Data were analyzed using descriptive statistics. Thirty-eight percent of students experienced a change in food security as a result of the pandemic, with 59.6% becoming less food secure, and 40.4% becoming more food secure. Characteristics that were associated with changes in food security included changes in housing and employment status as a result of the pandemic. These findings suggest that the pandemic led to changes in food security among college students, and that economic relief efforts should include college students, who are disproportionately affected by food insecurity. While the Covid-19 pandemic has increased the number of food insecure households in the United States (US), it is unclear how it has affected college student food security status. College students are ineligible for many Covid-19-related economic relief programs and may find it even more difficult to cope during the pandemic. Therefore, the purpose of this study was to identify and describe the prevalence of food insecurity at a public university before and after the onset of Covid-19 as well as factors associated with any change in food security. Researchers administered a cross-sectional, non-probability survey to college students ( On 11 February 2020, the World Health Organization named the virus that was first identified in Wuhan China and later spread across the globe ,4,5. GovOne cause of financial hardship in the United States (US) is the rise in unemployment. The unemployment rate increased from 4% in March 2020 to 14.7% in April 2020 and has since fallen but not to pre-pandemic levels . In an eWhile many people are struggling financially during the pandemic, one population especially affected by Covid-19 is college students. Many college students will not be eligible for financial assistance during the Covid-19 pandemic. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, funds the Higher Education Emergency Relief Fund, which provides funding to institutions for emergency financial aid to students and suspends student loan payments for six months. The amount of money students receive varies based on their financial need and the way the university allocates the funding . One pubAlthough the USDA has responded to the Covid-19 pandemic to help families access food for a healthy diet, many college students will not be eligible for food assistance through these channels. College students are only eligible for SNAP benefits if they are enrolled in college at least half time and meet at least one of the following criteria: 17 years old or younger or 50 years old or older, have a disability, receive Temporary Assistance for Needy Families (TANF), work at least 20 h, participate in various work study or on-the-job training programs, or care for a child . A recenPrior to Covid-19, college students were disproportionately affected by financial stress and food insecurity. This has been attributed to more students with low income going to college, higher college costs, insufficient student aid, a weak labor market for part-time workers, and SNAP policies that exclude many students from participation, among other reasons . A 2017 While it has been well established that many students experience food insecurity during college and that the Covid-19 pandemic is creating a financial hardship for Americans, the literature is limited on changes in food security that college students are facing because of the Covid-19 pandemic. Therefore, the purpose of this study was to (i) identify and describe the prevalence of food insecurity at a public university before and after the onset of the Covid-19 pandemic and (ii) examine differences in academic and sociodemographic characteristics of students who experienced changes in food security as a result of Covid-19. A cross-sectional, non-probability, web-based  survey was completed by students attending a large, public land grant university. To improve survey validity, one validation question was included in the survey to address potential misreporting by participants. “Please answer ‘somewhat agree’ for this row. Thank you for reading carefully.” was placed within a question asking about feelings toward an on-campus food pantry. Participants who did not answer this question correctly were excluded from analysis. A sample of undergraduate and graduate students were asked to review the survey questions prior to survey distribution to ensure appropriate readability. The survey was distributed to all undergraduate and graduate students via email and was open for approximately 3.5 weeks between April 2020 and May 2020. This was several weeks after the onset of the Covid-19 pandemic and five weeks after the University transitioned students to online learning and postponed campus activities. Participants agreed to participate prior to taking the survey. Every third participant who completed the survey (up to the first 1200 students) received a $10 electronic gift card for participating. The study protocol received Institutional Review Board approval. The ten-item US Adult Food Security Survey Module was adapted to assess the prevalence of food insecurity before the Covid-19 pandemic (pre-Covid) and after the onset of Covid-19 (post-Covid-onset)  34]. Ei. Ei34]. Food security status was calculated by coding affirmative responses with a “1” and other responses with a “0” in accordance with the USDA Guide to Measuring Household Food Security to create raw composite scores for pre-Covid and post-Covid-onset time points . Raw scoChanges in food security status were calculated by comparing pre-Covid and post-Covid-onset raw scores. Participants were classified as less food secure at post-Covid-onset if their food security raw score was higher at the post-Covid-onset time point compared to the pre-Covid time point. Participants were classified as more food secure at the post-Covid-onset time point if their food security raw score was lower at the post-Covid-onset time point compared to the pre-Covid time point. Individuals who did not change food security status raw scores from pre-Covid to post-Covid-onset time points were categorized as no change in food security. This method of classifying changes in food security  was selected instead of measuring categorical changes  to better account for acute changes in food security brought on after the onset of the Covid-19 pandemic. Some participants who were classified as becoming more or less food secure may have stayed within the same food security status category . For example, a participant who received a raw score of 3 at the pre-Covid time point and raw score of 4 at the post-Covid-onset time point would be classified as becoming less food secure, though they remained in the “low food security” category. Participant characteristics, such as age, gender, ethnicity, race, living situation, university classification, residence status, employment status, Pell grant status, and financial status were collected. Additional questions were asked to assess changes in students’ sociodemographic characteristics since the Covid-19 outbreak, including, “Has your housing situation changed as a result of the Covid-19 outbreak?”, “Where are you currently living?” (if affirmative response to previous question), and “Has your employment status changed as a result of the Covid-19 outbreak?”.n (percentage) for categorical variables. Chi-square tests of independence were computed to determine if there were categorical associations between food security status and sociodemographic characteristics  for continuous variables and eristics  and betweristics . All expn = 3206) were primarily female (70.7%), non-Hispanic (79.0%), White (72.9%), in-state students (83.9%) who resided off-campus not with parents pre-Covid (71.9%). A mix of students, ranging from freshman to graduate students participated in the survey. Just over half of the sample (54.0%) was employed at least part-time pre-Covid, and 65.2% received financial support from their family pre-Covid.Participants (p = 0.007), race (p < 0.001), and ethnicity (p < 0.001). A greater proportion of students who identified as Hispanic/Latino experienced food insecurity compared to students who did not identify as Hispanic/Latino. Moreover, students who identified as Black/African American and other race/multiple races experienced food insecurity compared to students who identified as White or Asian. College student characteristics including university classification, residence status, and place of residence at the beginning of the Spring 2020 semester were significantly (p < 0.001) associated with pre-Covid food security status. Additionally, economic characteristics such as employment status at the beginning of the Spring 2020 semester, Pell grant status, and financial independence were significantly (p < 0.001) associated with pre-Covid food security status. Students who received a Pell grant and were financially independent experienced higher rates of food insecurity compared to other students in the sample. Pre-Covid food security status is displayed in p < 0.001) associated with pre-Covid food security status. Change in housing was significantly (p < 0.001) associated with change in food security status raw score after the onset of Covid-19. Over half (53.4%) of the sample experienced a change in housing situation, and a greater percentage of those who moved because of Covid-19 became more food secure compared to those who did not move . Nearly all students reported living off-campus after the onset of Covid-19 (94.2%), and approximately half (50.7%) reported living with parents. When only looking at the subset of students who experienced a housing change because of Covid-19, 88.6% moved in with parents. A similar percentage of students who moved in with their parents became less food secure (17.9%) as those who became more food secure (19.9%). Pre-Covid employment status (p = 0.005) and change in employment status because of Covid-19 (p < 0.001) were both associated with change in food security status raw score after the onset of Covid-19. Changes in employment because of Covid-19 were common, with 19.7% of students experiencing a loss of employment. A higher proportion of students who were employed fewer hours (28.7%) or no longer employed (31.0%) became less food secure after the onset of Covid-19 compared to students employed more hours (25.8%) or whose employment status did not change (19.1%). Gender (p = 0.010), ethnicity (p < 0.001), and race (p < 0.001) were all associated with changes in food security raw score after the onset of Covid-19. Students who identified as Hispanic/Latino were less likely to retain the same food security status at the two time points compared to non-Hispanic/Latino students . Over one quarter (28.1%) of Hispanic/Latino students became less food secure after the onset of Covid-19, and 19.7% became more food secure. Compared to other races, Asian students were more likely to become less food secure after the onset of Covid-19. Residence status was associated with change in food security raw score after the onset of Covid-19 (p < 0.001), with a greater proportion of international students (35.6%) becoming less food secure compared to in-state (22.2%) and out-of-state (19.1%) students. Additional characteristics associated with higher proportions of becoming less food secure after the onset of Covid-19 included being financially independent (p = 0.010) and being a Pell grant recipient (p < 0.001).Comparisons made in food security before and after the onset of Covid-19 were determined by comparing changes in food security survey raw scores. Approximately one in five students (22.6%) became less food secure after the onset of Covid-19, while 15% became more food secure. Change in food security raw score after the onset of the pandemic was significantly (n = 1218), 59.6% became less food secure, and 40.4% became more food secure. The aim of this study was to assess the food security status of students at a large public university prior to and after the onset of the Covid-19 pandemic. Data show that 24.8% of the students experienced food insecurity prior to the pandemic, and that 38.0% of students experienced a change in food security after the onset of the pandemic. Of those who experienced a change  had a change in housing after the onset of Covid-19. Of those who did experience a change in housing, the majority (88.6%) moved in with their parents. Interestingly, moving home did not help guarantee increased access to food with similar percentages of students becoming more food secure (17.9%) and less food secure (19.9%). Students were encouraged to return home if possible, during an announcement made on 11 March 2020 [One characteristic that was associated with a change in food security after the onset of Covid-19 was changing housing because of the pandemic. Over half of the participants , while the remaining were graduate students (45.9%). When the university president recommended that students return home in the Spring 2020 semester, he also announced that resources would remain open for students who could not leave campus . Dining Like the housing situation, students also experienced changes in their employment status due to Covid-19. When asked how employment changed after the onset of the pandemic, 19.7% of respondents answered that they were no longer employed, and 9.2% said they were employed fewer hours. This parallels the spike in unemployment that was seen in the United States after the onset of Covid-19  or federFood insecurity during college is associated with poor academic outcomes , poor sln = 3206). The timing of the dissemination of the survey and adaptation of the US Adult Food Security Survey Module questions allowed researchers to appreciate acute changes in food security that occurred just after the onset of the Covid-19 pandemic. Questions about changes in housing and employment status were added to the survey to better understand how college students were impacted by the pandemic. Finally, many demographic characteristics were collected to discover associations with food security before the pandemic and changes in food security after the onset of Covid-19. One limitation is the cross-sectional study design, which only provides a snapshot in time. Therefore, the researchers cannot assess changes in food security as the pandemic continued through the summer or attribute changes in food security specifically to the pandemic. The survey included questions that asked students to recall their food security situation currently (just after the onset of Covid-19) and over the past 12 months. Students may have experienced recall bias when answering these questions or other survey questions. Additionally, a convenience sample from one public university was used, which was not fully representative of all college students at the institution where the study was conducted, nor did authors post-stratify or weight the sample to account for this discrepancy.This study presents several strengths and limitations. The survey reached a large number of students (Taken together, findings from this survey revealed that many college students experienced a shift in food security after the onset of Covid-19, which may be related to the closure of college campuses, changes in housing situation, or changes in employment. Because college students may be missing out on economic and nutrition assistance during the pandemic, it is important that policies are enacted at the university, community, state, and/or federal level to alleviate the financial and health burden that college students are facing during the pandemic. University administrators must be aware of the lack of federal-  and stat


Respiratory syncytial virus (RSV) and influenza are prevalent seasonal community viruses. Although not completely understood, SARS-CoV-2 may have the same means of transmission. Preventive social measures aimed at preventing SARS-CoV-2 spread could impact transmission of other respiratory viruses as well. The aim of this study is to report the detection of RSV and influenza during the period of social distancing due to COVID-19 pandemic in a heavily affected community.Prospective study with pediatric and adult populations seeking care for COVID-19-like symptoms during the fall and winter of 2020 at two hospitals in Southern Brazil. RT-PCR tests for SARS-CoV-2, influenza A (Flu A), influenza B (Flu B) and respiratory syncytial virus (RSV) was performed for all participants.1435 suspected COVID-19 participants . were included between May and August. Median age was 37.7 years (IQR = 29.6-47.7), and 4.92 years (IQR = 1.96-9.53), for the adult and child cohorts, respectively. SARS-CoV-2 was positive in 469 (32.7%) while influenza and RSV were not detected at all.Measures to reduce SARS-CoV-2 transmission likely exerted a huge impact in the spread of alternate respiratory pathogens. These findings contribute to the knowledge about the dynamics of virus spread. Further, it may be considered for guiding therapeutic choices for these other viruses. Since December 2019 the world experienced the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 has spread throughout the world with a catastrophic impact not only on public health but also with significant social and economic burden. Brazil is currently the third most affected country, with 9 447 165 confirmed diagnosis of COVID-19 and 230 034 related deaths up to February 7, 2021 [The response to the pandemic has triggered a major change in overall human behavior, with social distancing measures, teleworking, closing of schools and daycare facilities, closing of businesses, strict hygiene behaviors, widespread use of face masks, travel restrictions, and avoidance of activities associated with population gatherings. Brazil has not been an exception to this new scenario, and while it took a while for efficient measures of social distancing to take place, schools and daycare facilities have been closed since mid-March and children have been home since then .As respiratory viruses such as influenza, respiratory syncytial virus (RSV) and SARS-CoV-2 share similar routes and means of transmission, these huge social efforts to prevent the spread of SARS-CoV-2 are also likely to affect the epidemiology of influenza and RSV . Both RSThe aim of this study was to report influenza and RSV diagnosis during the SARS-CoV-2 pandemic in pediatric and adult populations with suggestive symptoms of COVID-19 in two health care facilities that serve communities with very different socio-economic backgrounds in the city of Porto Alegre, during local well-defined influenza and RSV seasons .This prospective study was conducted from May 13 to August 31, 2020, in two general hospitals (one private and one public) in Porto Alegre, Southern Brazil, a city whose estimated population was 1 488 252 inhabitants in 2020 . ConsecuTM 1-Step RT-qPCR Master Mix, CG,  and TaqManTM 2019-nCoV Assay Kit v1 , the TaqManTM 2019-nCoV Control Kit v1  as reaction control. QuantStudio 5  was used to perform protein chain reaction. For RSV, Flu A and Flu B analysis, material from both nostrils were collected with the Xpert®Nasal Sample Collection Swab B/F-100 . and allocated in proper transport media . Samples were transferred and analyzed in Xpert®Xpress Flu/RSV cartridges  [RT-PCR tests were performed for SARS-CoV-2, influenza A (Flu A), influenza B (Flu B) and RSV for all included subjects. For SARS-CoV-2 analysis nasopharyngeal and oropharyngeal swabs were collected, both swabs allocated in the same transport media. The qualitative Real Time PCR (RT-PCR), was performed with TaqPathFor the statistical analyses, proportions of specimens positive for SARS-CoV-2, influenza, and RSV were stratified by age . Normally distributed quantitative data, according to the Shapiro-Wilk test, were expressed as mean ± standard deviation (SD), and non-normally distributed quantitative data were expressed by median and interquartile range (IQR). Categorical variables were described as absolute (n) and relative (%) frequencies.The study protocol was approved by the Institution’s ethics review board. Written consent was obtained from all participants and/or legal representatives. The study was conducted according to good laboratory practices and in accordance with the Declaration of Helsinki.A total of 1435 participants were included in the study from May 13 to August 31, 2020. Of the 1704 screened subjects, 269 were excluded , as shown in .SARS-CoV-2 was detected in 469/1435 (32.7%) participants . Percentage of weekly detection of SARS-CoV-2 varied from 2.2% at the beginning of the inclusion (May) to 54.3% towards the peak (July) of winter in adults, and from 0.0% to 43.8% in children, respectively. 1428 samples from the 1435 (99.5%) were processed for Flu A, Flu B and RSV, and they all resulted negative. Clinical, demographic, and laboratory information about all included patients is summarized in We have initially expected that COVID-19 frequencies should increase significantly during the fall and winter months, and that the usual patterns of community spread of RSV and influenza A and B would likely change due to public health measures taken to reduce transmission of COVID-19. Interestingly, we have observed a striking absence of these two usually prevalent pathogens in our cohort of symptomatic subjects, despite a detection of 32.7% of SARS-CoV-2. It is important to stress that the region has very well-defined and significant RSV and influenza seasonality yearly ,5. AlthoIn USA, Asia and Europe, a number of public health measures aiming to prevent the rapid spread of COVID-19 have started mostly at the end of the winter season. The findings of concomitant viral infections in these communities may have been biased by a natural decline in the incidence of both RSV and influenza, although an unprecedented drop in hospitalization due to RSV has been recently described in Alaska . Wu et aAnother possible explanation for lower influenza rates could be heightened awareness due the pandemic, with a subsequent increase in influenza vaccination numbers. However, in Brazil, influenza vaccination rates were 88.8% for the target population, similar to historical values . FurtherThe pattern of RSV was similar, with a significant reduction in the number of hospitalized cases with acute viral bronchiolitis throughout the whole country. In our region hospital admissions for infants were 85% lower than in the previous years . AlthougThere are a few limitations that may be worth addressing. Data refers to only one city in Brazil at only two health care facilities. Also, subjects were not enrolled using a population-based strategy. However, we believe that the large number of patients in the study, its prospective design, and the inclusion of children and adults from diverse environmental and social backgrounds evaluated throughout usual influenza and RSV seasons outweigh issues of external validity from a convenience sample.The complete absence of detection of influenza and RSV could raise an issue about the quality of our tests and the specimen collection, still we feel confident with our results. GeneXpert© provides a very automated process, less prone to human processing errors. Moreover, its internal controls (Sample Processing Controls and Probe Check Control) are able to check if there was enough nucleic acid in each sample. We do believe that both influenza and RSV are present in the community, but their numbers are so low that a sample of over 1400 subjects was not able to detect these pathogens.In summary, our study adds important information regarding the spreading dynamics of high burden respiratory viruses during a period of effective public health measures. The low incidence of RSV and influenza, in contrast with SARS-CoV-2 should be considered in the development of guidelines for antiviral treatment of influenza or in the prevention of RSV with monoclonal antibodies. Moreover, although maintenance such restrictions are not feasible continuously, similar measures could be adopted to control outbreaks due to these viruses. Further, as SARS-CoV-2 prevention depends currently only on non-pharmacological interventions, continuous monitoring of its transmission dynamics is necessary. Hygiene practice and social distancing measures appear to be associated with dramatic reduction of the spread of RSV and influenza.


Background: As age progresses, decline in physical function predisposes older adults to high fall-risk, especially on exposure to environmental perturbations such as slips and trips. However, there is limited evidence of association between daily community ambulation, an easily modifiable factor of physical activity (PA), and fall-risk. Smartphones, equipped with accelerometers, can quantify, and display daily ambulation-related PA simplistically in terms of number of steps. If any association between daily steps and fall-risks is established, smartphones due to its convenience and prevalence could provide health professionals with a meaningful outcome measure, in addition to existing clinical measurements, to identify older adults at high fall-risk.Objective: This study aimed to explore whether smartphone-derived step data during older adults' community ambulation alone or together with commonly used clinical fall-risk measurements could predict falls following laboratory-induced real-life like slips and trips. Relationship between step data and PA questionnaire and clinical fall-risk assessments were examined as well.Methods: Forty-nine community-dwelling older adults (age 60–90 years) completed Berg Balance Scale (BBS), Activities-specific Balance Confidence scale (ABC), Timed Up-and-Go (TUG), and Physical Activity Scale for the Elderly (PASE). One-week and 1-month smartphone steps data were retrieved. Participants' 1-year fall history was noted. All participants' fall outcomes to laboratory-induced slip-and-trip perturbations were recorded. Logistic regression was performed to identify a model that best predicts laboratory falls. Pearson correlations examined relationships between study variables.Results: A model including age, TUG, and fall history significantly predicted laboratory falls with a sensitivity of 94.3%, specificity of 58.3%, and an overall accuracy of 85.1%. Neither 1-week nor 1-month steps data could predict laboratory falls. One-month steps data significantly positively correlated with BBS  and ABC , and negatively correlated with fall history .Conclusion: Older participants with fall history and higher TUG scores were more likely to fall in the laboratory. No association between smartphone steps data and laboratory fall-risk was established in our study population of healthy community-dwelling older adults which calls for further studies on varied populations. Although modest, results do reveal a relationship between steps data and functional balance deficits and fear of falls. Falls are a common and a serious problem in older adults aged 60 years and above , demonstrated that fallers had lower PASE scores (less PA) compared to non-fallers and that the low scores were associated with high fall-risk and fear of falling  and commercially available (FitBit and Apple watch) motion sensors automatically track and store PA and thus effectively combat the issue of recall-bias. Such accelerometer-based wearable sensors are able to identify PA patterns  under both controlled laboratory conditions and uncontrolled, realistic conditions of daily living  due to the need of carrying an extra device and sometimes the cost associated with it , did not have entire 1 month smartphone data (n = 8) or if the smartphone steps data was not recorded even if the participants mentioned that they carried their phones (n = 5) or had incomplete laboratory data due to missing markers (n = 5). Ultimately, 49 participants were included in the final analysis , possessed a smartphone with the “Google Fit” application for Android phones or “Health” application for iPhones for steps data collection, and if they had installed and enabled their respective application for at least 1 month prior to screening. Exclusion criteria included participants with acute (<6 months) musculoskeletal conditions such as back pain or fracture or having a surgical history 6 months prior to the laboratory perturbation test. Seventy-six participants agreed to participate in this pilot study and were included in the initial screening. Participants were excluded if they did not pass the initial screening test ], balance confidence [Activities-specific Balance Confidence scale (ABC)], functional mobility [Timed Up-and-Go test (TUG)], and PA [Physical Activity Scale for the Elderly (PASE)]. The BBS assesses balance during functional tasks, and the scores range from 0 to 56 with higher scores indicating better balance and lower fall-risk . The unannounced release of the platform occurred at heel strike of the perturbed (right) limb, and, following the platform's release, it was free to slide a distance of up to 60 cm  for all variables including demographics, that is, age, height and weight, fall-risk measurements such as BBS, TUG, ABC, PASE as well as previous 1-year fall history and 1-week and 1-month smartphone steps. In addition, means and standard deviations were also calculated for each sub-category based on 1-month data . Paired Based on the results of the qualitative questionnaire, 12 older adults used Android phones whereas 37 used an iPhone. On average, participants carried their phones 9 h (9.06 ± 5.6 h) per day. Of all the participants, 38 reported they were active most of the time they carried their phones, 6 reported they were active even during the time they did not carry their phones, and 5 were unable to recall or answer the question. Only 11 participants owned a wearable device such as a Fitbit.t-test there was no significant difference in overall 1-week and 1-month step data or its sub-categories between fallers and non-fallers (p > 0.05). Based on the univariate regression analyses, age, and TUG were the only significant variables with the significance value set at p = 0.05 . The area under the curve (AUC) for the model was 0.807. A model before the final model included TUG in addition to variables age and fall history (Model 2). Addition of TUG in the final model (Model 2) improved the overall accuracy to 85.1% with a sensitivity of 94.3% and a better specificity of 58.3% (p = 0.002). The AUC of this model increased to 0.831 *TUG + (1.324)*History of fall. Based on this, the odds of falling for a person who had a fall history in the previous year would be 3.75 times more than those with no falls. Similarly, for each 1 s increase in TUG score (slower), the odds of experiencing perturbation-induced falls would be 1.69 times higher. Further, for every 1-year increase in age, the odds of falling on laboratory perturbation would be 1.22 times higher.Thus, participants who were older, had a higher TUG score (took longer to complete the test), and had a history of falls were more likely to fall during the laboratory-induced perturbations. The best logistic regression model which predicted immediate laboratory fall is represented as Predicted Logic of  = 18.175 + (0.207)r = −0.300, p = 0.046), indicating that the older participants carried their phones for less time than the younger ones. One-week steps data did not correlate with any clinical fall-risk measure and history of fall. However, 1-month steps data positively correlated with higher BBS  and ABC  scores and negatively correlated with previous 1-year fall history . Additionally, hours of phone carriage positively correlated with steps data  and, hence, was inputted as a covariate in logistic regression. There was no significant correlation between steps data and PASE score.Pearson correlations revealed a significant negative correlation between age and hours of phone carriage  with a sensitivity of 97.1%, specificity of 47.1%, overall accuracy of 83%, and AUC of 0.807, indicating that older adults with a previous history of fall were predisposed to a greater fall-risk during laboratory-induced perturbations. Our results are consistent with the previous literature indicating that older adults with a fall history have difficulty maintaining postural control and thus are at a higher fall-risk  than trip falls (n = 18). However, in spite of being a significant predictor in the univariate regression analyses, it was not included in the final multivariate logistic regression model comprising of age and fall history probably due to the opposite effect of walking speed on the recovery of slip and trip explained above (Model 1). Even though TUG was included in the second model, surprisingly the individual significance of the variables fall history and TUG was lost. This might possibly be because in Multivariate logistic regression analysis, the two variables are basically “competing” with each other for explaining laboratory falls.A model before the final model included TUG in addition to variables age and fall history (Model 2) with similar sensitivity of 94.3%, a better specificity of 58.3%, overall accuracy of 85.1%, and a higher AUC of 0.831. Additionally, TUG as a single factor had significant prediction for laboratory-induced falls, indicating that participants who took longer to finish the test had greater risk for laboratory-induced falls. Our results were similar to a previous study, wherein TUG was able to independently predict 60% of slip-induced falls  or smartphone is an insufficient tool in collecting steps data under free-living condition. Our study survey indicated that only 22.44% (11/49) of participants in the current study had access to an extra wearable PA tracker (Fitbit). Thus, older adults majorly relied on smartphones for PA monitoring. However, a few study participants mentioned in the survey that they only carried their phones when going outside. Thus, we might have missed out on data when older adults were physically active but not carrying their phones, especially when they were walking inside their homes while performing daily routine activities. Moreover, participants were not given any instruction by the experimenter on the way they should carry their smartphone. Thus, the participants could have carried their smartphones in many different manners, and the phones could have recorded steps differently based on their position and orientation , the potential of smartphones to be used as a screening tool to identify older adults with reduced balance and balance confidence needs further investigation.The correlation between the ABC scale could also be expected and justified. It is known that any improvements in balance and stability may aid in reducing both fall-risk and the subsequent fear of falling in older adults  which could have affected the step data accuracy. However, these factors could not be controlled due to the design of the study aiming at maximally collecting data in a natural manner and environment. Future studies could conduct studies with a uniform type of hardware (smartphone) and software (application) and additionally use wearable motion sensors to validate the association between daily steps data and older adults' fall-risk in response to laboratory-induced, real-life like external environmental perturbations. Lastly, study participants were among the healthiest community-dwelling older adults with a good physical performance and scores on clinical measurements. Hence, it is unknown whether current findings would also apply to frail older adults who are more susceptible to falls.The study revealed no association between smartphone steps data and laboratory fall-risk in a group of community-dwelling older adults with good physical performance. However, being the first of its kind, the current results could be leveraged to design further studies intending to use smartphone step data for fall-risk prediction. Further, the study reinforced previous findings that, older participants with fall histories and higher TUG scores were more likely to fall in the laboratory.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board at the University of Illinois at Chicago. The patients/participants provided their written informed consent to participate in this study.YW, RG, and TB made substantial contributions toward conception, design, and execution of the study. YW, RG, LK, and EW organized the data and performed statistical analysis. YW, RG, TB, EW, LK, and AS contributed in drafting the manuscript and revising it to create a final version for submission. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The cluster randomized controlled trial on (cost-)effectiveness of integrated chronic obstructive pulmonary disease (COPD) management in primary care (RECODE) showed that integrated disease management (IDM) in primary care had no effect on quality of life (QOL) in COPD patients compared with usual care (guideline-supported non-programmatic care). It is possible that only a subset of COPD patients in primary care benefit from IDM. We therefore examined which patients benefit from IDM, and whether patient characteristics predict clinical improvement over time.Post-hoc analyses of the RECODE trial among 1086 COPD patients. Logistic regression analyses were performed with baseline characteristics as predictors to examine determinants of improvement in QOL, defined as a minimal decline in Clinical COPD Questionnaire (CCQ) of 0.4 points after 12 and 24 months of IDM. We also performed moderation analyses to examine whether predictors of clinical improvement differed between IDM and usual care.Regardless of treatment type, more severe dyspnea (MRC) was the most important predictor of clinically improved QOL at 12 and 24 months, suggesting that these patients have most room for improvement. Clinical improvement with IDM was associated with female gender (12-months) and being younger (24-months), and improvement with usual care was associated with having a depression (24-months).More severe dyspnea is a key predictor of improved QOL in COPD patients over time. More research is needed to replicate patient characteristics associated with clinical improvement with IDM, such that IDM programs can be offered to patients that benefit the most, and can potentially be adjusted to meet the needs of other patient groups as well.NTR2268. Registered 31 March 2010.Netherlands Trial Register,  Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder with a high burden of disease. It is a growing problem worldwide, due to continued exposure to risk factors such as smoking . COPD trWhich baseline characteristics are related to clinically relevant improvement in COPD-specific health-related QOL after IDM or usual care, at 12-month and 24-month follow-up?Does treatment condition  moderate relations between baseline characteristics and clinically relevant improvement?As far as we know, no studies to date have examined this question in IDM programmes, although there are studies which addressed this in the context of self-management. These are relevant for the current investigation because self-management is an important element of IDM programs for COPD patients . An indiThis exploratory post-hoc study is embedded within the RECODE study. The RECODE study was a pragmatic 1:1 cluster randomized controlled trial with 12-month and 24-month follow-up that assessed the long term (cost-)effectiveness of IDM incorporated in primary care in COPD patients , 15. TheThe IDM intervention included a two-day training in essential components of COPD IDM for general practitioners, practice nurses and specialised physiotherapists. They received information on proper diagnosis, optimizing medication adherence, motivational interviewing, smoking cessation counselling, applying self-management plans including early recognition and treatment of exacerbations, and physical (re)activation and nutritional support, and they were trained in using an IT application that aimed to facilitate communication within the team and with patients. Subsequently, each primary care team designed its own practice plan to implement IDM in daily practice. Usual care was based on Dutch general practice COPD guidelines, in line with GOLD guidelines , 25, andPatients were included if they were diagnosed according to national/international guidelines with COPD by their treating physician. Patients were invited for formal lung function assessment if spirometry data were unavailable. Exclusion criteria were terminal illness, dementia or cognitive impairment, abuse of hard drugs or alcohol and inability to fill in Dutch questionnaires. In total 1086 COPD patients were included. Participant characteristics are provided elsewhere , 14.Several variables were assessed in the RECODE trial, of which those relevant to the current analyses are reported below.Socio-demographic factors. Participants provided their gender; age; living condition ; and socioeconomic status based on their educational level ; and employment status.Lung function and symptoms. We extracted Forced Expiratory Volume in 1 s (FEV1), post-bronchodilator, % predicted according to age and height from medical files. FEV1 was measured by practice nurses or respiratory nurses if unknown. Dyspnea was assessed with the Medical Research Council [MRC] Dyspnea Scale), with 2 as cut-off value for dyspnea  minutes, measured by the International Physical Activity Questionnaire [IPAQ] [e [IPAQ] ; and sele [IPAQ] .Clinical COPD Questionnaire (CCQ). Clinical improvement was assessed with the CCQ, a 10-item COPD-specific QOL questionnaire that includes a symptoms, functional and mental domain [l domain . Each itl domain , 31. Thel domain , 32. In p < 0.05) were then added to the multivariable model to examine which characteristics were independently related to clinical improvement. Sensitivity analyses were performed by repeating this procedure with the numeric CCQ difference scores as outcome variables, using univariable and multivariable linear regression analyses. We also performed generalized linear mixed model (GLMM) analyses to account for the effect of clustering, with cluster team added as random effect . Specifically, for each time point and group we first performed univariable logistic regression analyses with the dichotomous CCQ improvement variable as outcome. Significant predictors , as well as the treatment condition variable, in Step 1. The interaction between the treatment condition variable and a specific predictor  was entered in Step 2. Participants with full data for the variables included in a specific model were included in the respective analysis. We ensured that assumptions of all analyses were met. Statistical analyses were performed using IBM Statistics SPSS version 23.One hundred and eighteen (23%) patients in the intervention group of 514 patients that completed 12-month follow-up were classified as improved patients, compared to 134 (28%) in the control group of 476 patients. Furthermore, at 12-month follow-up 136 (26%) and 146 (31%) patients in the intervention and control group, respectively, showed a clinically significant deterioration, and 260 (51%) and 196 (41%) intervention and control patients, respectively, did not show clinically significant change. At 24-month follow-up, 57 patients in the intervention group (14% of 394 patients) and 55 patients in the control group (15% of 363 patients) were classified as improved patients. In addition, 195 (49%) intervention and 172 (47%) control group patients deteriorated compared to baseline, and 142 (36%) and 136 (37%), respectively did not show clinically significant change.In the univariable analyses, clinical improvement with IDM at 12-month follow-up was more likely in female and lower-SES patients, and in patients with an MRC dyspnea score > 2, and higher scores on the Charlson co-morbidity index . Improvement in CCQ from baseline to 24-month-follow-up was related to being female, younger, and having a depression in univariable analyses. In the multivariable model, the effects of gender  and age  remained significant, whereas the effect of depression became nonsignificant . MRC dyspnea score did not emerge as a significant predictor in these analyses.Univariable linear regression analyses showed that only lower SES predicted change in CCQ at 12 months , such that those with lower SES showed more improvement from baseline to 12-month follow-up than those with middle or higher SES . Improvement at 24 months was related to higher FEV1% predicted scores, and presence of hypertension and depression in the univariable analyses. The multivariable model showed that improvement was significantly related to higher FEV1 scores  and hypertension , but not to depression .Univariable linear regression analyses showed that patients with higher FEV1% predicted scores showed stronger improvement in CCQ from baseline to 12-month follow-up  indicating higher disease burden, such that they may have had more room for improvement in general. In line with this reasoning, female patients in previous studies showed more emotional and psychosocial benefit from pulmonary rehabilitation compared to males [This exploratory study examined which COPD patients benefit most from an integrated disease management (IDM) program or usual care in a primary care setting, in terms of clinically relevant improvement in COPD specific health-related QOL (CCQ), in a study that revealed overall no effect. Baseline MRC dyspnea scores appeared most important for clinical improvement , such that patients with more severe dyspnea in either group were more likely to have improved at 12-month follow-up, and this effect remained at 24-month follow-up in the intervention group. This finding is in line with previous studies showing that MRC dyspnea scores are important for clinical improvement , 34. In to males , 36. Furto males , 36–39. Finally, although some predictors were related to improved QOL regardless of how improvement was defined , FEV1% predicted scores only predicted numeric change scores but not clinically relevant improvement. This could be because both  changes in CCQ scores and FEV1% predicted scores are not directly noticeable to patients in daily life. That is, patients’ objective lung function may not be directly related to their experienced level of disease burden, such that patients with relatively well maintained lung function may experience high burden of disease, whereas patients with a worse lung function may experience fewer limitations . FurtherThis study has several limitations. First, this post-hoc study was embedded in the RECODE study which had a different primary aim and was not powered for subgroup analyses, and several statistical tests were performed . The results of our study should therefore be considered as hypothesis generating, rather than confirming or rejecting specific directional hypotheses with regard to treatment type and patient subgroups . Second,In this study, more severe dyspnea was the most important predictor of clinically improved QOL, regardless of treatment type. This suggests that these patients have most room for improvement, but should not necessarily be assigned to an IDM program, because the interaction term was not statistically significant. Clinical improvement with IDM was associated with female gender (12-months) and being younger (24-months), and improvement with usual care was associated with having a depression (24-months). More research is needed to replicate patient characteristics associated with clinical improvement with IDM, such that IDM programs can be offered to patients that benefit the most, and can potentially be adjusted to meet the needs of other patient groups as well. In addition, it would be useful to know which patients respond best to which intervention components .Additional file 1. Supplementary Material. Predictors of clinical improvement with IDM in the intervention group (12-months follow-up): Generalized linear mixed model.


Tracking COVID-19 infections in the care home population has been challenging, because of the limited availability of testing and varied disease presentation. We consider whether National Early Warning Scores (NEWS/NEWS2) could contribute to COVID-19 surveillance in care homes. We analysed NEWS measurements from care homes in England (December 2019 to May 2020). We estimated pre-COVID (baseline) levels for NEWS and NEWS components using 80th and 20th centile scores for measurements before March 2020. We used time-series to compare the proportion of above-baseline NEWS to area-matched reports of registered deaths in care home residents from the Office for National Statistics We analysed 29,656 anonymised NEWS from 6,464 people in 480 care home units across 46 local authority areas. From March 23rd to May 20th, there were 5,753 deaths  in corresponding geographical areas. A rise in the proportion of above-baseline NEWS was observed from March 16th 2020. The proportion of above-baseline oxygen saturation, respiratory rate and temperature measurements also increased approximately two weeks before peaks in deaths. We conclude that NEWS could contribute to disease surveillance in care homes during the COVID-19 pandemic. Oxygen saturation, respiratory rate and temperature could be prioritised as they appear to signal rise in mortality almost as well as total NEWS. This study reinforces the need to collate data from care homes, to monitor and protect residents’ health. Further work using individual level outcome data is needed to evaluate the role of NEWS in the early detection of resident illness.


Hedgehog (Hh) signaling aberrations trigger differentiation and proliferation in colorectal cancer (CRC). However, the current approaches which inhibit this vital cellular pathway provoke some side effects. Therefore, it is necessary to look for new therapeutic options. MicroRNAs are small molecules that modulate expression of the target genes and can be utilized as a potential therapeutic option for CRC. On the other hand, nanoformulations have been implemented in the treatment of plethora of diseases. Owing to their excessive bioavailability, limited cytotoxicity and high specificity, nanoparticles may be considered as an alternative drug delivery platform for the Hh signaling mediated CRC. This article reviews the Hh signaling and its involvement in CRC with focus on miRNAs, nanoformulations as potential diagnostic/prognostic and therapeutics for CRC. Colorectal cancer (CRC) is one of the leading causes of death globally with incidence rate around two million . A numbeMolecular link of Hh signaling with cancer was reported in basal cell carcinoma when mutation in human PTCH1 gene was observed , 13. It +/− mice models, inhibition of Hh signaling is an approach to limit cancer cell proliferation (ᾳ (PDGFR-ᾳ). Furthermore, molecular crosstalk of Hh is reported to interplay with many other pathways including NOTCH, mTOR, Wnt, Muc5, EGF, IGF, TGF-β, RACK1, and PKC in different types of cancers  is a natural compound and has been used for years as a potential compound among traditional Chinese medicines against multiple cancers. In vitro and in vivo clinical trials have proved that its ethanol extract of SB is an effective agent to induce apoptosis and limit cancer cell proliferation  is a key culprit in the metastasis, invasion, and proliferation of various cancer cells. Ample lines of evidence have shown that expression of miR-150 declines with the pathogenesis of CRC. NCM-460 and SW-620 CRC cell lines were examined by using dual luciferase assay to decipher the molecular relation of miR-150 with GLI-1, and it has been noted that miR-150 inhibits the expression of GLI-1 protein in Hh signaling . MoleculExtensive research work on miRNAs has been done in recent years to unfold the molecular complexity of carcinoma and to bridge the gap towards new and effective therapeutic approaches. miR-338-3p interaction with hedgehog pathway by using recombinant lentiviral vectors PLV-THM-miR-338-3p and PLV-THM-miR-338-3p inhibitor has been reported and successful transfection in SW-620 CRC cells was achieved. Increased expression of miR-338-3p was observed, it significantly suppresses SMO protein and inhibits proliferation ability. Molecular interplay of miR-338-3p is also confirmed by using PLV-THM-miR-338-3p inhibitor, and it was concluded that it upregulates the SMO protein expression to initiate hedgehog signaling pathway and induces CRC onset. miR-338-3p could be a therapeutic agent to suppress CRC growth by targeting SMO, 3 94). . 94). NoAccumulation of genetic and epigenetic errors can trigger the aberrant signaling cascades. miRNAs are the critical key players to fine-tune genetic expression upon exogenous factors including DNA hypermethylation, hypomethylation, histone modification, and deacetylation. Thus epigenetic-miRNA regulatory molecular cascades are the contributing agents for onset of different types cancers . TumorigCancer stem cells are the cells with self-renewal potential within the tumor and are the key responsible agent for radio- and chemo- resistance behavior of cancer cells. Increasing evidence strongly suggests that CSCs are the responsible factor for the onset of carcinogenesis in many human cancer types as cancer cells have self-renewable stem cell like characteristics. Several microRNAs expression have been associated to regulate cancer stemness pathways and its downstream targeting genes . Tumor c+/CD44+ and CD133−/CD44− surface phenotype antigen for comparative analysis. Researcher found 62 differentially expressed miRNAs in cancerous and non-cancerous stem cells and noted 31 miRNAs overexpressed including miR-29a and miR-29b, as well as 31 miRNAs under-expressed including miR-449a, miR-4524, and miR-451 ..166). Diferation .Oral chemotherapeutics are reported to have multiple limitations that demand novel alternative therapeutics for cancer treatment. Recently, the concept of oral nanotherapeutics paved the avenue in pharmaceutics towards more stable and high tumor targeted therapy with minimize adverse effects. A successful pre-clinical attempt has been performed by synthesizing redox nanoparticles (RNPs) for colon cancer treatment. This novel RNP contains nitroxide radicals for antioxidant activity and to scavenge ROS (reactive oxidative species) in cellular microenvironment. RNPs are specialized to accumulate in colonic mucosa and targeted cancer cells predominantly. These specialized oral-nanotherapeutics are also reported to limit cellular toxicity issues upon prolong exposure and is significant agent to inhibit tumor growth Figure 5in-vivo therapeutic studies. In one of the recent studies, SN38 (7-ethyl-10-hydroxycamptothecin) nanoparticles and water insoluble curcumin are proved to be a significant candidate to limit carcinogenesis and shrink tumor diameter >4 mm. Thus, bio-adhesive chitosan based stable colloidal nanotherapeutics is a novel and reliable approach to improve the outcome of colon cancer treatment . Compelling research has dictated the fact that only 0.7% of the total nanoformulation reaches the solid tumor (The Hh pathway is activated during regeneration and tissue repair in adults. Compelling pieces of evidence have indicated that inhibition of Hh pathway can prevent tumor progression and increased apoptosis. However, the clinical outcomes of such inhibition are unsatisfactory. The tumor heterogeneity and complex signaling crosstalk are the two major stumbling blocks that challenge the specificity of a specific Hh inhibitor. A tumor cell can trigger multiple signaling pathways simultaneously that can hamper the anti-proliferative abilities of a single inhibitor. Therefore, an outlook for new inhibitors of Hh signaling pathway that can hamper the activity of interconnected pathways is necessary. miRNAs have been reported to regulate the expression of vital genes involved in the proliferation and spread of CRC. They have been extensively examined for their putative role as diagnosis and prognosis markers for stratification of risk groups. Exploring the interplay between miRNAs and Hh signaling can aid in the development of therapeutics for Hh mediated CRCs. In addition to this miRNAs can regulate the cancer stem cells proliferation and metastasis . Therefoid tumor . This caZJ, MJ, and AR drafted the manuscript. HS, SR, AI, and WC revised the draft. HS, WK, WK-K, AG-L, JS-R, and WC conceptualized the study and reviewed it critically. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Purpose: To investigate the efficacy of fertility-sparing treatment for young women with grade 2 presumed stage IA endometrioid endometrial adenocarcinoma (EEA).Methods: We performed a retrospectively review of eight patients affected by grade 2 presumed stage IA endometrioid endometrial adenocarcinoma who underwent fertility-sparing treatment in the Peking Union Medical College Hospital between 2011 and 2018.Results: The median age of patients was 26 years . Complete response (CR) was found in seven of the eight cases. The median time to response was 3 months . Among patients who achieved CR, three had recurrence and were treated with second-line fertility-sparing therapy. Two of the three recurrent patients achieved CR, and one patient subsequently conceived. Pregnancies and successful deliveries were achieved in two of four patients. The average follow-up period was 31 months .Conclusions: Fertility-sparing therapy is a feasible treatment option in patients with presumed stage IA, grade 2 endometrial cancer. Although our results are encouraging, they are based on very limited numbers, and patients should be informed the risk of tumor progression during treatment. Further evaluations are still required before recommending fertility-sparing therapy to endometrial cancer patients with more advanced disease in routine practice. Endometrial carcinoma (EC) is the most common gynecological malignancy in the world. It is typically diagnosed in post-menopausal women. The standard treatment for EC consists of hysterectomy and bilateral salpingo-oophorectomy with or without pelvic and para-aortic lymph node assessment . This trApproximately 3–14% of endometrial cancer cases are diagnosed in women equal to or under 40 years of age who want to preserve their fertility , 3. The The medical records of patients with grade 2 presumed stage IA endometrioid endometrial adenocarcinoma (EEA) who underwent fertility-sparing treatment at the Peking Union Medical College Hospital between 2011 and 2018 were retrospectively reviewed. The Institutional Review Board (IRB) of “the Ethics Committee of Peking Union Medical College Hospital” approved the use of patients' clinical data for this retrospective study. Patients must be informed that data about fertility-sparing treatment are not so robust to draw firm conclusion due to the limitation in sample size of available studies, and, most importantly, there is a risk of disease progression during treatment or after the initial response. All patients were informed that hormone therapy is not the standard treatment and requires serial dilation and curettage (D&C) or hysteroscopy during treatment period. Inclusion criteria were fertile age (40 years or younger), desire to preserve fertility, and histologically proven grade 2 EEA, tumor presumed to be International Federation of Gynecology and Obstetrics (FIGO) stage IA limited to the endometrium. The diagnosis was confirmed by endometrial biopsy under hysteroscopy. All of the histological slides were reviewed by at least two pathologists specializing in gynecological oncology. All patients were evaluated by pelvic examination, ultrasound scan/abdominal, and pelvic computed tomography/pelvic magnetic resonance imaging at baseline to confirm tumor limited into the endometrium and no evidence of lymph node involvement or extrauterine metastasis.in vitro fertilization (IVF) immediately. Those with CR who opted to postpone pregnancy were prescribed oral contraceptives/progestin or LNG-IUS to prevent cancer recurrence.Patients were scheduled to receive medroxyprogesterone acetate (MPA) 500 mg qd or megestrol acetate (MA) 160 mg bid orally on a daily basis or the combination of intramuscular injections of 3.75 mg gonadotropin-releasing hormone agonist (GnRHa) every 4 weeks plus levonorgestrel-intrauterine system (LNG-IUS) inserted. Response was assessed histologically every 3 months after the start of treatment. Complete blood counts and biochemistry panels along with renal function and liver profiles were performed every month, and serum CA125 and pelvic ultrasound were carried out every 3 months. Endometrial tissue sampling for diagnosis should be carried out by hysteroscopy and endometrial curettage or D&C. All histology was reported by two expert pathologists specialized in gynecological oncology. Pathological response to MPA treatment was categorized as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). CR was defined as the absence of evidence of hyperplasia or carcinoma. PR was defined as histological regression or endometrial decidual change. SD was defined as the persistence of EC or AH. PD was defined as progression to a lesion of higher grade or clinically progressive disease including myometrial invasion, extrauterine disease, or lymph node metastasis . EvaluatBetween 2011 and 2018, there were eight patients included in this study . The medOf the eight patients, seven (87.5%) achieved CR. The median time to CR was 3 months . One patient (patient 2) changed therapeutic regimen in initial treatment due to no response to initial 3 months of progestin therapy. The only patient (patient 1) who failed to respond to initial 7 months of hormone treatment finally underwent hysterectomy with surgical staging. The post-operatively histopathological result showed FIGO stage IIIC1. This patient, who was treated with chemotherapy and radiotherapy after surgery, was alive and free of disease at last follow-up.in vitro fertilization and embryo transfer (IVF-ET). Patient 7 delivered successfully after the first recurrence and relapsed again with pathology of AH3. She achieved CR at 6 months after a third round progestin treatment using MA 160 mg bid after the second recurrence. Among the eight patients, one patient (patient 6) underwent hysterectomy according to the patient's decision even though she showed CR.Three of the seven who achieved CR  developed recurrent disease. The time to recurrence was 17, 24, and 36 months, respectively. After recurrence with G2-3 endometrial carcinoma, patient 4 who insisted on receiving 4 months of MA failed to respond. She underwent hysterectomy with surgical staging. The final pathology of the uterus was FIGO stage IIIC1 grade 3 EC, and she received chemotherapy post-operatively and was free of disease at last follow-up. The remaining two (patients 2 and 7) who still desired fertility were treated with second round of fertility-sparing management and got CR again. Patient 2 with the recurrent pathology of AH2-3 were treated with the combination of intramuscular injections of GnRHa every 4 weeks combined with LNG-IUS. She achieved CR again after 3 months and is undergoing Of the seven patients with complete remission, three patients desired to conceive immediately, and two patients had pregnancies and successfully delivered during the follow-up period.The remaining patients  are all alive and free of disease. The median follow-up of the eight patients was 31 months , with no disease-related death and no major adverse effects related to high-dose progestin.The incidence of endometrial cancer is increasing with lower average onset age, and most patients have not yet completed the reproductive function. Therefore, fertility-sparing treatment has received much attention during recent years. Since progesterone was first reported to be used in the fertility-sparing treatment of early endometrial cancer, researchers continue to validate that conservative treatment for young women with G1 EC and AH who desire to conceive is a safe and feasible therapy. Previous literature shows that oral progestin therapy can achieve CR rates ranging between 67 and 80% –8. Our rTo date, there are 15 articles regarding the fertility-sparing treatment of stage IA, G2 EC in young patients  Table 3Table 3. Conservative treatment of endometrial adenocarcinoma traditionally involved oral progestin therapy; more recently, many reports have introduced LNG-IUS alone or combined with GnRHa or oral progestin as an alternative to oral systemic progestin alone for the treatment of women with EC and AH , 27–30. Most of the patients who underwent hysterectomy after conservative treatment failure were confirmed to be early clinical stage, well-differentiated endometrioid adenocarcinoma, indicating the disease was less likely to progress during hormone therapy. However, in our study, one patient who failed to respond to 7 months of hormone treatment underwent staging surgery, and the final pathology suggested stage IIIC1 EC. According to the European Society of Gynecological Oncology recommendation, we should consider it unsuitable for patients with persistent or progressive disease after 6 months of progestin treatment to continue conservative treatment . As for There are few papers focusing on the pregnancy outcome of fertility-sparing treatment in patients with intramucosal G2-3 EC , 25, 27.Although our study is a single-center retrospective study with a limited number of cases, we believe it can provide useful clinical data to support the feasibility of conservative treatment in patients with stage IA G2 EC. Meanwhile, it is necessary to conduct a regional or international randomized clinical trial that focused only on fertility-sparing treatment in patients with stage IA G2 EC in order to clarify the oncologic and fertility outcomes. The fertility-preserving treatment for early EC should be performed on the basis of the following requirements: first of all, a good prognosis after fertility-sparing therapy ; second, in terms of overall survival rate, fertility-sparing therapy should be not inferior to standard surgical treatment. At present, G2 intramucosal endometrial cancer is a low-risk type that does not require adjuvant treatment after primary surgery. However, the long-term prognosis is not clear because of the limited number of cases. The follow-up time of this center is limited, and long-term follow-up of these patients will also be performed to verify long-term survival.Based on our own encouraging results, fertility-sparing treatment can be a feasible and effective option for patients with grade 2 presumed stage IA EC without myometrial invasion who desire to preserve their fertility. However, conservative management in this population should still be considered with caution, and patients need to be monitored more closely so that fertility-sparing treatment can be terminated in time when patients failed to respond to treatment.The datasets generated for this study are available on request to the corresponding author.This retrospective study had obtained approval of the Institutional Ethical Committee of Peking Union Medical College Hospital. All patients had signed an informed consent.MY, JY, DC, and KS: conceived and designed the study. MY, JY, DC, and XH: data acquisition. YW, MY, ZY, and XZ: analyzed the data. MY: wrote the original draft. YW, MY, JY, DC, and KS: wrote, reviewed, and edit. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Zea mays L.) production constraint in sub-Saharan Africa. Fourteen, fifteen, and twenty-five extra-early maturing maize cultivars, with varying Striga resistance and drought and low soil N tolerance, were developed from 1995 to 2000 (Period 1), 2001 to 2006 (Period 2), and 2007 to 2012 (Period 3), respectively. The objectives of this study were to examine yield gains in the cultivars and to investigate inter-trait relationships and yield stability under six drought and 17 rainfed conditions in West Africa from 2013 to 2016. Annual rate of yield increase across cultivars was 0.034 (3.28%) and 0.068 Mg ha−1 (2.25%), whereas yield gains per period were 0.17 and 0.38 Mg ha−1 under drought and rainfed environments, respectively. Yield gains under drought and rainfed environments were related to prolonged flowering period, increased plant and ear heights, improved stalk lodging, and ear and plant aspects, whereas delayed leaf senescence and increased number of ears per plant accompanied yield improvement under drought only. Ear aspect and number of ears per plant were primary contributors to yield and could be used as selection criteria for yield enhancement under drought and rainfed conditions. High-yielding and stable cultivars across all environments based on additive main effects and multiplicative interaction (AMMI) biplot included ‘2004 TZEE-Y Pop STR C4’ and ‘TZEE-W Pop STR BC2 C0’ of Period 2 and ‘2009 TZEE-W STR’, ‘TZEE-Y STR 106’, ‘TZEE-W STR 107’, and ‘TZEE-W DT C0 STR C5’ of Period 3. These cultivars could be commercialized to improve food self-sufficiency in sub-Saharan Africa.Drought is a key maize ( MAIZE (Zea mays L.) is a major staple crop in West and Central Africa (WCA). The development and commercialization of extra-early maize that matures in 80 to 85 d have made it possible for maize to spread into the savannas of WCA. This has resulted in the expansion of the crop and rapid replacement of the traditional crops, including the indigenous sorghum [Sorghum bicolor (L.) Moench] and pearl millet [Pennisetum glaucum (L.) R. Br.], particularly in the savannas of WCA. This is attributable to the fact that extra-early maize cultivars respond better to application of fertilizer, have a shorter growing cycle, and are ready for harvest much earlier than the indigenous sorghum and millet crops. In addition, as a result of the dry spell usually experienced from November of each year to March of the following year, early and extra-early crops are preferred to reduce the hunger gap in July of each year because of the shorter maturity period of the crop. An important factor constraining maize production in the savanna agroecology is drought, which accounts for huge yield losses annually in sub-Saharan Africa (SSA). Global warming, which is usually associated with irregular rainfall patterns, calls for an urgent and effective genetic intervention to increase grain yield and tolerance to drought stress  under natural drought, low N, optimal conditions, and infestation of the Maize streak virus (MSV), respectively, in Eastern and Southern Africa (ESA). Genetic gains under random drought, low-N, rainfed, and MSV-infested conditions for the intermediate-late-maturing cultivars were reported to be 0.042, 0.053, 0.079, and 0.109 Mg ha−1 yr−1, respectively ; the N levels were used as main plots and the six hybrids as subplots. Results revealed that mean grain yield increased by 48.4 and 62.4%, as N increased from 0 to 30 kg ha−1 and from 30 to 90 kg ha−1, respectively . The two hybrids of the 2000 era were outstanding in all the agronomic traits and leaf chlorophyll concentration at all N levels. It was concluded that improving traits associated with fertilizer N response could accelerate rate of genetic gains in maize hybrid yields. In another study conducted by Badu-Apraku et al. (−1 era−1 (13.29%) under low N and 0.493 Mg ha−1 era−1 (16.84%) under high N. In a similar study conducted between 1988 and 2010 under induced drought stress and optimal (stress-free) growing conditions, Badu-Apraku et al.  and husk cover (HUSK), whereas under optimal conditions, yield gains were associated with improved PASP and ear aspect (EASP), increased number of ears per plant (EPP), increase in PHT and ear height (EHT), and improved HUSK. Badu-Apraku et al.  to the third era (2007–2012) cultivars, respectively. Despite the results of these studies, there is complete lack of information on yield gains and changes in other agronomic traits of extra-early-maturing cultivars of the three breeding periods under drought stress and optimal growing conditions. Furthermore, information on trait association during the different breeding periods is crucial for identifying valuable traits and different breeding strategies for enhancing progress in improving extra-early maize for stress tolerance  and yellow (TZEE-Y Pop STR) source populations of extra-early maturity. After genetic enhancement of these populations, a large number of cultivars and inbred lines of extra-early maturity, combining drought tolerance and resistance to S. hermonthica and MSV, were extracted from each population. Several extra-early inbred lines in the IITA Maize Program possessed drought escape mechanism(s) and drought tolerance genes. It was therefore expected that the inbred lines would withstand the drought stress occurring during flowering and grain filling in the savannas of WCA, as had been observed in cultivars of other maturity groups. Thus, a tremendous opportunity existed for improvement of the performance of the cultivars in the program by introgressing genes for improved tolerance to drought and Striga resistance. We recognized at the very early stages of the IITA extra-early maize improvement program that several genes governed the expression of drought tolerance in maize. Therefore, a major strategy of the program was to adopt various methods to identify maize inbred lines with tolerance to drought from diverse germplasm sources. Since 2007, various strategies have been used in the program for the genetic enhancement of the populations for drought tolerance at various testing sites in Nigeria. The focal point of the IITA extra-early-maturing maize program for improving adaptation to drought has been to screen maize inbred lines from diverse genetic backgrounds for tolerance to drought under managed moisture stress at Ikenne . The soil at the Ikenne experiment station is classified as eutric nitrosol .Badu-Apraku and Fakorede  describe5) and the extra-early yellow (TZEE-Y Pop STR C5) Striga-resistant source populations was improved by introgressing drought and low-N tolerance genes from 19 white and 20 yellow extra-early inbred lines with elevated levels of tolerance to drought and/or low N , possessing enhanced drought tolerance and Striga resistance, were used for the present study .By 2007, extra-early inbreds and hybrids that possessed genes for tolerance to drought during flowering and grain-filling periods, and which were also capable of escaping drought (characteristic of extra-early-maturing cultivars) and had low-N tolerance genes, had been identified  was applied to the managed drought stress experiments during planting, whereas 60 kg N ha−1 was top-dressed at 2 WAP. However, for terminal drought and rainfed environments, basal fertilizer application rates were 60 kg ha−1 each of N, P and K at 2 WAP and 60 kg of N ha−1 at 4 WAP. Crop management practices were similar for both drought stress and rainfed experiments. Weeds were controlled manually, as well as through the use of herbicides, as needed.The extra-early cultivars were evaluated under six induced or terminal-drought environments in Nigeria and Ghana and 17 optimal environments in Ghana, Republic of Benin, and Nigeria, from 2013 to 2016 . The drought trials at Ikenne were planted during the dry season, and 17 mm of water was supplied to the plots weekly using the sprinkler irrigation system. To create induced drought stress at this location, the drought trials were irrigated for only the first 21 d after planting, causing the maize plants to rely on residual moisture in the soil for growth and development. In contrast, terminal drought was achieved by delaying the planting of the trials such that the occurrence of drought stress coincided with 1 to 2 wk before flowering. Optimal environments used in the present study refer to environments where water and N were adequate for plant growth and development. An eight-by-seven lattice design, with three replications, was adopted for the trial. Each experimental unit comprised two 4-m-long rows, with inter-row spacing of 75 cm and a spacing of 40 cm between plants within rows. Initially, three seeds were planted per hill, and 2 wk after planting (2 WAP), thinning was done to two seedlings per hill to obtain a final population density of 66,666 plants ha−1 moisture and estimated from the shelled grain weight. In the rainfed experiments, grain yield was determined from ear weight using 80% shelling percentage, adjusted to moisture content of 150 g kg−1.Data were recorded on the measured traits as described in detail by Badu-Apraku et al. . Brieflyb value) under drought stress and rainfed environments. The relative genetic gain per year was estimated as the b value divided by the intercept and multiplied by 100  for grain yield were computed for each environment, and all the environments included in the present study revealed an H2 value of 0.30 . The H2 of grain yield and other traits were estimated as follows:Observations recorded on plot means for grain yield and other agronomic traits were subjected to ANOVA for drought stress and rainfed environments separately using PROC GLM statement of SAS 9.3 , and σ2 is the error variance.where P ≤ 0.05, which were categorized as first-order traits. The first-order traits thereafter were each regressed on other traits that were not in the first-order category, to identify traits with significant contributions to grain yield through the first-order traits. These traits were classified as second-order traits. The same procedure was repeated to identify third-order trait(s), and so on. The path coefficients were obtained from the standardized b values of the stepwise regression analysis  + EPP − ASI − PASP − EASP − STGR]Based on this characterization, 35 cultivars  were selected for stability analysis. The additive main effects and multiplicative interaction (AMMI) analysis was adopted to investigate the relationships among cultivars, environments, and GEI components of the yield of the selected 35 extra-early cultivars. The AMMI model partitioned GEI into several interaction principal component axes (IPCAs) through principal component analysis  were obtained for grain yield, DA, DS, PHT, EHT, and EPP, whereas significant negative b values were observed for SL, PASP, EASP, and STGR. The same set of traits showed similar trends under rainfed environments, except EPP, for which no significant gain was obtained; STGR was not measured under rainfed environments  produced yield lower than those of Period 1 cultivars. The extra-early Period 3 cultivars exhibited the most outstanding performance under both drought stress and rainfed environments. The grain yield of the cultivars under drought stress adequately predicted the yield performance of the cultivars under rainfed environments and vice versa  as the first-order traits . These ty ordinate). The stable cultivars were those placed close to the horizontal line, with little interaction with the environments, whereas the less stable cultivars were those farther from the horizontal line. The high-yielding cultivars were placed to the right of the grand mean line, and the farther such cultivars were from the grand mean, the greater their grain yield. Across drought and rainfed environments, the percentage contributions of environment, cultivar, and IPCA 1 to the total variation in grain yield sum of squares were 80.78, 9.22, and 2.8, respectively. The 84.6% of the grain yield sum of squares captured by AMMI analysis was a clear indication that the biplot was effective in decomposing the GEI across drought stress and rainfed environments . Similarly, significant mean squares observed for environments for all measured traits under drought and rainfed environments were an indication that the environments were unique in their ability to discriminate among the cultivars under drought and rainfed environments. These findings corroborate results reported by Badu-Apraku et al. , who com−1 yr−1 under drought conditions, and 2.25% annual yield gain corresponding to an annual increase of 0.068 Mg ha−1 under rainfed conditions, which are greater than the yield gains obtained for the early-maturing cultivars reported by Badu-Apraku et al. (−1) and 1.3% (0.040 Mg ha−1) under drought and well-watered conditions, respectively. The annual yield gain obtained for this set of extra-early maize cultivars under drought was also higher than the annual yield gains of 2.56% reported under artificial Striga infestation . The implication of this result is that the performance of the cultivars relative to grain yield under drought is a reliable indicator of expected yield performance of the cultivars under rainfed environments, and vice versa. Therefore, cultivars with outstanding performance under drought stress also display superior grain yield under rainfed conditions, and vice versa. Similar results were obtained by Badu-Apraku et al.  and under rainfed conditions (0.068 Mg ha−1), it can be concluded that considerable progress has been made during the last three decades in the genetic enhancement of extra-early maturing maize cultivars for drought tolerance in WCA. The availability of these extra-early cultivars is expected to contribute to improved food self-sufficiency, farmers’ incomes, and farmers’ livelihoods in SSA. The significant improvements in grain yield under drought and rainfed conditions were associated with prolonged DA and DS, increased EHT and PHT, and improvement in SL resistance, EASP, and PASP. In addition, delayed senescence and increased EPP accompanied significant improvement in productivity under drought. The EASP and EPP were consistently identified as highly reliable indirect selection criteria for improving grain yield through index selection under drought and rainfed environments. Highyielding and stable cultivars across all environments based on AMMI biplot included ‘2004 TZEE-Y Pop STR C4’ and ‘TZEE-W Pop STR BC2 C0’ of Period 2 and ‘2009 TZEE-W STR’, ‘TZEE-Y STR 106’, ‘TZEE-W STR 107’, and ‘TZEE-W DT C0 STR C5’ of Period 3. These cultivars could be commercialized to improve food self-sufficiency in SSA. Considerable improvement has been achieved in development and commercialization of drought-tolerant maize cultivars in the extra-early maturity group for the subregion.Based on the average annual rate of increase in grain yield under drought conditions (0.034 Mg haClick here for additional data file.


In multiple logistic regression analysis, the job of a stone-crusher was associated to wheezing . Stone-crushers had higher values (% predicted) than taxi-drivers for Forced Vital Capacity , Forced Expiratory Volume in 1 Second , and Maximum Expiratory Flow at 25% of the Forced Vital Capacity . Conclusion: Stone-crushers were more heavily exposed to mineral dust and various trace elements than taxi-drivers, and they had a fourfold increased risk of reporting wheezing, but they did not have evidence of more respiratory impairment than taxi-drivers.Background: Thousands of artisanal workers are exposed to mineral dusts from various origins in the African Copperbelt. We determined the prevalence of respiratory symptoms, pulmonary function, and urinary metals among artisanal stone-crushers in Lubumbashi. Methods: We conducted a cross-sectional study of 48 male artisanal stone-crushers and 50 male taxi-drivers using a standardized questionnaire and spirometry. Concentrations of trace metals were measured by Inductively Coupled - Plasma Mass Spectrometry (ICP-MS) in urine spot samples. Results: Urinary Co, Ni, As, and Se were higher in stone-crushers than in control participants. Wheezing was more prevalent ( Several studies have documented high to very high levels of mineral dust in worksites—and also the surrounding environment—where stones or rocks are crushed or milled using various types of mechanical crushers to produce aggregates for use in the construction of roads and buildings ,3,4,5,6.Lubumbashi is the second largest city of the Democratic Republic of Congo (DRC) and the capital of the Haut-Katanga Province, which is situated in the African Copperbelt, an area of intense past and current mining and processing of copper and cobalt ores. Artisanal mining has also become widespread in the past 20 years, with tens of thousands of young people involved. These activities have led to widespread environmental pollution by various trace metals . BiomoniWe, therefore, performed a cross-sectional study using urinary biomonitoring to assess metal exposure and spirometry to assess pulmonary function among artisanal stone crushers, taking drivers of collective taxis as controls without occupational exposure to mineral dust.This cross-sectional study took place in Lubumbashi in October 2014 (dry season). Potential participants were recruited by convenience sampling at their place of work over a period of 6 days, during which 48 men working as artisanal stone-crushers and 50 men working as drivers of collective minibus taxis were included. All participants found at their workplace were invited to participate, and those giving their oral consent replied to a respiratory questionnaire, performed spirometry, and provided a spot sample of urine, all procedures being done at their worksite. The study protocol, including the oral consent procedure, was approved by the medical ethics committee of the University of Lubumbashi.We used a combination of questionnaires, as in a study of workers performed in Algeria , namely ® Air device . In accordance with ATS/ERS (American Thoracic Society/European Respiratory Society) guidelines  were analyzed in 100 µL urine by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS), using an Agilent 7500ce instrument , in the internationally accredited Laboratory of the Louvain Center for Toxicology and Applied Pharmacology  using validated methods, as previously described . In brieMetal concentrations were corrected for dilution by the concentration of creatinine, as measured by using a Beckman Synchron LX 20 analyzer .For the statistical analysis, independent variables were age, height, educational level (below vs. above 12 years of study), tobacco smoking (no smoking vs. current smoker or any regular smoker at home), alcohol consumption (none vs. current drinker), living close to mining, i.e., within visible distance from home (yes vs. no), type of drinking water , the use of personal protective mask, gloves, and glasses (yes vs. no).The outcome variables were positive/negative replies to 4 questions on respiratory symptoms  currently or during the last 12 months, and on 5 oculo-nasal symptoms .t-test, and/or Mann–Whitney rank-sum tests were used. Unadjusted (uOR) and adjusted odds ratios (aOR) and associated 95% confidence intervals (CIs) were calculated to summarize the strength of association between baseline characteristics and symptoms  among groups. A stepwise logistic regression was performed, adjusting for variables considered clinically or epidemiologically relevant, and the variables with p-value less than 0.2 in the bivariate analysis. The threshold level for significance was set at p ˂ 0.05.Descriptive statistics consisted of frequency and percentages for categorical variables and means with standard deviation (SD) and range for continuous variables, or geometric means with their 95% confident interval (CI) for trace metal concentrations. To compare groups, the Fisher exact test, Graphpad 6  was used to perform descriptive statistics and bivariate comparisons, and JMP Pro 14.2.0  was used for multivariate analyses.The characteristics of the 98 participants are presented in The urinary concentrations of trace metals/metalloids (expressed as µg/g creatinine) are presented in In general, most urines proved to be highly concentrated since the creatinine concentration averaged 2.46 g/L (SD 1.04) for the 75 participants, with no sample having a creatinine concentration below 0.7 g/L and 20 samples (10 in each group) having a concentration exceeding 3 g/L. However, the concentrations of creatinine did not differ between stone crushers and taxi-drivers.The concentrations of five elements  were below detection limits in most subjects and are, therefore, not reported. Of the 19 other measured elements, four  exhibited significantly higher concentrations in urine from stone-crushers than in the urine of taxi-drivers, the highest contrasts being observed for Ni and As, for which the concentrations were about two-fold higher among stone-crushers than among taxi-drivers. For two elements (Sn and Sb), urinary concentrations were higher in taxi-drivers than in stone-crushers.Because it has been recommended to exclude too concentrated samples , we repep = 0.07) to be lower among the stone-crushers (35%) than among the taxi drivers (54%) (p = 0.021) (The proportion of participants without reported respiratory symptoms tended (rs (54%) . However= 0.021) .In a multivariate analysis involving the entire population , tobaccop = 0.02) from that of the 47 participants who failed to produce satisfactory spirometries (26 ± 6 y), but it did not differ (p = 0.16) from that of the 30 participants who did not perform spirometry (31 ± 1 y). Although none of the 21 participants with acceptable spirometries reported wheezing, subjects who reported nasal or other respiratory symptoms were not more likely to have failed spirometry (not shown).Of the 68 participants who performed spirometry, 39 did not provide reliable spirometric results based on the quality check of the spirograms (score 0), and only 21 participants provided fully acceptable curves (score 3); three additional subjects had acceptable FEV1 (score 1) and five additional subjects had acceptable FVC (score 2). The age of the 21 participants with fully acceptable spirometry (29 ± 5 y) differed significantly (p = 0.038).Overall, the stone-crushers had better pulmonary function than the taxi-drivers, this being significant for FVC and nearly significant for FEV1 and MEF25 . Among tIn this cross-sectional design, we studied trace metal exposure and respiratory health of a group of male artisanal workers involved in stone-crushing in Lubumbashi, a city in the African Copperbelt well-known for its mining-related environmental pollution . CompareIn both groups of participants, trace metals in urine were substantially higher than reference values from industrially developed countries , as wellAnother possible explanation for the high urinary As in the stone-crushers may be the presence of high concentrations of As in their drinking water since more than 50% of the stone-crushers reported drinking only well water, and well water can be highly polluted by metal(oid)s in Lubumbashi . HoweverOn the other hand, the metal concentrations found in the present study were generally considerably lower, especially for Co and U, than those observed in artisanal miners of cobalt in Kolwezi  and elseRegarding respiratory symptoms, logistic regression analysis revealed that wheezing, cough, and shortness of breath were positively associated with age, even in our relatively young population. However, the only significant difference found between stone-crushers and taxi-drivers concerned wheezing, which was more frequently reported by stone-crushers. The difference was significant both in bivariate analysis and in logistic regression analysis, which revealed an adjusted OR of more than 4 for wheezing among the stone-crushers compared to taxi-drivers. Within the limits of a questionnaire-based cross-sectional survey, we attribute this excess risk of wheezing to their exposure to high levels of dust. Further studies are needed to determine whether this reported wheezing corresponds to asthma.We did not find an effect of smoking on respiratory symptoms or pulmonary function in our study. We speculate that this can be explained by the low prevalence and low daily consumption of cigarettes in our (relatively young) study population.Against our expectation, pulmonary function was or tended to be better among stone-crushers than among taxi-drivers, at least as assessed among the minority of participants in whom satisfactory spirometries could be obtained. The problem of obtaining good measurements of pulmonary function is not often acknowledged in published surveys done in low-income countries, where precarious field conditions, including unavailable electric power supply, render spirometry testing much less reliable than when spirometry is done in well-equipped pulmonary function laboratories. Although the ndd EasyOne portable spirometer has been recommended for epidemiological studies  , its useTo our knowledge, studies of respiratory health in relation to stone crushing have been exclusively done in quarries using mechanical crushers, and we found no published surveys of workers who only used hand tools to break and crush stones, as was the case in the present study. Only a few longitudinal studies have investigated workers employed in stone quarries. In the USA, a large longitudinal study of granite workers in Vermont showed excessive exposure-related declines in FEV1 and FVC, especially among subjects who failed spirometry or were lost to follow-up ,26. In SMoreover, the exposure to dust and the high physical demands associated with stone-crushing may have led to the “healthy worker effect,” whereby people with respiratory impairment tend to quit their job early. Of note, in a study of 272 stone-crushing workers and 123 control agricultural workers in West-Bengal, India, Chattopadhyay et al.  found thOn the other hand, we cannot exclude an effect of higher exposure to traffic-related air pollution in the taxi-drivers. These issues can only be investigated by well-powered longitudinal observations.The strengths of our study include its originality as a first field study of respiratory health among artisanal stone-crushers, with characterization of their metal exposure by urinary biomonitoring. Nevertheless, we also acknowledge several limitations. A first limitation is the cross-sectional design of our survey and the convenience sampling of our population, thus giving rise to uncontrolled selection biases, among which the healthy worker effect is probably an important drawback. We also only included a relatively small group of adult male workers, even though women and children also work on the stone crushing sites. A second limitation is that we do not have information on the levels and composition (including free-silica content) of the dust inhaled by the workers. A further limitation concerns the logistic and technical difficulties of obtaining good quality spirometry in precarious field conditions.This study shows that artisanal stone-crushers and taxi-drivers are highly exposed to trace metals in this highly polluted area (Lubumbashi). Wheezing was more prevalent among stone-crushers than among controls and, although no evidence for functional impairment was detected in this preliminary study, this excess wheezing may be indicative of a higher risk of long-term respiratory impairment.In view of the limitations of our cross-sectional study, which involved small groups of relatively young participants, the lack of a detectable impact on spirometry in the group of stone crushers should not be interpreted as suggesting the absence of risk of respiratory impairment for workers engaged in such artisanal activities. Legislation enforcement and advocacy are warranted to protect the workers.