Ruminococcus, Eubacterium, and Prevotella and a lower number of bacteria belonging to the genera Bacteroides, Parabacteroides, Roseburia, Dialister, and Akkermansia. Recently, many studies have focused on treating GDM with methods targeting GM. Several previous studies have analyzed the effect of probiotics on the course of GDM, but their data are inconclusive. In view of this state, the aim of the study was to collect and comprehensively discuss current knowledge regarding the role of probiotic supplementation in preventing and treating GDM. According to the analyzed data, probiotics have a positive influence on glycemic control and are a promising tool for lowering the frequency of GDM. However, further studies must be conducted to determine the optimal model of probiotic therapy  in pregnant women with GDM.Gestational diabetes mellitus (GDM)is one of the most common perinatal pathologies, with a prevalence of 5–20% depending on the population or diagnostic standards. It is diagnosed when glucose intolerance is first detected during pregnancy. In the pathogenesis of GDM, genetic, environmental, and pregnancy-related factors (excessive fat storage and increased adipokine and cytokine secretion) play important roles. A growing amount of scientific data has indicated the role of gut microbiota (GM) dysbiosis in the development of glucose intolerance during pregnancy. Previous studies have indicated that, in comparison to healthy pregnant women, GDM individuals have a greater abundance of bacteria belonging to the genera  The necessity of providing an ideal environment and optimum conditions for a developing fetus induces many anatomical and metabolic changes in maternal physiology. In the first few weeks of pregnancy, significant changes can be observed in the circulatory system, the respiratory system, and kidney function. To meet the growing cellular demand for oxygen and nutrients, blood volume increases, which entails an increase in heart output (by around 40%), heart rate, peripheral vasodilatation, stroke volume by up to 30%), hydrostatic capillary pressure, and renal and uterine flow. As the increased red blood count is not as intense as the changes in the circulating blood volume, many pregnant women develop anemia. The pregnancy period is also characterized by a progressive decrease in platelet count and a hypercoagulable physiological state , pregnan0%, hydroUp to a point, insulin sensitivity impairment is compensated for by an increase in insulin production by pancreatic beta cells, but in women with impaired glucose tolerance, this mechanism is insufficient to protect against the development of further disturbances in carbohydrate metabolism . EnvironGDM is diagnosed when glucose intolerance is first detected during pregnancy . GDM is Hyperglycemia in pregnancy has serious and long-term clinical implications for the mother, the fetus, and the future of the newborn baby. The most common is macrosomia, which can lead to other perinatal complications, such as preeclampsia, elevated risk of Cesarean delivery, fetal death, birth injury (shoulder dystocia), and respiratory distress . PreviouRoseburia intestinalis and Faecalibacterium prausnitzii [The gut microbiota (GM) isa vast collection of microorganisms composed of bacteria, fungi, archaea, and viruses inhabiting the gastrointestinal tract. They form a complex ecosystem involved in, for example, harvesting energy, metabolizing nutrients and drugs, synthesizing vitamins, defending against inflammation, and protecting against pathogens ,21. The usnitzii .Numerous studies have been conducted during the last two decades to compare the GMs of GDM and healthy pregnant women . A depleRuminococcus, Eubacterium, and Prevotella and a lower number of bacteria belonging to the genera Bacteroides, Parabacteroides, Roseburia, Dialister, and Akkermansia. Ruminococcaceae is involved in energy metabolism, insulin signaling, and inflammatory processes, and an increase in the relative abundance of Ruminococcaceae correlated with fasting glucose concentration and IR ledto a greater risk of GDM development [Blautia and Eubacteriumhalliigroup and depletion of Faecali bacterium, Subdoligranulum, Phascolarctobacterium, and Roseburia. Bacteria belonging to the genus Faecalibacterium were found to be important producers of short-chain fatty acids (SCFAs), especially butyrate, that promote β-cell differentiation and proliferation, improving insulin resistance [Feacali bacterium was negatively correlated with the fasting blood glucose level, while the number of Blautia was positively correlated with the fasting blood glucose level. What is more, the study showed that changes in the GM may lead to GDM development by deregulating the peroxisome proliferator-activated receptor (PPAR) signaling pathway, the insulin signaling pathway, and the adipocytokine signaling pathway [Blautia, Butyricicoccus, Clostridium, Coprococcus, Dorea, Faecalibacterium, Ruminococcus, and Lachnospiraceae (reduced numbers) and of Collinsella and Rikenallaceae (increased numbers) and GDM development has also been proved [p < 0.001), elevated Firmicutes, and reduced numbers of Bacteroidetes and Actinobacteria. A higher ratio of Bacteroidetes to Firmicutes correlates with increased plasma glucose levels [Feacalibacterium and fasting blood glucose; between Collinsella (directly) and Blautia (inversely),insulin, and HOMA-IR; and between Sutterella and C-reactive protein levels [In a study by Cortez et al. , in compelopment . A studysistance . In a stsistance , the num pathway . SCFA de pathway . A relatn proved ,30. Impon proved  showed te levels . Addition levels . Disturbn levels .In view of this context, the aim of this study was to collect and comprehensively discuss current knowledge regarding the role of probiotic supplementation in GDM prevention and treatment.In this review, we included original studies on probiotic supplementation in GDM involving human subjects and published in English from 1 January 2010 to 30 July 2022 (a study from 2008 was added because it was related to a study from 2010).The eligibility criteria were as follows: (1) the studies were randomized controlled trials (RCTs) comparing probiotics with placeboes, but we did not exclude interventions based on probiotics along with other supplements; (2) diagnostic criteria for GDM included International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, Carpenter and Coustan criteria, and the criteria of the Fourth International Workshop–Conference on Gestational Diabetes Mellitus, but we did not exclude articles in which pregnant women were stated to be diagnosed with GDM but no diagnostic criteria were described; (3) the women were ≥ 18 years old; (4) the treatment duration was more than7 days; (5) the study group had over 10 participants. Only human studies were eligible; animal studies were excluded.During the research, articles with data duplication, studies not meeting the inclusion criteria , and studies with inadequate information were removed.Two reviewers (M.M. and K.K.) independently completed screening, data extraction, and quality assessment. In all, 96 records were retrieved. The “human species” criterion was added using automation tools, and 14 studies were removed. After the abstracts were read (W.B. and K.K.), another 21 studies were removed. The screening process was performed mechanically by checking the date of publication, GDM diagnosis, and the intervention protocol. The articles were browsed through and another48 were eliminated, including 1 study from 2008.The process left us with 12 studies that we included in our analysis.This review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed and Web of Science  were searched to identify eligible studies. The following keywords were used: “gestational diabetes mellitus” or “GDM” or “glucose” or “HOMA” or “insulin resistance “or “gestational diabetes” AND “pregnancy” or “maternal” or “pregnant” or “gestational” AND “probiotics” or “Lactobacillus” or “Bifidobacterium” or “probiotic”. The primary outcome was the influence of probiotic supplementation on the prevention and treatment of GDM (improvement in the glucose level).Probiotics are live microorganisms that bring health benefits to the host when administered in appropriate amounts . The rolLactobacillus rhamnosus HN001 from early pregnancy, without additional changes in the patient’s diet, on the incidence of GDM. It was a two-center, double-blind, randomized, parallel, placebo-controlled trial that eventually enrolled 423 pregnant women with a personal or partner history of atopic disease. Women were assigned to groups at 14–16 weeks of gestation. GDM diagnosis was a secondary outcome, and the women were assessed for GDM at 24–30 weeks of gestation. Lower relative indices of GDM (as defined by IADPSG criteria) were found for the L. rhamnosus group . L. rhamnosus was associated with a lower percentage of GDM in women ≥35 years old  and in women with a history of GDM . However, these indicators were not significantly different from those of women without these issues. According to the definition provided by the New Zealand study, the frequency of GDM was significantly lower in the L. rhamnosus HN001 group—i.e., 2.1% —than in the placebo group (p = 0.03); i.e., 6.5% .The results of the study indicate that the probiotic L. rhamnosus HN001 at a dose of 6 × 109 CFUs per day could reduce the incidence of GDM by almost 40% according to the guidelines of IADPSG, especially among women over the age of 35 and those with prior GDM, or by up to 69% according to the New Zealand GDM diagnosis guidelines [A study from New Zealand published in two papers  ,38 invesidelines ,38.n =144). It assessed the influence of myo-inositol and probiotic supplementation  on the incidence of GDM in women with three or more risk factors for developing GDM (according to IADPSG criteria). The control group consisted of women undergoing regular prenatal care without supplementation with the above ingredients. The patients were matched according to age and body mass index (BMI). After the intervention, the frequency of GDM in the supplemented group was 29.2% and, in the control group, it was 47.9% . The study concluded that supplementation with myo-inositol and probiotics starting at 12–14 weeks of pregnancy reduced the incidence of GDM in Mexican women [Another study that showed promising results was conducted on Mexican women  were assessed (n = 256). Two intervention groups received dietary advice; one took a placebo and the other a probiotic. The control sample consisted of women who were not given dietary advice. The results showed that the use of probiotics reduced the incidence of GDM. In total, GDM occurred in 13% of the women in the probiotic group, in 36% of the women in the placebo group, and in 34% of the women in the control group (p = 0.003). The risk of GDM was significantly reduced in the diet/probiotic group compared to that in the control group , while in the placebo group, the risk was not significantly different from that in the control group  [p = 0.025) and at12 months after childbirth .It turned out to be the lowest in the group that took probiotics. This group was also at the lowest risk of increased plasma glucose levels (p =0.013). Some of the subjects (45%) passed the glucose tolerance test. The probiotic group had the lowest incidence of pathological results. The group also showed improved insulin sensitivity compared to the control group (without dietary intervention) and the placebo group  and HOMA  and the highest quantitative insulin sensitivity check index ) in the last trimester of pregnancy. Diet has a huge impact on the microbiome and on certain diseases, such as GDM. Due to the lack of a control group with nutritional advice, the differences in the results cannot be clearly attributed to probiotics. The study seems to be promising, but it is not known exactly what influenced the results—nutritional recommendations, probiotics, or a combination of both [A study by Luoto et al.  also sug= 0.823) . In exac of both .Despite various studies confirming the efficacy of probiotics in preventing GDM ,39,40,41L. rhamnosus (LGG) and B. animalis subspecies lactis (Bb-12)) with a placebo in the prevention of GDM in overweight and obese pregnant women (n = 411) in Brisbane, Australia. Ultimately, GDM occurred in 12.3% of the patients (25 out of 204) in the placebo group and in 18.4% of the patients (38 out of 207) in the probiotic group (p = 0.10). In the OGTT conducted during the study, mean fasting blood glucose was higher in women randomized to the probiotics group compared to the placebo group . A similar dependence was noticed in the measurements in the first and second hours of the test. In the study, the results of the probiotic group and the placebo group were similar, showing that probiotics did not prevent GDM in overweight and obese Australian women [Callaway et al.  conductean women .10 CFUs each of L. rhamnosus HN001 and B. animalis ssp. lactis 420. The percentage of women with GDM and the changes in glucose, insulin, or HOMA2-IR concentration did not differ between the intervention groups (p > 0.11 for each comparison). Thus, the study did not show any effectiveness of probiotics (neither fish oil nor a combination of both) in preventing GDM [Another study   that didting GDM .Lactobacillus salivarius UCC118 at a dose of 109 CFUs was used. In the study, no significant difference in the change in fasting glucose of women was found between the probiotic and placebo groups ,nor any significant differences in the incidence of GDM and IGT. Ultimately, there were 6 cases of GDM (3 cases from each group) and 15 cases of IGT (7 cases in the probiotic group and 8 cases in the placebo group) (p = 0.561) [In a study by Lindsay et al. , the eff= 0.561) .The importance of probiotics in preventing carbohydrate disorders in pregnant women is an area that requires more research. Although the results of some studies appear to be promising ,39,40,41The available studies show divergent and inconclusive results. The heterogeneity of the results may have been related, inter alia, to the variety of probiotic preparations used, differences in the duration of exposure to probiotics, and the selection of patients based on various requirements. More homogeneous research is needed to determine an appropriate preparation containing specific probiotic strains . There aCurrently, several studies are available on the use of probiotics in preventing GDM ,45,46,47L. acidophilus LA-5, B. BB-12, S. thermophilus STY-31, and L.delbrueckii bulgaricus LBY-27) on indicators of glucose metabolism and changes in body weight in women with newly diagnosed GDM (n = 64) [p < 0.05). The insulin resistance index in the probiotic group decreased significantly during the study period (by 6.74%). The insulin sensitivity index increased in both groups. These changes in the probiotic group (5.76%) were statistically significant. The researchers concluded that probiotic supplementation effectively improves glucose metabolism indices in patients with GDM. The results of this study are promising; however, the study should be conducted on a larger number of people not limited to Iranian women [The aim of one RCT conducted in Iran was to assess the effects of 8week multistrain probiotic supplementation ((n = 64) . Accordian women .L. acidophilus, L. casei, and B. bifidum, at a dose of 2 × 109 CFUs/g each plus 800 mg of inulin) on markers of insulin metabolism and lipid profiles in GDM women (n = 70). After 6 weeks of intervention, compared to placebo, supplementation with the symbiotic preparation led to a significant decrease in serum insulin levels , the HOMA-IR index , and HOMA-B  and a significant increase in QUICKI . The results suggest that symbiotic supplementation has favorable therapeutic potential for GDM patients, who often also exhibit with insulin resistance. More studies are needed on other patients, with larger groups, and over a longer time to determine the safety of this type of intervention. There is also a question of whether a probiotic would be as effective as a combination of a probiotic and a prebiotic [Another RCT, also conducted in Iran, investigated the effect of a synbiotic preparation  or a placebo for 6 weeks. The results showed that supplementation with probiotics significantly decreased the level of fasting glucose , insulin concentration , and insulin resistance  and significantly increased insulin sensitivity compared to the placebo . The results indicate that supplementation with probiotics for 6 weeks in patients with GDM had a beneficial effect on glycemic control and insulin action. The study also showed a beneficial effect of supplementation on inflammatory markers, oxidative stress, and the expression of insulin-related genes; all of these elements may be involved in GDM development. This was thus another study that confirmed the effectiveness of probiotics in treating carbohydrate metabolism disorders in pregnant women [One more RCT conducted in Iran examined the effects of probiotic supplementation on the genetic and metabolic profiles of patients with GDM. This study was conducted on a small group of 48 patients with GDM. The women were randomly divided into two equal groups that took either probiotic capsules containing nt women .n = 82) was investigated. VSL#3 is a freeze-dried pharmaceutical probiotic preparation containing 112.5 × 109 CFUs/capsule of eight strains of bacteria . A comparison between the two groups showed no significant differences in several glycemic parameters, such as fasting blood glucose and HbA1c (p > 0.05), but significant differences in insulin levels and HOMA-IR . The study suggests that supplementation with various subspecies of Lactobacillus, Bifidobacterium, and Streptococcus may benefit glycemic status. In the study, the use of the supplement did not significantly influence fasting glucoseorHbA1c but it prevented an increase in serum insulin concentration and resulted in an improvement in insulin resistance [In one study, the effects of 8weeks of intake of a probiotic mixture (VSL#3) on the glycemic status in women with GDM (sistance .n = 60). One group of women received the Infloran® probiotic, each capsule containing 109 CFUs of L. acidophilus and 109 CFUs of B. bifidum. Changes in metabolic parameters after randomization showed a significant improvement in glucose metabolism in the probiotic group compared to the placebo group, including improvements in fasting glucose , fasting plasma insulin , and the HOMA-IR index . In addition, probiotic supplementation was found to be well-tolerated and safe in the participants. These results confirmed the beneficial effect of probiotics on glucose metabolism in women with GDM in Thailand [A study conducted in Thailand examined the effects of 4weeks of probiotic therapy on insulin resistance in women with newly diagnosed GDM , and C-reactive protein (CRP), becomes significantly higher and the elevated concentrations of these cytokines, combined with elevated placental lactogen, progesterone, and estrogen, can increase insulin resistance and glucose intolerance considerably . FurtherResearch shows that the composition of the GM in pregnant women changes in a significant way. In the last trimester specifically, there is a sudden decrease in bacteria essential for the regulation of metabolism and an increase in Proteobacteria and Actinomycetes, which lead to the development of the inflammatory condition mentioned above. What is more, the amounts of accumulated fat and stored nutrition depend on the condition and composition of the microflora, and the related disorders often lead to the formation of easily digestible monosaccharides and lipoprotein lipase activation as a result of hydrolysis of undigested polysaccharides. The consequence is excessive storage of substances of hepatic origin (triglycerides) . TherefoAs mentioned above, probiotics may contribute to glycemic stabilization. Both probiotic therapy and the supply of prebiotics can be important elements in preventing and treating carbohydrate disorders in pregnancy.Research has shown the potential of these substances; however, for clinical practices, it is crucial that we find answers to the questions that have not yet been resolved. There is still much research required before we can routinely recommend probiotics in the treatment of women at risk of GDM.L. rhamnosus HN001 in the prevention of GDM. However, people who had had an atopic disease in the past were recruited for the study and it is not known whether the obtained results would be the same if a healthy population was taken into account, without the risk of atopic disease or allergy. The study by Reyes-Muñoz et al. [The secondary results of the study described by Barthow and Wickens et al. ,38 regarz et al.  was condz et al. ,41 also z et al.  indicatez et al.  and Lindz et al.  did not L. rhamnosus HN001 from early pregnancy and the Luoto study used L. rhamnosus GG in combination with B. Lactis BB12 [The heterogeneity of the results may be related, inter alia, to the variety of probiotic preparations used, the different durations of exposure to probiotics, and the selection of patients based on the various requirements. For example, the New Zealand study used tis BB12 ,38,40.As regards the effects of probiotics on the treatment of carbohydrate disorders in pregnant women, the results are more conclusive, but more research is still needed to determine the appropriate strains of bacteria and their dosage. Most of the available studies were conducted in Iran, so further studies are needed on a wider population.®; Babadi—a mixture of strains: L. acidophilus, L. casei, B. bifidum, and L. fermentum; Ahmadi– a synbiotic; Dolatkhah—a mixture of strains: L. acidophilus LA-5, B. BB-12, S. thermophilus STY-31, and L. delbrueckii bulgaricus LBY-27) [Dolatkhah et al.  showed t LBY-27) ,58,59,607 CFUs/day showed a positive impact on the metabolic health of a pregnant woman [L. rhamnosus HN001 administered in dosages of 6 × 109 CFU/day can lower the prevalence of GDM. A similar supplementation with myo-inositol and probiotics L. rhamnosus GG and B. lactis BB12 from the 12th to the 14th weeks of pregnancy can improve glucose metabolism and insulin sensitivity. Supplementation with L. acidophilus, L. casei, B. bifidum, and L. fermentum (2 × 109 CFUs each) can effectively lower fasting blood glucose levels. Administration of 109 CFUs of L. acidophilus and 109 CFUs of B. Bifidum can improve glucose metabolism. The above data are supported by research results. However, we still lack absolute certainty that this is indeed an effective intervention. Further research is required to determine the optimal probiotic dose for pregnant women. There are also studies that exclude the influence of probiotics on carbohydrate metabolism.Probiotics can reduce some of the negative metabolic side effects experienced by pregnant women. Supplementation can improve glycemic control for women who are in their third trimester. It can also lower the risk of GDM, which is suspected to be mainly achieved by lowering insulin resistance . Dosage nt woman . As discL. rhamnosus and L. reuteri was associated with an increased risk of vaginal discharge and changes in stool consistency. Nevertheless, the adverse effects of probiotic supplementation during pregnancy are not life-threatening and do not pose serious health problems for mother or child [Probiotics and prebiotic products are safe to use during pregnancy and lactation. Among other things, thanks to the Generally Recognized As Safe(GRAS) status, consumers can be informed that the microorganisms used in probiotics are not hazardous to health. Similarly, other governments and associations around the world  have regulatory protocols, which vary from country to country. Considering their low and chronic toxicity, probiotics are considered safe. Of course, preparations used by pregnant women must be of high quality, contain tested strains, and be free from contamination . Some stor child .Lactobacillus and Bifidobacterium have beneficial effects on the metabolic health of pregnant women. Lactic acid bacteria exhibit antioxidant properties, reducing the oxidative stress associated with hyperglycemia, which often occurs during pregnancy. In addition, probiotics can reduce the levels of interleukin-6 (IL-6), tumor necrosis factor (TNF-α), and high-sensitivity C-reactive protein (hs-CRP), thereby reducing inflammation in the body. Pregnant women can also balance the properties of abnormal native intestinal microflora using probiotics. Research on other strains and their effects on the health of pregnant women is limited, so more research is needed in this direction [B. lactis, which can improve the intestinal transit time, frequency, and consistency of stools in the case of constipation, which pregnant women often face [L. fermentum 57A, L. plantarum 57B, and L. gasseri 57C are recommended. They improve values such as the vaginal pH and Nugent Score. They also positively affect the total number of vaginal lactobacilli [irection . Anotherten face . Intimatobacilli .L. rhamnosus GG results in accelerated tolerance development in children allergic to cow’s milk, as the strain affects the structure of the infant’s intestinal microflora [Consumption of a probiotic by mothers can also benefit their babies. Supplementation in the last month of pregnancy and the administration of a probiotic to an infant for the next 6 months of life reduce the risk of allergies in a child. Administration of the extensively hydrolyzed casein preparation with the addition of croflora . Despitecroflora . So far,croflora . The stucroflora . More recroflora . No signcroflora .In sum, supplementation with probiotics may positively affect glycemic control but it does not affect the level of blood lipids in pregnant women with GDM. Further studies should be carried out to establish and compare the efficacy of different probiotic strains and different doses of CFUs. These interventions should determine the optimal dose and the specific strain recommended for supplementation in cases of healthy pregnant women and pregnant women with GDM .On the basis of the research presented in this article, it can be concluded that supplementation with probiotics positively affects glycemic control  and may lower the frequency of GDM. Although the results of some studies on GDM prevention  and treatment  appear to be promising, further studies must be conducted to determine the mode of action of probiotics in pregnant women with GDM. The available studies provide divergent and inconclusive results. The heterogeneity of the results may be related, inter alia, to the variety of probiotic preparations used, different exposure times to probiotics, and the selection of patients based on different requirements. Therefore, future studies should aim to standardize the study group, strain, and dose of probiotics so that, on the basis of reliable data and results, probiotics can be safely implemented in the prevention and treatment of GDM in pregnant women.


Aedes aegypti can lead to operational failures in control programs. Knowledge of the spatial and temporal trends of this resistance is needed to drive effective monitoring campaigns, which in turn provide data on which vector control decision-making should be based.The development of resistance against insecticides inAe. aegypti mosquitoes from established laboratory colonies were evaluated for resistance against the organophosphate insecticide temephos. The 39 populations were originally established from eggs collected in the field with ovitraps in eight departments of Peru during 2018 and 2019. Dose–response bioassays, at 11 concentrations of the insecticide, were performed following WHO recommendations. Third-stage larvae (L3) from the F1 and F2 generations of 39 Peruvian field populations of Ae. aegypti tested for resistance to temephos , 11 showed high levels of resistance (resistance ratio [RR] > 10), 16 showed moderate levels of resistance  and only 12 were susceptible (RR < 5). The results segregated the study populations into two geographic groups. Most of the populations in the first geographic group, the coastal region, were resistant to temephos, with three populations  showing RR values > 20 . The populations in the second geographic group, the Amazon jungle and the high jungle, showed moderate levels of resistance, with values ranging between 5.1 (JN) and 7.1 (PU). The exception in this geographic group was the population from PM, which showed a RR value of 28.8 to this insecticide.Of the 39 field populations of Ae. aegypti populations in Peru present different resistance intensities to temephos, 3 years after temephos use was discontinued. Resistance to this larvicide should continue to be monitored because it is possible that resistance to temephos could decrease in the absence of routine selection pressures.The results of this study demonstrate that The online version contains supplementary material available at 10.1186/s13071-022-05310-x. Aedes aegypti is the main vector of arthropod-borne viral infections transmitted to humans, which include dengue, yellow fever, chikungunya and Zika [and Zika , 2. The and Zika . It has and Zika  and in Band Zika , and thaand Zika , 7. ThesAe. aegypti has been responsible for the spread of chikungunya and Zika to regions of the Americas, placing a significant burden on healthcare systems and also causing social and economic disruption [Ae. albopictus is widely distributed in the Americas (present in 21 of 44 countries), it has not been detected in Peru. However, Peru shares borders with countries reporting widespread distribution of Ae. albopictus, such as Brazil, Colombia, Bolivia and Ecuador  [It is estimated that about 2.5 billion people, representing 40% of the human population worldwide, live in areas at risk of dengue transmission  and thatsruption . While Ain 2017) .Ae. aegypti. Aedes aegypti was eradicated locally in 1958, but it subsequently recolonized the country in 1984 [In Peru, the vector of dengue, chikungunya and Zika is  in 1984 . The fir in 1984 . Low-inc in 1984 . Signifi in 1984 . The fir in 1984 , 16.Aedes-borne arboviruses are present in three ecological regions: the coast, the Amazon jungle and the Andes Mountains [Aedes-borne arboviruses only affect areas of lower altitude. Aedes aegypti are widely distributed in 21 of Peru’s 24 departments and the constitutional province of Callao, and have been identified in 527 districts [In Peru, ountains , 18. Theountains . Aedes-bistricts , where aAe. aegypti populations in association with knockdown resistance (kdr) mutations . This led the Peruvian Ministry of Health (MINSA) to implement a control strategy in which PYs were rotated with the OP malathion. For larval control, the OP temephos was switched with the insect growth regulator (IGR) pyriproxyfen because temephos shares the same mode of action as the OP malathion. This switch away from using temephos, however, was made without any knowledge of the susceptibility status of Ae. aegypti populations to this insecticide.The main dengue control strategy implemented in Peru until 2016 was focal treatment of larval habitats with the organophosphate (OP) insecticide temephos due to its easy dosage, application and acceptability by the community. For the same reasons, the adulticides used in the 1990s were the OPs fenitrothion and malathion . Since tAedes-borne arboviruses. The continuous use of insecticides results in selective pressures that in turn drive physiological and/or behavioral adaptation, a phenomenon known as resistance [Surveillance of insecticide resistance in arthropod vectors in Peru is an activity that falls under the Instituto Nacional de Salud  and Regional Reference Laboratories (LRRs) which, in the context of a decentralized healthcare system, requires coordinated work. However, many of the LRRs do not have entomology laboratories or insectaries and thus do not have the facilities or knowledge to routinely perform the various tasks/responsibilities placed on them , 24. Thisistance . Insectisistance . Ideallysistance .Ae. aegypti from the three ecological regions of Peru after having used temephos for > 25 years, following an interruption in its use of 3 years.The aim of the present study was to determine the levels of resistance to temephos in 39 Peruvian field populations of Ae. aegypti from colonies maintained at INS that were established from eggs collected in 39 localities in the Peruvian departments of Tumbes, Piura, La Libertad, San Martín, Loreto, Ucayali, Junin and Madre de Dios during April 2018 and January 2019  for each study population. Four replicates per concentration, and 11 concentrations were evaluated with 20 third-stage larvae (L3) in 100 ml of insecticide solution per replicate. Insecticide solutions were prepared with ethanol solvent and temephos active ingredient , using a concentration range of 0.004 to 0.324 mg/ml for the field populations, and 0.002 to 0.012 mg/ml for the control Rockefeller strain. Simultaneously, a control group with four replicates exposed only to 600 µl of ethanol solvent was evaluated [Dose–response susceptibility tests were performed with temephos following WHO recommendations . The larvaluated .50 and LC95 were calculated from a log dosage-probit mortality regression line using probit analysis (Polo-PC statistics package [50 (where i = 50) and the RR95  for eacThe population was considered to be susceptible when the RR < 5; when the RR was between 5 and 10, the population was considered to have moderate resistance; and when the RR ≥ 10, the population was to be considered highly resistant.Ae. aegypti mosquitoes from localities with different incidences of arboviruses and located in three ecological regions of Peru were tested. A total of 37,440 L3 were tested across all bioassays.Third-stage larvae from the F1 and F2 generations of 39 Peruvian populations of 50 and LC95, the resistance ratios (RR50 and RR95) and the slope of the probit regression lines for the insecticide temephos in the 39 populations of Ae. aegypti. The differences between the RR95 of all populations were analyzed according to the criteria of Mazzarri and Georghiou [Table eorghiou  and Sá eeorghiou .The resu50 but showed high resistance to temephos (RR > 10) in the RR95, and populations CS, MI, ES, LA, MR, BS, ST, BN, JN, SY and MY) had low values in the RR50 but showed moderate resistance in the RR95. Populations CZ, MA and LO were more homogeneous due to their high resistance to temephos, with high values of RR50  and RR95 . Some populations  showed moderate levels of resistance (5 ≤ RR < 10), and 12 populations  were considered to be more susceptible (RR < 5) in both the RR50 and RR95. In general, jungle localities were more homogeneous.However, the RRs of the populations were heterogeneous, even within the same department. In Tumbes, for example, most populations were highly resistant to temephos (RR > 10), except for the PG population (RR = 8.9) which showed moderate resistance to this insecticide. Piura, in comparison, had two populations (MA and LO) that exhibited high RR values (RR > 19), but also had two susceptible populations with low values (RR < 5). In La Libertad, the RRs varied between 2.1 in CA and 11.3 in FL, showing that the mosquito populations in this department also showed heterogeneous resistance RRs; however, there were also two populations in which the lowest RRs were detected (RR < 2.5). The departments of San Martin, Junín, Loreto and Ucayali were more homogeneous, with RR values ranging from 2.2 in MO to 7.1 in PU. However, despite the generally lower RR values in the jungle areas, in the jungle department of Madre de Dios, the PM population showed a RR value of 28.8. However, the RRs of the populations were heterogenous even within in the same locality. Populations AG, ZA, SA, PG, CR, CB, PO, FL and PM had moderate levels of resistance (5 ≤ RR < 10) in the RR The slope values of the probit regression lines of the field populations were lower than those obtained with the Rockefeller lineage, except in the CA population (slope = 7.18) Table ; Fig. 3.Ae. aegypti to temephos was undertaken. The Peruvian INS, in coordination with Regional Health Directorates, surveyed 39 dengue endemic localities from April 2018 to January 2019. Overall, Peruvian populations of Ae. aegypti showed variable levels of resistance to temephos. Based on the results, these populations were clustered into two groups: (i) coastal populations with moderate to high levels of resistance to temephos, and (ii) jungle populations, which showed a moderate level of resistance to temephos, and some susceptibility, except for the Puerto Maldonado population which showed a very high level of resistance. Interestingly, from 2015 to 2017, the dengue cases reported in the coastal departments accounted for between 54 and 86% of the total number of dengue cases reported in Peru, while from 2018 to 2021, dengue cases reported in the jungle regions accounted for between 55 and 87% of the total number of dengue cases reported [As part of a national strategic plan to eliminate dengue, chikungunya and Zika, a national survey to ascertain the susceptibility of reported , 37  and Arenas showing susceptibility, while the populations from San Lorenzo and Nueva Loja show high levels of resistance. This variability could be due to variations in the intensity and frequency of temephos use across Ecuador [Ae. aegypti. However, the west coast of Peru is a long desert strip interrupted by valleys, and the main characteristic of the region is a scarcity of rainfall [Higher levels of resistance to temephos were detected in coastal populations than in jungle populations, despite the northern coast having been recolonized by n Amazon , 39. The Ecuador . It is k Ecuador . Another Ecuador , 42. Thirainfall , which srainfall . Overallrainfall , 26. Evirainfall . As a rerainfall , as recorainfall .Ae. aegypti population in this city was the only one in the Peruvian Amazon that presented a high level of resistance to temephos. The vector was introduced into this city in 1999 [Ae. aegypti population has not experienced strong selection pressure from the larvicide temephos. The explanation for the high levels of temephos resistance detected in the present study could be due to the vector having spread across the border from Brazil and Bolivia. On the Brazilian side, the Ae. aegypti population from Rio Branco (Acre State) is highly resistant to temephos [Ae. aegypti population in the border city of Cobija (department of Pando) shows moderate levels of resistance to temephos [The ecosytems of the Peruvian Amazon differ from those on the coast. These jungle areas typically include humid and rainy tropical forests . In this in 1999 , 15 year in 1999 . Dengue  in 1999 . This lo in 1999 , who foutemephos  and simitemephos .It is also important to consider that the use of pesticides in the agricultural sector in Peru is intense at the national level, with the most widely used insecticides being OPs . In a hiAe. aegypti populations show diverse levels of resistance to the OP temephos, and are consistent with resistance patterns observed in other field populations that have been subjected to intense selection pressure from temephos [The results of the present study demonstrate that Peruvian temephos . In Perutemephos . Resistatemephos , Caldas temephos , Pernambtemephos , Martinitemephos  and Bahitemephos ; moderattemephos , Laos . Also in Brazil, Rahman et al. [Chemical control of proxyfen ; this reproxyfen  who deteproxyfen  to a RR proxyfen  and thenproxyfen . Similarproxyfen  observedproxyfen , a decren et al.  observedn et al. . ConsequAe. aegypti to pyrethroids, the OP malathion is being reintroduced [Following the observed resistance of Peruvian troduced . It is utroduced  suggestetroduced . If thisAe. aegypti population presented variations in the intensity of resistance to different OPs , with elevated activity of esterases related to resistance to temephos, while mono-oxygenases were associated with resistance to pirimiphos-methyl and chlorpyrifos.An important limitation to this study was the lack of additional evaluations that would allow us to better understand the evolution of resistance to temephos, as well as the characterization of the observed resistance by molecular and enzymatic methods. On this last point, Rodriguez et al. , in a stAe. aegypti populations in Peru have different levels of resistance to temephos, even after its widespread use was suspended, spanning the spectrum from susceptible to high levels of resistance. It is necessary to continue monitoring resistance to this larvicide to understand if in the absence of its widespread use, susceptibility may be recovered in the future. The implementation of insecticide resistance management strategies is important to preserve the efficacy of insecticides used in public health programs, and it is necessary to carry out vector control with multisectoral components that can improve the effectiveness of the Ae. aegypti control program in Peru.The results of this study demonstrate that Additional file 1: Table S1. Number of cases of dengue according to departments and geographic regions, Peru 2015–2021.


This study aims to determine the mediating role of physical fitness in the relationship between fatness indicators and academic achievement, exploring the influence of school vulnerability.A total of 1,296 Chilean adolescents  participated in this study. The global fitness score (GFS) was obtained by adding the three main components of the ALPHA fitness test: cardiorespiratory fitness (CRF), muscular fitness (MF), and speed/agility fitness (SAF). CRF was evaluated through the 20 m shuttle run test; MF by upper and lower limb strength tests; and SAF by the 4 × 10 shuttle run test. BMIz and WHtR were evaluated as general (unspecific) and central (specific) fatness indicators. Academic achievement was established through grades in math, language, and science and their average scores. Multiple mediation analyses were performed according to two models, adjusted for sex, maturity, and schools (model 1), and in model 2, the school vulnerability index (SVI) was added. The SVI is an important proxy of socioeconomic status at the school level, and it was categorized as high-, mid-, or low-SVI. Mediation percentages were calculated, and confidence intervals (bootstrapping) were used to establish significant findings.CRF, SAF, and GFS mediate the relationship between fatness indicators and academic achievement, both partially and totally (ranging from 12.7 to 59.2%). However, MF did not show any mediation effect. After controlling for SVI, CRF, and GFS, mediation changed from partial to total in the associations between math and science with WHtR. Although SAF contributed to GFS mediation, CRF seems to have the most significant mediation role for all academic achievements, regardless of SVI and the fat indicator studied.A higher level of general physical fitness, especially CRF, significantly mediates the detrimental influence of fatness on the academic achievement of schoolchildren. This study suggests that physical fitness plays a relevant role in academic and public health, considering the high prevalence and detrimental influence of obesity and school vulnerability in children and adolescents. The detrimental impact of obesity on a variety of metabolic and brain health indicators in childhood is being widely addressed  , 2, and,In general, evidence has established the inverse relationship between fatness indicators and academic achievement –12. MostPromoting regular physical activity is essential to counteract the impact of fatness on health. This is a low-cost strategy that contributes to the control of childhood overweight and obesity and can improve several parameters of physical fitness, such as cardiorespiratory fitness (CRF), muscular fitness (MF), and speed-agility fitness (SAF), related to brain health and academic achievement –19. RegaMediation analysis plays a relevant role in finding a suitable statistical approach to study the relationship between fatness, fitness, and academic achievement, particularly the influence of fitness on this relationship. To date, some studies have shown that CRF, MF, and SAF positively mediate the inverse association between fatness and academic achievement , 23. HowTherefore, the present study aimed to determine the mediating role of several physical fitness variables in the association between fatness indicators and several academic achievements in adolescents, exploring the influence of school vulnerability.This study is part of the Cogni-Action Project (from March 2017 to October 2019), which establishes associations between physical fitness, physical activity, and sedentary life with academic achievement, cognitive performance, and brain structure and function in Chilean schoolchildren . This prth to 8th grade, while exclusion criteria for this study were based on a lack of data for the following variables: body mass index Z-score (BMIz), WHtR, CRF, MF, SAF, GFS, math, language (Lang), science (Sci), academic achievement average (AAA), and SVI. Finally, a range of 920–951 school children was included based on the mediation analysis.The Cogni-Action Project collected information on 1,296 girls and boys (1:1) between 5th and 8th grade (aged 10–14 years) from public, subsidized, and private schools in Valparaiso, Chile. A total of 19 schools participated in the project. More information on the Cogni-Action Project is provided in Solis-Urra et al. . It is iN = 951,962). It was considered an alpha error of 5%, a confidence interval of 99%, heterogeneity of 50%, and a 20% dropout. Hence, a total of 797 participants was necessary to reach a representative sample size from the second most populated region in Chile.The total sample size and power calculations were based on the total enrolment of schoolchildren in the Valparaiso region (5th to 8th grades) indicated by the Chilean Ministry of Education in the year 2016  were evaluated in the first session, and physical fitness was assessed in the second session. Trained instructors from our research team evaluated all measurements. Academic achievement variables were obtained from each student’s school.The general and unspecific adiposity indicators  were calculated using the World Health Organization’s 2007 growth reference for school-aged children . Height The central adiposity indicator  was obtained by measuring the waist circumference with an inextensible tape  at the mid-axillary line, at the midpoint between the costal margin and the iliac crest. The result was divided by height to obtain the waist-to-height ratio (waist[cm]/height [cm]).Z-score CRF. Appropriate sportswear was suggested to perform this test, and it was held during the morning (between 9:30 and 12:00) in an indoor gym or sports field. The instructors gave verbal instructions about how to perform the test and a brief demonstration of the technique to ensure correct test execution. Adolescents could practice the test and begin when they felt confident.CRF was evaluated through the 20-m shuttle run test . BrieflyMF was obtained after considering upper and lower limb strength. The maximum result of the handgrip strength test was used to determine upper limb strength using a dynamometer . The instrument allowed 0 to 90 kg measurements with a 0.1 kg precision and was adjusted to the schoolchildren’s hand size. The procedure to evaluate it was to stand up with the elbow completely extended; the instrument should be pressed firmly with one hand and then with the opposite hand, two attempts per hand, and the maximum score would be registered. The score (kg) was divided by body weight to create a relative measure of this indicator.Z-scores of both tests (adjusted for age and sex).A standing long jump test was used to assess lower limb strength. The test consists of standing behind a previously marked line. The instructors give a verbal signal, and the schoolchildren must jump as far as possible and use both feet. This test was performed twice, resting for at least one minute between them. The maximum score was registered in centimeters (cm). The MF score was calculated by adding the standardized Z-score was adjusted for age and sex.Speed, Agility Fitness was evaluated using the 4 × 10 shuttle run test. Movement, agility, and coordination were involved in this test. The application of this test is obtained by demarcating two lines (five meters long) separated by 10 m; additionally, two cones were positioned on each line. Each participant was asked to run as fast as possible from the first line, pick up a piece of cloth located ∼50 cm after the first line, and carry it to the following line. Then they had to leave the cloth, pick up another one, and run to the opposite line. Each schoolchild had two chances to perform the test; the best performance was used, registered in seconds, and multiplied by −1. The SAF Z-score), and all scores were adjusted for sex and age, with all three added. The procedure for each test is detailed as follows.The global fitness score (GFS) was obtained by calculating the three main components of the ALPHA fitness test  . Each coAccording to the school records, academic achievement was established through three school subjects  at the end of the school year. In Chile, the grade scoring range is between 1 and 7 points, and the three subjects are the main subjects included in the Chilean education quality agency evaluation system (SIMCE) and the Programme for International Student Assessment (PISA) by the Organization for Economic Cooperation and Development (OECD). Grades are expressed on a national scale, ranging from 1 to 7. An average of these three subjects was also computed.In this study, we sought to reduce bias by adjusting the analyses to relevant confounders, such as sex, peak height velocity (PHV), participants’ schools, and SVI. Sex is considered an important moderator in this discipline because visceral fat may affect girls more than boys . PHV is The mediation effect of fitness indicators on the association between BMIz and WHtR with academic achievements was analyzed using the PROCESS SPSS script  through p < 0.05.The indirect effects (equation a by equation b) and confidence interval (CI) were established to define a mediation effect (CI not including zero). The percentage of mediation was estimated as 1- (equation c’/equation c). A detailed set of findings  is presented as Supplementary material , 2. The p = 0.603 and sex*fitness p = 0.138).The characteristics of participating adolescents and differences by sex are summarized in p < 0.05), except for Lang, with MF and SAF .The correlation matrix between all study variables is presented in Overall, a mediation role of CRF, SAF, and GFS is observed, but not of MF. Additionally, the SVI inclusion in the model (model 2) generates significant variations in the mediation percentage and classification.In particular, the association between BMIz and math, CRF, SAF, and GFS presented “complementary” mediation (models 1 and 2). For Lang, only CRF showed a complementary mediation (models 1 and 2); no mediation was observed for MF, SAF, and GFS. For Sci, only SAF presents a “complementary” mediation (models 1 and 2). Finally, AAA, CRF, and GFS showed “complementary” mediation (models 1 and 2), but SAF lost its mediation role in model 2. In general, no mediation role was observed for MF, and the percentage of mediations ranged from 12.7 to 42.4%, where CRF was the strongest mediator between BMIz and academic achievements.For the association between WHtR and math, CRF, SAF, and GFS presented “complementary” mediation in model 1; only SAF maintained its mediation after adjusting for SVI model 2). For Lang, only CRF showed a complementary mediation (models 1 and 2); no mediation was observed for MF, SAF, and GFS (models 1 and 2). With Sci, both CRF and GFS presented an “indirect only” mediation , and SAF showed a “complementary” mediation role (models 1 and 2). Finally, AAA, CRF, and GFS showed “complementary” mediation (models 1 and 2). In general, no mediation role was observed for MF, and the percentage of mediations ranged from 15.6 to 59.2%, where CRF was the strongest mediator between WHtR and academic achievements. A complete description of all mediation indicators  is available as Supplementary material , 2.. For LanThis study aimed to determine the mediating role of fitness indicators  between two fatness indicators related to fat distribution (BMIz and WHtR) and main academic achievements at the national and international levels , as well as to explore the influence of a strong SES factor, such as SVI.The primary finding confirmed the significant mediating role of fitness in the relationship between fatness and academic achievement. The secondary results showed that (a) CRF, SAF, and GFS had a significant mediation role in the inverse association between fatness and academic achievement, but MF did not; (b) CRF seems to be the most relevant mediator; (c) differences between fatness indicators were observed, in which WHtR obtained the highest percentage of mediation by fitness indicators; and (d) SVI was able to significantly modify both percentages and mediation classifications.Presently, the positive association between physical fitness and academic achievement is well established in the literature , 48, 49.In particular, several studies have shown the short- and long-term effects of aerobic exercise and its physiological marker (CRF) on brain health indicators  . HoweverTransferring these findings to the educational and public health arenas, we have shown several interventions that have shown the positive impact that physical activity has on the academic achievement of schoolchildren , 54 and,A key contribution of the present study is to have studied a general adiposity indicator (BMIz) and a central adiposity indicator (WHtR) to establish their differential association with academic achievement when mediated by physical fitness. Our findings showed that WHtR seems more sensitive than BMIz and is affected significantly by physical fitness indicators, mainly CRF. Thus, our results support the importance of studying fatness indicators related to its distribution because the mediation role of fitness would depend on them .In this sense, our findings displayed a differential association between the two fat indicators analyzed in this study. This could be because BMIz is considered a surrogate and unspecific obesity marker , while WHtR seems more specific and more substantially related to inflammation and cognitive functioning , 16. TheTo achieve this goal, physical activity and improved physical fitness are fundamental. For instance, in children and adolescents with obesity, exercise is more effective than diet alone or in combination with diet and exercise to reduce visceral fat , 61. In A novel approach in this study was to explore a complex SES indicator related to adolescents’ vulnerability in school and establish its implications in the relationship between fatness, fitness, and academic achievement. It is pertinent to carry out this type of methodology because most of the academic differences among schoolchildren can be explained by their social background , 65. ThuOverall, we found that SVI showed a differential influence according to the model analyzed, generating greater variation (percentages and classification mediations) in WHtR than BMIz. This scenario supports our study aim due to this statistical approach’s higher specificity of WHtR than BMIz. In addition, it reinforces that both CRF and GFS play a relevant role regardless of adolescents’ school vulnerability influence.These findings become significant if we consider two main points. First is the high dependence of fatness, fitness, and academic achievement on SES –67. SecoThe main limitation of the present study is its cross-sectional design, which reduces the possibility of determining causality among variables. In addition, fitness and fatness indicators were evaluated by field-based and indirect tests, respectively, which could increase methodological biases; nonetheless, it is feasible to implement these measurements in school settings. Finally, the academic evaluation depends on the school’s increasing biases.The main strengths are the large sample size of adolescents from a Latin American country and the inclusion of several fatness and fitness indicators, improving understanding in this research area. Moreover, we analyzed the three main subjects evaluated internationally (PISA). Finally, we explored the influence of a powerful SES indicator, such as the SVI, which allowed us to determine a novel finding concerning the mediator role of fitness, regardless of the adolescents’ social background profile.In conclusion, a higher level of global physical fitness, but mainly CRF, mediates the detrimental influence of fatness on adolescent academic achievement. This favorable influence was shown to be constant, even for a central fatness indicator such as WHtR and a critical socioeconomic factor. Indeed, our findings reinforce the relevant role of CRF and GFS, regardless of adolescents’ school vulnerability influence. This is crucial at a public health level, considering the strong relationship between obesity and adolescent socioeconomic background. Thus, these findings become essential if we consider the current high rate of obesity, low educational and fitness performance in childhood, and the increasing poverty rate globally in low- to middle-income countries. Therefore, governments should create public policies that encourage physical activity, focusing on enhancing adolescents’ physical fitness. Experimental and longitudinal studies in this research area are warranted.carlos.cristi.montero@gmail.com.The datasets presented in this article are not readily available because of ethical restrictions. Requests to access the datasets should be directed to CC-M, The studies involving human participants were reviewed and approved by Ethics Committee of the Pontificia Universidad Católica de Valparaíso (BIOEPUCV-H103–2016). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.CC-M contributed to the design of the project. CC-M and GG-A conceptualized the design of the study, analyzed the data, and wrote the concept version of the manuscript. SH-J, JO-A, GF, and PD-F critically reviewed the manuscript and edited the article. All authors have given final approval of the manuscript and agreed to be accountable for the accuracy and integrity of any part of the work.


A major development in solid malignancy treatment is the application of immune checkpoint inhibitors (ICIs), which have produced durable responses and increased survival rates. However, the therapeutic effect of ICIs has great heterogeneity in patients with cancer. We propose a systematic review to evaluate the predictive value of tumour mutation burden (TMB) on efficacy of ICIs.2≤50%) or a DerSimonian-Laird random effects model (I2>50%). In addition, subgroup analysis, sensitivity analysis, heterogeneity analysis and publication bias will be conducted. We plan to conduct a subgroup analysis on age, sex, area, number of patients (high/low TMB), cancer type, tumour size, stage, line of therapy, TMB sequencing method, type of immunotherapy and follow-up period.A systematic literature search will be conducted in the PubMed, OVID, Web of Science, Embase and Cochrane Central Register of Controlled Trials Library databases up to 31 May 2022. We will compare the efficacy of ICIs between TMB high group and TMB low group in terms of the HRs of overall survival (OS) and progression-free survival (PFS), and the OR of the objective response rate/overall response rate (ORR). The HRs of PFS and OS, and the OR of ORR, will be measured by an inverse variance weighted fixed effects model (IEthical approval and informed consent are not needed, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care. This systematic review is anticipated to be finished in December 2023, and the results will be published in a peer-reviewed journal.CRD42021262480. This will be an update comprehensive systematic review focused on the tumour mutation burden (TMB) and the efficacy of immune checkpoint inhibitors (ICIs) for the prognosis of patients with solid tumours.We plan to conduct a comprehensive subgroup analysis of the association between TMB and the efficacy of ICIs, including age, sex, area, number of patients (high/low TMB), tumour size, stage, TMB sequencing method, type of immunotherapy and follow-up period.We will focus on the long-term efficacy of ICIs in patients with solid tumours.We will search databases for studies published in English, while other languages may be ignored.Immune checkpoint inhibitors (ICIs) have been shown to prolong response and increase survival rates in various solid tumours and haematologic malignancies. However, the efficacy of ICIs seems satisfactory in some patients and unsatisfactory in others,11–13Retrospective evidence suggests that TMB can predict the efficacy of ICIs, and recent US Food and Drug Administration approval of pembrolizumab for the TMB—high tumour subgroup. However, the predictive value seems inconsistent in patients with different tumour types, which may be associated with the degree of variability in TMB. Current investigations indicate that some cancer types have less variability in TMB such as lung and head and neck cancers, and some have greater variability such as colon, bladder and uterine cancers.Hence, we propose an update to the evidence by conducting a comprehensive systematic review and meta-analysis to evaluate the value of TMB on the efficacy of ICIs in malignant solid tumours. We will also proceed overall subgroup analyses to determine the promising effects of ICIs.We submitted this study protocol to PROSPERO (CRD42021262480). This systematic review and meta- analysis will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.21 22We will include all prospective or retrospective studies that meet the following criteria.We will include cohort or clinical trials assessing ICIs, such as PD-1/PD-L1, cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), or their combination, or with chemotherapy, in patients with malignant solid tumours. A cut-off of ≥10 mutations per megabase (mut/Mb) was chosen to define the ‘high TMB’ patient population.ICI treatment in patients with cancer with malignant solid tumours.We will evaluate the efficacy of ICI therapy in the TMB high group and the TMB low group. The HRs of progression-free survival (PFS), the HRs of overall survival (OS), the OR of overall response rate (ORR) and their 95% are reported in our article. Besides, we will calculate them using the sufficient data collected in studies.Association between different levels of TMB and response rate of ICIs in all kinds of malignant solid tumour types, including OS, PFS, DFS, RFS, DSS and others.Association of subgroup analysis between different levels of TMB and efficacy of ICIs, including age, sex, area, number of patients (high/low TMB), tumour size, stage, TMB sequencing method, type of immunotherapy or follow-up period.Correlations between TMB and clinicopathological features, such as tumour size, stage and metastasis.The exclusion criteria will be as follows:Review, comments, case reports, non-human study.There is no control groups and analysis.The data are incomplete.The PubMed, Ovid, Web of Science, Embase and the Cochrane Central Register of Controlled Trials databases will be searched from inception to 31 May 2022, using the MeSH terms ‘Immune Checkpoint Inhibitors’ and the related keywords ‘Immune Checkpoint Inhibition’, ‘Immune Checkpoint Blockers’, ‘Immune Checkpoint Blockade’, ‘PD-L1’, ‘CTLA-4’, ‘PD-1’ or the name of the drugs , ‘Mutational Burden’ or ‘Mutation Burden’. The languages will not be limited in our search strategy. The search strategy for Ovid is presented in 10.1136/bmjopen-2021-058692.supp1Supplementary dataXX and WG will independently assess the eligibility of reports from the title and/or abstract. A third reviewer, YL, will be consulted in case of inconsistent. We will select studies that meet the inclusion criteria for further analysis. For the included studies that have no insufficient data, we will ask for the original data from corresponding authors analysis. The following items will be extracted from all included studies: first author, study design, year of publication, median age, sex, TMB sequencing method, follow-up period, type of cancer, tumour size, stage, type of immunotherapy, TMB cut-off, number of patients (high/low TMB), area of patients and outcomes .Two systematic review authors (YL and WG) will independently assess the risk of bias for each study using the Newcastle-Ottawa Scale (NOS). The NOS will be adopted to assess the quality of the included studies.If at least 10 studies are included, we plan to use Egger’s test and the funnel plot to estimate the potential publication bias by R V.4.0.2. P<0.05 will be considered to indicate significant publication bias.2 test will be used to estimate heterogeneity in pooling analysis. Heterogeneity is considered to be statistically significant when p<0.10 in all qualitative tests. The I2 test will be used to examine the proportion of total variation, with values of 25%, 50% and 75% indicating low, moderate and high heterogeneity, respectively. We plan to conduct a meta-regression to confirm the source of heterogeneity within R V.4.0.2. We also plan to conduct a subgroup analysis on age, sex, area, number of patients (high/low TMB), tumour size, stage, TMB sequencing method, type of immunotherapy or follow-up period.The χTo determine the robustness of the pooled results, sensitivity analysis will be performed by examining individual studies using R V.4.0.2.2>50% and/or p<0.10 will be considered to indicate significant heterogeneity.The primary outcome of our article is the comparison of the efficacy of ICIs between the TMB high group and TMB low group, which will be assessed by the HRs of PFS and OS, and the OR of ORR. Heterogeneity among individual studies will be evaluated by the Q test; IAs our study is a protocol of meta-analysis, which based on the previously published literature, the primary patient data will not need to be collected. Existing databases will be used for the purpose of this study. The public or patients will not be involved in the study design, recruitment or data analysis.The data included in this project will be collected from the original studies; therefore, ethical approval and informed consent of patients will not be needed. This systematic review will assess the predict value of TMB in patients with malignant solid tumours. Patients treated with ICIs with high/low levels of TMB will eventually benefit from the knowledge of this study. We will publish the results of this protocol as a complete meta-review paper in an academic journal and scientific conferences.


Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment of refractory ventricular fibrillation (RVF). This review aims to compare the advantages of DSED with standard defibrillation in the treatment of refractory ventricular fibrillation.PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to May 1, 2022. Studies included adult patients who developed RVF. The study used random-effects and fixed-effects models for meta-analysis, which was reported by risk ratio (RR) with 95% confidence interval (CI), mean difference (MD), or standardized mean difference (SMD). The risk of bias in individual studies was assessed using the Robins-I tool for observational studies and the Cochrane Risk of Bias 2 (ROB-2) tool for clinical trials. Primary outcomes included the termination of RVF, prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological recovery. Secondary outcomes included age, total defibrillation attempts, emergency medical system arrival time, and dose of epinephrine and amiodarone used.Z = 0.42, P = 0.678 > 0.05) for Termination of RVF,  for ROSC,  for survival to hospital admission,  for survival to hospital discharge,  for good neurologic recovery,  for age,  for total defibrillation attempts,  for emergency medical system arrival time,  for epinephrine, and  for amiodarone.In this systematic review and meta-analysis, 10 studies containing 1347 patients with available data on treatment outcomes were included. The pooled estimate was (RR 1.03, 95% CI, 0.89 to 1.19; We discovered no differences between DSED and standard defibrillation in termination of RVF, prehospital return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses in patients with RVF. There were some differences in the number of defibrillations and epinephrine doses utilized during resuscitation.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329354], identifier [CRD42022329354].[ Out-of-hospital cardiac arrest (OHCA) is the leading cause of death and disability in public health events worldwide , 2. AlthTo further deepen our understanding of the treatment and potential impact of DSED in patients with RVF, based on the knowledge of existing animal studies, case reports, and clinical research evidence, and to address the limitations of previous reviews, we conducted a systematic review and meta-analysis that focused on assessing two questions. (1) Primary outcome: Compared with standard defibrillation, is there an advantage in assessing double sequential external defibrillation on prehospital return of spontaneous circulation, termination of refractory ventricular fibrillation, survival to hospital admission, survival to hospital discharge, and good neurological recovery in patients with RVF? (2) Secondary outcomes: In addition to the observation of the primary outcome, age, number of defibrillations, emergency medical system arrival time, and dose of epinephrine and amiodarone used these measures have an impact on and improve the outcome? Neurological outcome was measured using the Glasgow–Pittsburgh cerebral performance category (CPC). CPC1∼2 were considered good neurological outcomes; CPC 3∼5 were defined as poor neurological outcomes , 10. OurWe conducted and reported this systematic review and meta-analysis study protocol according to the criteria outlined in the PRISMA guidelines . The stuThe researcher (YL) searched four databases: PubMed, Embase, Web of Science, and Cochrane Library. There was no specific date, age, gender, or language restrictions. The coverage dates for this systematic review and meta-analysis start at the beginning of each database  and ends on May 1, 2022. Search criteria combined free text search exploded [Medical Subject Headings (MeSH) terms/EMTREE terms] and refractory ventricular fibrillation, Cardiopulmonary Resuscitation, Heart Arrest, Electric Countershock, and Double sequential external defibrillation. The search was initially developed for PubMed and then adapted to each of the other 4 databases by searching for medical subject term terms and mapping to other controlled vocabularies, ensuring that the search strategy was relevant and comprehensive.(1) Consensus guidelines, animal studies, letters, case reports (<5 cases), or non-peer-reviewed or unpublished reports. (2) Patients whose families refused Cardiopulmonary Resuscitation (CPR); patients with cardiac arrest due to cachexia and trauma; patients with cardiac arrest due to drowning, pulseless ventricular tachycardia, hypothermia, and suspected drug overdose. (3) Literature with incomplete or inaccessible valid data.(1) Adult patients (≥18 years) in refractory ventricular fibrillation during cardiac arrest. (2) Patients eligible for RVF are defined as the initial presentation of VF and still in ventricular fibrillation at the time of analysis after 3 or more consecutive standard defibrillation attempts. (3) Literature published in English and available in the full article.I2 was used to determine the magnitude of statistical heterogeneity in the literature. Meta-analysis was performed using a fixed-effects model when P ≥ 0.10 and 2I < 50% were considered to have no statistical heterogeneity; Meta-analysis was performed using a random-effects model when P < 0.10 or 2I ≥ 50% were considered to have statistical heterogeneity, and meta-analysis was performed after analyzing the source of heterogeneity and excluding the effect of significant clinical heterogeneity; when significant clinical heterogeneity existed, subgroup analysis or sensitivity analysis, or only descriptive analysis was performed.The literature was screened and managed using EndNote . Statistical methods were performed using Stata 14.0  software and RevMan 5.4 provided by the Cochrane Collaboration  software for meta-analysis. Differences in categorical outcomes were reported by risk ratio (RR) with 95% confidence interval (CI), mean difference, or standardized mean difference. The Q test (test level α = 0.1) combined with Two (YL and JY) investigators will independently evaluate each article and will perform title and abstract screening and full article screening, and in case of disagreement, resolve it through discussion or with the assistance of a third investigator. Information extracted included: author, year, research method, total sample size, gender, age, defibrillation mode, outcome events, survival to hospital discharge, and medication used. Tables were created using Microsoft Excel 2019 software to extract and record data from the literature. All studies considered eligible by title and abstract screening were reviewed in full by two independent reviewers (YL and JY) using the same criteria. The quality rating of each study was assessed independently by two reviewers (YL and JY), and any disagreements were subsequently resolved through discussion and involvement of a third reviewer (DL), and two (YL and JY) researchers independently assessed the risk of bias for the included studies. The risk of bias in individual studies was assessed using the Robins-I tool  for obseA total of 2345 studies were found in the search of the four databases. After removing duplicates of 912 studies, 1433 studies were screened for eligibility. These included 276 studies from animal studies, 47 studies from reviews and meta-analyses, 291 studies from case reports and case series (<5 patients), 32 studies from consensus guidelines and reports, and one unpublished article from clinical registry trials. 786 studies were eligible for full-text review, 776 studies were finally excluded after reading the title and abstract content, and ten studies  met the 2I = 46.9% < 50%), and P = 0.094 < 0.1 of the Q-test, suggesting that the heterogeneity among the article selected for this study was statistically significant, and further examining L’ Abbe Plot , the heterogeneity was acceptable for the meta-analysis using a random-effects model. The RR value for the six studies . The details are shown in the following forest plot  and P = 0.335 > 0.1 of the Q-test, suggesting that the heterogeneity between the literature selected for this study was not statistically significant and that the fixed-effects model could be selected for meta-analysis. The RR value for the two studies . The details are shown in the forest plot  and P = 0.015 < 0.1 of the Q-test, suggesting that the heterogeneity among the selected studies for this study was statistically significant, and further examining the L’Abbe Plot , and the fixed-effects model was used for the meta-analysis. The RR value for the four studies . The details are shown in the forest plot  and P = 0.222 > 0.1 of the Q-test, suggested that the heterogeneity between the literature selected for this study was not statistically significant, five studies . The details are shown in the forest plot  and P = 0.771 > 0.1 of the Q-test, suggested that the heterogeneity between the literature selected for this study was not statistically significant. Three studies . The details are shown in the forest plot  was not superior to standard defibrillation in terms of survival to good neurological outcomes in patients with RVF, and there was no significant difference between the two in good neurological recovery outcomes.2I = 0% < 50%) and P = 0.95 > 0.1 of the Q-test, indicating that there was no heterogeneity among the selected studies and that the fixed-effects model could be selected for meta-analysis. Sensitivity analysis was continued to ensure the accuracy and stability of the study. Sensitivity analysis was performed on these six studies . The details are shown in the forest plot  and P = 0.001 < 0.1 of the Q-test, suggesting heterogeneity among the papers selected for this study. The sensitivity analysis of five studies (2I = 20% < 50%), and P < 0.001 of the Q-test, there was no heterogeneity the studies selected for the fixed-effects model for meta-analysis. The MD value for the three studies . The details are shown in the forest plot  and P = 0.52 > 0.1 of the Q-test, suggesting that there was no heterogeneity between the studies selected for this study and that the fixed-effects model could be selected for meta-analysis. Sensitivity analysis was continued to ensure the accuracy and stability of the study. Sensitivity analysis was performed on the two studies . The details are shown in the forest plot  and P = 0.1 of the Q-test, suggesting that the mild heterogeneity between the studies selected for this study was within acceptable limits, and fixed-effects model was selected for meta-analysis. Sensitivity analysis was continued to ensure the accuracy and stability of the study. Sensitivity analysis was performed on these five studies . The details are shown in the following forest plot  and P = 0.002 < 0.1 of the Q-test, suggesting heterogeneity among the studies selected for this study. Sensitivity analysis of the four papers in this study revealed that the Sheldon Cheskes 2019 study , and a random-effects model was used for the meta-analysis. The SMD value for the three studies . The details are shown in the following forest plot (Four studies , 18, 19 19 study , 18, 19  studies , 18, 19 est plot .There was no difference in the dose of amiodarone used in patients during the rescue with DSED versus standard defibrillation, which was not statistically significant. There were no significant differences in the use of amiodarone doses during the rescue.From the nine included observational studies , 14–21, This systematic review and meta-analysis summarize 10 studies , 14–21 tA total of 1347 patients were enrolled in this study to assess whether DSED is more advantageous in the treatment of refractory ventricular fibrillation by observing the primary outcome. Heterogeneity tests, sensitivity analyses by L’ Abbe Plot and Radial Plot, forest plot representation by fixed-effects model or random-effects model, and bias tests by Begg’s test were used to draw the conclusions. The DSED was found to have no advantage in comparison with standard defibrillation for refractory ventricular fibrillation for ROSC, termination of RVF, survival to admission, survival to discharge, and good neurological outcome, with no statistically significant difference in the comparison.The analysis of the relevant factors affecting the outcome revealed differences and statistical significance in the comparison of the number of defibrillations and the dose of epinephrine used. There were no statistically significant differences in age, emergency medical system arrival time, or amiodarone dose, suggesting better homogeneity between the two groups in terms of these factors. The DSED did not show a significant advantage over standard defibrillation in the primary outcome, possibly because the number of defibrillations and epinephrine dose used had an impact on the outcome indicators, making the two groups less homogeneous and thus affecting the outcome. In this study, the number of defibrillations and the dose of epinephrine may have an impact on the results. The DSED was performed after three shocks, and the paramedics applied a second set of defibrillation pads and used two defibrillators to deliver two almost simultaneous defibrillation shocks for defibrillation attempts. Therefore, the total number of defibrillations was higher in the DSED group. Physiologic increases in the plasma epinephrine concentration may increase the number and energy of shocks needed to terminate VF , the DSEOur study has limitations. First, to safeguard the population in which the intervention was implemented in the study, we excluded various effects of passersby on the study that could have had additional effects on outcome indicators. Second, the literature search was limited to publications that were in English, and most of the studies we included were observational and susceptible to receiving confounding factors, as we attempted to reduce these effects by assessing and reporting the risk of bias. Third, with only 1 study in the entire study being an RCT and a limited sample size, the study still needs a large multicenter randomized controlled study to ensure the rigor of the study. Despite these limitations, our systematic review also has several strengths. This is the first analysis that combines the effects of relevant influencing factors on outcome indicators, ensuring the rigor of the systematic review and meta-analysis, controlling for confounding factors in the study, improving the quality of the study, and making it more convincing.This systematic review and meta-analysis compared the effect of DSED and standard defibrillation on the outcome of rescue in patients with RVF and did not find differences in termination of RVF, ROSC, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses. However, some differences were found in the number of defibrillations and the dose of epinephrine used during rescue. Considering the high number of confounding factors in this type of study, there is still a need to work on expanded clinical trials for this population and use real-world research data.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.YL designed the research question and drafted the manuscript. YL and JY reviewed all abstracts, selected full text for inclusion, and performed data abstraction. DL adjudicated any disagreements. XH, ZL, and XY performed the bulk of the analysis with input from YL. JY takes responsibility for the manuscript as a whole. All authors contributed substantially to its revision.


Background and objective: The worldwide prevalence of food allergies has been increasing recently. Due to limited data on food allergy (FA) in Saudi Arabia, this study was conducted to estimate the prevalence and risk factors of parent-reported food allergies and clinical manifestations in children in Taif, Saudi Arabia.Methodology: A cross-sectional questionnaire-based observational study was conducted from July 2019 to December 2020. A total of 508 parents of school children (aged five to eight years) responded to the questions based on the child’s health and food allergies.Results: FA (16.1%) was observed as the most common type of allergy among children. The prevalence of other atopic diseases was estimated at 30.5%. The most common allergy-causing foods were eggs (4.9%), peanuts (2.7%), and sesame (2.5%). Rash, itching without rash, and vomiting were the most common FA symptoms. The presence of childhood eczema (p< 0.0001), allergic rhinitis (p= 0.005), and the father’s history of allergy (p= 0.005) were all significant and independent predictors/risk factors for FA among the studied children.Conclusion: We noted substantial parents’ concern with food allergies among children in Saudi Arabia, which necessitates the establishment of effective diagnosis and treatment strategies and primary prevention initiatives. Food allergy (FA), according to the National Institute of Allergy and Infectious Diseases, may be defined as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food” . ChildhoManifestations of immunoglobulin E (IgE)-mediated FA vary and, depending on the intensity, they may range from cutaneous symptoms, such as pruritus, urticaria, and angioedema, to severe symptoms in the form of anaphylaxis involving multiple systems, including the respiratory, gastrointestinal, or even cardiovascular systems; in rare cases, it can be life-threatening, requiring hospitalization . The sevSeveral studies have shown that the prevalence of FA in children and related emergency hospital visits is increasing in developed countries, especially in the last decade -19. The Due to limited epidemiological data on childhood FA in Saudi Arabia, this cross-sectional study aimed to estimate the prevalence and manifestations of parent-reported FAs among school children in Taif, Saudi Arabia, and to assess the relationship between FA and identify factors associated with it.Study design and subjectsThis observational, cross-sectional, survey-based study was conducted from July 2019 to December 2020. A total of 508 parents with children aged five to eight years studying in 17 selected kindergartens (n = 9) and primary schools (n = 8) from all regions in Taif city, Saudi Arabia were enrolled. The population size was calculated based on the extrapolated data from the 2019 General Authority for Statistics of the Kingdom of Saudi Arabia. The calculated population of children aged five to eight years in Taif city was approximately 106,468.Data collectionData were collected using a study-specific questionnaire that was reviewed by two pediatric allergists for content validity and modified accordingly. It was further reviewed by noncontent experts to assess the clarity of the questions, and a final version was adopted thereafter. The questionnaire was divided into the following three sections: the first part was focused on demographic data, for instance, the child’s age, sex, nationality, parents’ age, and parent's level of education. The second part contained questions related to the parents’ atopic history, and the third section had four questions related to the child’s health and FAs (Appendix). Written informed consent was obtained from all participants  before starting the study. The study was approved by the Research Ethics Committee of Taif University . For distributing the questionnaire to the selected schools in different regions of the city, approval was obtained from the General Directorate of Education in Taif city.Statistical analysesThe data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) version 26 . Categorical variables are presented as frequencies and percentages and the chi-square test (χ2) was used to compare them. All p-values < 0.05 were considered statistically significant. We modeled the data using generalized linear multivariate logistic regression analysis. We have used a full model with a term representing every single demographic variable as a predictor and "reported food allergy" as the only predicted variable. Validation was performed using residual analysis in terms of assessment of randomness, plotting residuals against fitted values and leverage, standardized residuals against fitted values, and calculation of deviance value.Demographic characteristics of the study participants and childrenAltogether, 508 parents participated in the study and completed the questionnaire with valid responses on behalf of their children. The demographic characteristics of the participants and their children are summarized in Table Prevalence of parental-reported FAs and symptomsAltogether, 30.5% (n = 155) of the surveyed parents reported that their children had an allergy. FA was the most common allergic disease among the children, with a prevalence of 16.1%, while 30.5% of the children had other atopic diseases, including eczema, asthma, allergic rhinitis, and drug allergy. Approximately 54.3% of the fathers and 26.4% of the mothers reported having an allergic disease, with allergic rhinitis being the most common type among the parents . Meanwhile, FA was reported in only 1.8% of the fathers and 3.7% of the mothers , peanuts (17.1%), and sesame (15.8%). Similarly, among all the studied children, the most common food allergen was found to be eggs (4.9%), followed by peanuts (2.7%) and sesame (2.5%) . However, we could not identify a significant association between reported FA in children and a history of allergy in their mothers   or those who had any type of allergy , allergic rhinitis , or eczema  had a significantly higher risk of having FA than the other children  or only selected food allergens, or use of different protocols and definitions of FA. Moreover, self-reported FA prevalence is usually overestimated or higher than the actual physician-diagnosed prevalence, and the estimates confirmed by the gold standard of oral food challenges (OFCs), because of adverse food reactions, such as food poisoning, food intolerances, and enzyme deficiencies, being misinterpreted as FA ,29. In tSeveral latest research studies have delineated that in comparison to adults, children up to the age of 15 years are more likely to experience any type of allergies, including FAs ,36. AccoRegarding the foods that induced allergy among the children enrolled in the present study, eggs were the most frequently reported allergen, followed by peanuts and sesame, consistent with the findings of previous studies ,38,39. TIn this study, the most common FA signs were rash, itching without rash, diarrhea, and swelling of the lips and tongue. In a previous Saudi study, the most frequent symptoms were itching, swelling, and breathing alterations . The comSeveral risk factors leading to FA have been studied earlier and have been reviewed elsewhere ,46. The Prior studies have established a link between FA and a family history of allergies, with participants with a positive family history of allergies having a higher risk of food allergies than those with no family history of allergies . The infLimitations and strengthsThe use of a self-reporting questionnaire could have a recall bias. The questions in this survey had a high degree of complexity and were required to effectively identify food allergies. The intricacy of the questions was necessary to gain a better understanding of the respondents' allergies. Moreover, the use of a cross-sectional study design may have revealed the association between a few variables without investigation of the causal relationships. However, survey-based approaches can help capture even those patients with FAs who may not have received formal physician-led diagnoses or evaluations.This study in Taif, Saudi Arabia investigated sources of food allergens and the prevalence of self-reported FAs, as well as identified significant risk factors among children. Having eczema or allergic rhinitis in childhood and the father’s history of allergy were found to be significant and independent risk factors for a child’s reported FA; however, this association may require further investigation. It highlighted the importance of health education programs to increase awareness, knowledge, and perception of FAs and to support those with the burden of FA management. The data will help clinicians and policymakers to establish efficient treatment and primary interventions for FA prevention.