had dual nationality (2.4%). Most players lived with their parents (87.6%), a minority in a specific residential structure provided by the club (6.7%) or with one parent (4.3%).Participants were asked to give details about their age, month of birth, nationality , siblings, parental educational level, and some details related to sport, like sports practiced in the family, other sports practiced in the past, sports practiced by siblings, and current injuries.Psychological well-being was measured using Ryff’s PWB Scale . Ryff’s The Coach–Athlete Relationship Questionnaire  is used The 21 version of the Peer Motivational Climate in Youth Sport Questionnaire  was usedWe used the Parent-Initiated Motivational Climate Questionnaire . It is mAfter gaining the approval from the ethical commission of the university, professional, semi-professional, and amateur soccer clubs were contacted in different ways, but all thanks to the personal knowledge of the Italian authors of the present work. After the club’s formal acceptance, a presentation of the research  was sent by email. Managers used it to present the research to parents and coaches and give contacts for the researchers in case of questions from the participants. After gaining informed consent from participants or their parents, a session of group data collection was organized for each team before or after one of the weekly trainings. Before each data collection session, the researcher explained to the players the main aims of the research and the main tasks required . The total duration of each data collection session was between 30 and 45 min.Using SPSS 20.0 , we testStructural equation models (SEMs) are used in the analysis of behavioral data, as they make it possible to study the interrelationships between different latent factors and observed variables. They are particularly suitable for testing complex models in which the interactions provide for the inclusion of multiple variables and the presence of latent variables that cannot be measured directly. We adopted SEM because instead of studying singularly the impact of each relationship on PWB as in previous studies, we wanted to connect all the relationships with significant others and study their overall impact on the PWB of athletes. The SEM we tested using Mplus 7.11  is drawnTo identify potential differences among the three competitive level groups  on the dimensions investigated , we performed an ANOVA using SPSS 20.0.2(48) = 100.635; p < 0.001; RMSEA = 0.051, p < 0.001; CFI = 0.924; WRMR = 0.912]. Factor loading of the remaining factors are between 0.30 and 0.77 and significant (p < 0.001).The PWB scale shows a non-normal distribution for some items: this could be imputed to the four-point Likert scale, which could lead to a positive–negative polarization of responses, found also in other works ; therefo2(41) = 136.473; p < 0.001; RMSEA = 0.075, p < 0.001; CFI = 0.940; SRMR = 0.043]. Factor correlation is between 0.93 and 0.97, and this could indicate collinearity problems between factors: the literature reveals a high correlation among those dimensions, and many studies try to validate a single factor structure without obtaining satisfactory results (2(122) = 220.649; p < 0.001; RMSEA = 0.044, p < 0.001; CFI = 0.941; SRMR = 0.069]. Factor loadings were between 0.35 and 0.75 and significative (p < 0.0001). Finally, for the Parent-Initiated Motivational Climate Questionnaire, the CFA reveals only two motivational climates emerged as reliable in our sample; therefore, we only considered a double factorial solution, composed of the learning/enjoyment climate and worry conductive climate (by father and by mother). Fit indices for this model were acceptable . All results of the CFA are reported in The CFA for the Coach-Athlete Relationship Questionnaire shows a good internal consistency  (see The model fit information (reported in 049] see . The imp049] see .p < 0.05), as well as team competitiveness .Factor loading results see  show thaAll in all, results confirm our hypothesis about the importance of relationships for the well-being of young athletes. In particular, there are some very specific features within the relationships with significant others that positively impact on athlete’s PWB, specifically on self-acceptance and meaning in life dimensions.A comparison between the three competitive groups  was performed by an ANOVA see –25. NextF = 11.143, p < 0.001, autonomy, F = 9.943, p < 0.001, and composite PWB, F = 10.601, p < 0.001; parental worry motivational climate F = 6.463, p < 0.002 and parental learning motivational climate F = 6.174, p < 0.002, coach–athlete closeness F = 6.041, p < 0.003, and finally ANOVA on peer motivational climate show a difference only in intrateam conflict, F = 7.601, p < 0.001.ANOVA results were significant for the following dimensions: meaning in life, Post hoc test (HSD Tukey) reveals that composite PWB in elite  is significantly higher than amateur ; autonomy in elite  is significantly higher than amateur ; meaning in life in elite  is significantly higher than amateur . For the dimension intrateam conflict, results show that amateurs  were significantly higher than elite . For the coach–athlete relationship, we obtained a statistically significant difference only in the dimension of closeness, where amateurs  were only lower than subelite . Finally, regarding parent-initiated motivational climate, amateurs  were significantly lower than elite  on the worry motivational climate and also on the learning motivational climate, where amateur  were lower than elite  . In the future, it could also be interesting to deepen the qualitative study of the meanings of well-being for this specific category of athletes.Therefore, the study also shows some limits. The sample involved in the data collection is made of players from clubs situated mainly in the north of Italy: this could influence the representativeness of the sample with respect to the Italian population. Moreover, the literature has suggested some differences in males and females’ perceptions of the motivational climate induced by parents . It coulThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Commissione Etica per la Ricerca in Psicologia (CERPS) of the Catholic University of the Sacred Heart, Milan. Written informed consent to participate in this study was provided by the participants, and where necessary, the participants’ legal guardian/next of kin.ER, CD’A, and CG conceived the study and the hypothesis. ER collected the data and run the analysis. CD’A and ER wrote the first draft of the manuscript, while CG and ML supervised the work. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The EG and CG performed the INT program and traditional PE activities two times per week within the first ~15 min of PE class, respectively. The Fitnessgram battery tests assessed the HRF  before and after the program. After eight weeks, the EG significantly reduced all fat measures, while the CG decreased only triceps skinfold but to a smaller extent . Both groups significantly improved the performance of almost all muscular fitness tests ; however, the EG increased the push-ups more than the CG . The EG additionally improved the modified pull-ups  and flexed arm hang  tests. The flexibility and cardiorespiratory endurance of both groups did not significantly change after eight weeks. This approach of exercise showed positive acceptance and relatively good results after only eight weeks. Integrated neuromuscular training (INT) showed benefits for improving fundamental movement skills (FMS). However, the INT health-related fitness (HRF) effects are lacking. The current study aimed to determine the effects of INT implemented during physical education (PE) in a primary school in the Republic of Serbia on HRF in female children. The sample consisted of 72 healthy girls who were divided into the intervention (EG:  Childhood is a sensitive period of life, characterized by dynamic changes in physiological and psychological development, as well as the establishment of healthy or unhealthy behaviors . In the Although Current National and International Youth Physical Activity Guidelines recommend that children accumulate a minimum of 60 min of moderate to vigorous physical activity (MVPA) daily, research indicates a timing match between the global decline in MVPA and physical fitness of children and adolescents ,8. FaigeChildren spend many hours in school, and physical education (PE) is the only subject in school that allows students to develop physical fitness and understand physical activity. It is one of the key factors for improving the quality of life and society as a whole ,13. SchoIntegrated neuromuscular training (INT), includes general activities , specific activities (exercises targeted to motor control deficits), and strength and conditioning exercises  designed to enhance health and the skill-related component of physical fitness in children and youth ,22. INT The problem of insufficient and inadequate physical activity has been constantly reported in schools in Serbia whilst reaching national proportions  and moreIn Serbia, this, or similar models of a holistic approach to exercise, especially in school conditions, have not been implemented so far, which is why the contribution of this research is even greater. Therefore, the current study aims to determine the effects of INT implemented during PE in a primary school in The Republic of Serbia on HRF in female children.n = 37) and control . All participants attended the standard school program during the day [This randomized controlled clinical trial consisted of 72 healthy girls  from the the day . The incParents were informed of the purpose and the risk and benefits of the study at the parent-teacher meeting and were required to confirm their child’s participation in the study with the written consent. This study has been approved by the Institutional Review Committee of the University of Novi Sad (Ref. No.46-11-08/2020-1) and it was conducted under the Declaration of Helsinki.N = 66) given the critical F = 3.99, an effect size f = 0.18, p = 0.05, 1-β = 0.8, groups and time points = 2, and corr = 0.5.G*power 3.1 power analysis software  determined the minimum sample size . The study began in September 2019 and was completed in December 2019. Physical performance testing was conducted in the morning at the school gym. The participants were informed about the purpose and the technique of the tests and were given clear instructions on how to do the tests precisely, quickly, and consistently, following the factor being measured. All the tests were carried out by professors of PE and sport science. Each examiner would be responsible for measuring the same test at the initial and final measurement to avoid the influence on the measurement results. On the first day, body composition was measured, followed by flexibility, muscular fitness. The second day was measured cardiorespiratory endurance. On the testing day, the subjects will strive to feel comfortable, dressed in shorts and T-shirts suitable for a simple way of measuring and testing, as well to wear their shoes or to be barefoot, depending on the needs of the tests.HRF was assessed using a Fitnessgram battery of tests ,41. Belo2).Body composition was measured according to the standardization of the International Biological Program . Body heFlexibility  is measuMuscular fitness  is measuCardiorespiratory endurance  is measuThe program used in this study was specifically designed for primary school children and was based on previous reports ,44,45, cParticipants performed all the exercises with a Pilates ball (diameter 25 cm). The exercises were presented by PE teachers and were conducted twice a week during the first ~15 min of regular 45 min PE class. The INT program began with a dynamic warm-up with the ball that lasted 2 min. Primary exercises were performed with high intensity in 2 series with a progressive increase in the number of repetitions from 7 to 10 during 8-weeks. Plank exercise starts with an endurance of 10 s and progressively increases to 30 s. To make the exercises challenging and fun, and to avoid the monotony of exercise, the primary exercises, one they could, were performed periodically added a slight modification, but care was taken that the function of each exercise remained the same . Secondary exercises were performed with lower intensity in 1 series with a progressive increase in performance from 15 to 30 s. Over the 8-week INT period, the secondary exercises prospered from simple to complex, to increase neuromuscular stimulation. We assessed warm-up intensity using the Borg rate of perceived exertion (RPE) scale (1–10), and external signs . Each session after warm-up, the girls rated their perceived exertion as moderate/vigorous (RPE 3–6). After the INT program, the girls participated in traditional PE activities .The CG included the implementation of traditional PE classes according to the Curriculum for the first and second grades of primary education. In the The ID numbers were assigned to each girl to preserve confidentiality by the principal investigator, and the data were collected, processed, and kept in compliance with General Data Protection Regulation.η2) and partial eta squared  × 2 (pre-test vs. post-test) mixed ANOVA was used to evaluate the INT effects on the HRF after eight weeks. A group*time interaction effect was the primary hypothesis of interest, while a simple main effect of time was used to estimate mean changes  after eight weeks for each group. Eta squared (e (0.14) .p = 0.01), body fat (p = 0.02), and trunk lift performance (p = 0.02) of EG were significantly higher compared to the CG. The CG, however, had a significantly higher mean performance of push-up (p = 0.05) and flexed arm hang (p < 0.01) than the EG. Groups did not differ in the remaining outcomes  and triceps skinfolds  and percent of body fat . The CG significantly decreased only triceps skinfold  for the same period, but larger decreases were observed in the EG . Visit After eight weeks of INT program, the EG significantly reduced all fat measures, calf , trunk lift , push-ups , respectively. The EG, however, increased mean performance of push-ups more than the CG . Moreover, the performance of modified pull-ups  and flexed arm hang  only increased in the EG. Mean performance of sit-and-reach (both legs) and one mile run-walk tests remained unchanged. The EG and CG significantly improved performance of almost all muscular fitness tests, curl ups (This study demonstrates the school-based INT program’s effects on selected HRF performance and anthropometric measures in prepubertal girls, assessed with a well-known and reliable Fitnessgram Testing Battery . The stuIn general, most studies examine INT’s sport-related benefits among prepubertal kids, where only a few studies examine INT’s effects on prepubertal children’s development in school ,16,25. FOne of the main findings in our study was a core and upper body strength improvement. Core strength and stabilization are fundamental to maintaining spinal integrity and body control during sports activities ,51. KnowIn this study, we examined only prepubertal girls, which makes this sample unique. It is encouraging to confirm our findings with others. The prepubertal period is susceptible and important for child development, motor skill learning, and represents the foundation for a healthy adulthood. At this age, the brain’s neuroplasticity opens a window of opportunity to develop and reinforce FMS ,56. LackThis study has a few limitations. First, the duration period of 8 weeks seems short, and maybe a longer intervention could provide even more significant results. Second is the motivation and willingness of children to perform throughout the testing. Finally, mediating factors such as children’s physical activity and/or daily energy expenditure should also be considered to provide unbiased INT effects. Although it has few limitations, this kind of innovative program tends to be effective among prepubertal girls.INT is an interesting exercise approach, easily feasible and highly effective. It could bring multiple benefits such as improved HRF and neuromuscular control. This exercise approach has shown positive acceptance and relatively good results after only 8 weeks of intervention. Future research should examine INT’s long-term effects on a larger sample size in a mission to improve HRF.