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1.
Open Med (Wars) ; 18(1): 20230862, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38075035

RESUMO

Studies on the COVID-19 pandemic effects on gestational diabetes mellitus (GDM) remain limited and controversial. This study aimed to investigate the impact of the COVID-19 lockdown on the glycemic balance of pregnant women and GDM risk. To this aim, a single-center retrospective cohort analysis assessing glucose homeostasis using the oral glucose tolerance test in 862 pregnant women before (from March 9, 2019 to March 8, 2020 - Group 1), during (from March 9, 2020 to March 8, 2021 - Group 2), and after (from March 9, 2021 to March 8, 2022 - Group 3) the COVID-19 lockdown in Molise, a region of central Italy, was conducted. We observed that the blood glucose concentration of pregnant women was significantly lower during the COVID-19 lockdown than during the previous and following years at all time points evaluated (time 0, 60', and 120'). Specifically, at time 0, it was 82.14 mg/dl for group 2 vs 85.94 for group 1 (p = 0.0001) and 85.87 for group 3 (p = 0.001). Similarly, at 60', it was 121.38 mg/dl for group 2 vs 129.30 mg/dl for group 1 (p = 0.0029) and 131.68 mg/dl for group 3 (p = 0.0006). Moreover, at 120', it was 104.20 mg/dl for group 2 vs 111.51 mg/dl (p = 0.0004) for group 1, and 116.06 mg/dl for group 3 (p = 0.0001). In contrast with previous findings, the COVID-19 lockdown was associated with an improved glycemic balance. Further studies are needed to better clarify the influence of lockdown restrictions on glucose metabolism and, consequently, on GDM risk.

2.
Aging Clin Exp Res ; 35(9): 1823-1834, 2023 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37340168

RESUMO

Accumulating evidence suggests that fatty acids (FAs) play an essential role in regulating skeletal muscle mass and function throughout life. This systematic review and meta-analysis aimed to examine the relationship between dietary or circulatory levels of monounsaturated FAs (MUFAs) and sarcopenia in observational studies. A comprehensive literature search was performed in three databases (PubMed, Scopus, and Web of Science) from inception until August 2022. Of 414 records, a total of 12 observational studies were identified for this review. Ten studies were meta-analysed, comprising a total of 3704 participants. The results revealed that MUFA intake is inversely associated with sarcopenia (standardized mean difference = - 0.28, 95% CI - 0.46 to - 0.11; p < 0.01). Despite the limited number of studies, our results suggest that lower MUFA intake is associated with a higher risk of sarcopenia. However, the available evidence is still insufficient and further investigations are needed to demonstrate this relationship.


Assuntos
Ácidos Graxos Monoinsaturados , Sarcopenia , Humanos , Ácidos Graxos , Dieta , Estudos Observacionais como Assunto
3.
J Clin Med ; 12(7)2023 Apr 04.
Artigo em Inglês | MEDLINE | ID: mdl-37048772

RESUMO

The concept that body fluids may reveal the presence of disease dates back to ancient Greek history, when Hippocrates (ca [...].

5.
Biomed Pharmacother ; 161: 114425, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-36812712

RESUMO

Sirtuin 1 (SIRT1) belongs to the histone deacetylase enzyme family and its activity regulates various signaling networks associated with aging. SIRT1 is widely involved in a large number of biological processes, including senescence, autophagy, inflammation, and oxidative stress. In addition, SIRT1 activation may improve lifespan and health in numerous experimental models. Therefore, SIRT1 targeting is a potential strategy to delay or reverse aging and age-related diseases. Although SIRT1 is activated by a wide array of small molecules, only a limited number of phytochemicals that directly interact with SIRT1 have been identified. Using the Geroprotectors.org database and a literature search, the aim of this study was to identify geroprotective phytochemicals that might interact with SIRT1. We performed molecular docking, density functional theory studies, molecular dynamic simulations (MDS), and absorption, distribution, metabolism, excretion, and toxicity (ADMET) prediction to screen potential candidates against SIRT1. After the initial screening of 70 phytochemicals, crocin, celastrol, hesperidin, taxifolin, vitexin, and quercetin had significant binding affinity scores. These six compounds established multiple hydrogen-bonding and hydrophobic interactions with SIRT1 and showed good drug-likeness and ADMET properties. In particular, crocin was further analyzed using MDS to study its complex with SIRT1 during simulation. Crocin has a high reactivity to SIRT1 and can form a stable complex with it, showing a good ability to fit into the binding pocket. Although further investigations are required, our results suggest that these geroprotective phytochemicals, especially crocin, are novel interacting partners of SIRT1.


Assuntos
Simulação de Dinâmica Molecular , Sirtuína 1 , Simulação de Acoplamento Molecular , Sirtuína 1/metabolismo , Compostos Fitoquímicos/farmacologia , Compostos Fitoquímicos/química
6.
Eur J Sport Sci ; 23(1): 134-142, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34694208

RESUMO

ABSTRACTThe aim of this study was to examine the association between biomarkers of polyunsaturated fatty acids (PUFA), such as omega-3 (ω-3) index and arachidonic acid (AA; 20:4 ω-6)/eicosapentaenoic acid (EPA; 20:5ω-3) ratio (AA/EPA), and the prevalence of running-related injuries (RRI) in a cohort of recreational runners. We performed a retrospective, observational study of 275 non-elite runners (mean age: 41.20 ± 12.47 years) who were not supplemented with ω-3 fatty acids. The training characteristics and RRI were recorded over a period of 12 months through a self-reported questionnaire. Using whole blood samples collected by finger prick, PUFA were quantified by gas chromatography and ω-3 index and AA/EPA ratio measured. A total of 191 RRI cases were reported, with an injury prevalence rate of 50.9% in the overall population. The injured runners ran a significantly greater weekly distance than uninjured subjects (53.54 ± 25.27 km/week; p = 0.007). In a multivariate regression analysis, the lowest number of RRI was associated with higher values of ω-3 index (ß = - 0.237; 95% CI - 0.308 to - 0.164; R2 = 0.172; p < 0.0001), while a higher AA/EPA ratio was correlated with higher number of RRI (ß = 0.019; 95% CI 0.007-0.031; R2 = 0.038; p = 0.003). This study identifies ω-3 index and AA/EPA ratio as potential parameters associated with the risk of RRI. Future research is needed to confirm these results and apply specific nutritional strategies to successfully modify these biochemical variables.Trial registration: ISRCTN.org identifier: ISRCTN12847156..


Assuntos
Ácidos Graxos Ômega-3 , Corrida , Humanos , Adulto , Pessoa de Meia-Idade , Estudos Retrospectivos , Ácidos Graxos Ômega-6 , Biomarcadores
7.
Geroscience ; 45(2): 781-796, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-36449220

RESUMO

Long-lived individuals (LLIs) are considered an ideal model to study healthy human aging. Blood fatty acid (FA) profile of a cohort of LLIs (90-111 years old, n = 49) from Sicily was compared to adults (18-64 years old, n = 69) and older adults (65-89 years old, n = 54) from the same area. Genetic variants in key enzymes related to FA biosynthesis and metabolism were also genotyped to investigate a potential genetic predisposition in determining the FA profile. Gas chromatography was employed to determine the FA profile, and genotyping was performed using high-resolution melt (HRM) analysis. Blood levels of total polyunsaturated FA (PUFA) and total trans-FA decreased with age, while the levels of saturated FA (SFA) remained unchanged. Interestingly, distinctively higher circulatory levels of monounsaturated FA (MUFA) in LLIs compared to adults and older adults were observed. In addition, among LLIs, rs174537 in the FA desaturase 1/2 (FADS1/2) gene was associated with linoleic acid (LA, 18:2n-6) and docosatetraenoic acid (DTA, 22:4n-6) levels, and the rs953413 in the elongase of very long FA 2 (ELOVL2) was associated with DTA levels. We further observed that rs174579 and rs174626 genotypes in FADS1/2 significantly affect delta-6 desaturase (D6D) activity. In conclusion, our results suggest that the LLIs have a different FA profile characterized by high MUFA content, which indicates reduced peroxidation while maintaining membrane fluidity.


Assuntos
Ácidos Graxos Monoinsaturados , Ácidos Graxos , Humanos , Idoso , Idoso de 80 Anos ou mais , Ácidos Graxos Monoinsaturados/análise , Ácidos Graxos Monoinsaturados/metabolismo
8.
Semin Thromb Hemost ; 49(4): 330-336, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-36368688

RESUMO

Assisted reproductive techniques (ART) allow infertile couples to conceive. Use of hormones to obtain a controlled ovarian stimulation and an adequate growth of the endometrium preparatory for embryo implantation are not riskless. Among others, thrombotic events can occur during the ovulation induction or pregnancy following ART. As the number of women approaching ART to conceive is steadily increasing, the issue of thrombotic risk in this setting is relevant. Data on the weight of each risk factor and on potential benefit of thromboprophylaxis are largely lacking. In this review, we discuss risk of venous thromboembolism during pregnancy following ART, with a focus on general (i.e.: age, body mass index, thrombophilia, bed rest, transfusions) and ART-specific (i.e., polycystic ovarian syndrome, ovarian hyperstimulation syndrome) risk factors. We also attempt to provide some suggestions to guide clinical practice, based on available data and studies performed outside ART.


Assuntos
Síndrome de Hiperestimulação Ovariana , Trombose , Tromboembolia Venosa , Gravidez , Feminino , Humanos , Anticoagulantes , Tromboembolia Venosa/etiologia , Técnicas de Reprodução Assistida/efeitos adversos , Indução da Ovulação/efeitos adversos , Síndrome de Hiperestimulação Ovariana/etiologia , Trombose/etiologia
9.
Curr Neuropharmacol ; 21(3): 651-668, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36321225

RESUMO

Adult neurogenesis deficiency has been proposed to be a common hallmark in different age-related neurodegenerative diseases. The administration of flavonoids is currently reported as a potentially beneficial strategy for preventing brain aging alterations, including adult neurogenesis decline. Flavonoids are a class of plant-derived dietary polyphenols that have drawn attention for their neuroprotective and pro-cognitive effects. Although they undergo extensive metabolism and localize in the brain at low concentrations, flavonoids are now believed to improve cerebral vasculature and interact with signal transduction cascades involved in the regulation of adult neurogenesis. Furthermore, many dietary flavonoids have been shown to reduce oxidative stress and neuroinflammation, improving the neuronal microenvironment where adult neurogenesis occurs. The overall goal of this review is to summarize the evidence supporting the role of flavonoids in modulating adult neurogenesis as well as to highlight how these dietary agents may be promising candidates in restoring healthy brain function during physiological and pathological aging.


Assuntos
Encéfalo , Polifenóis , Humanos , Adulto , Encéfalo/metabolismo , Polifenóis/farmacologia , Polifenóis/metabolismo , Envelhecimento/fisiologia , Flavonoides/farmacologia , Neurogênese/fisiologia
10.
Free Radic Biol Med ; 193(Pt 2): 736-750, 2022 11 20.
Artigo em Inglês | MEDLINE | ID: mdl-36402440

RESUMO

The transcription factor NRF2 and its endogenous inhibitor KEAP1 play a crucial role in the maintenance of cellular redox homeostasis by regulating the gene expression of diverse networks of antioxidant, anti-inflammatory, and detoxification enzymes. Therefore, activation of NRF2 provides cytoprotection against numerous pathologies, including age-related diseases. An age-associated loss of NRF2 function may be a key driving force behind the aging phenotype. Recently, numerous NRF2 inducers have been identified and some of them are promising candidates to restore NRF2 transcriptional activity during aging. Emerging evidence indicates that omega-3 (n-3) polyunsaturated fatty acids (PUFAs) and their electrophilic derivatives may trigger a protective response via NRF2 activation, rescuing or maintaining cellular redox homeostasis. In this review, we provide an overview of the NRF2-KEAP1 system and its dysregulation in aging cells. We also summarize current studies on the modulatory role of n-3 PUFAs as potential agents to prevent multiple chronic diseases and restore the age-related impairment of NRF2 function.


Assuntos
Ácidos Graxos Ômega-3 , Fator 2 Relacionado a NF-E2 , Proteína 1 Associada a ECH Semelhante a Kelch/genética , Fator 2 Relacionado a NF-E2/genética , Senescência Celular
11.
Front Med (Lausanne) ; 9: 872310, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35928292

RESUMO

Background: Aging is a phenomenon universally involving all organisms, genetically determined, and epigenetically influenced by the environment. Numerous observational studies have shown the positive impact of non-pharmacological approaches started in younger age on chronic conditions affecting the elderly health and survival. This meta-analysis aimed to investigate the effect of beta-carotene on the total and cause-specific mortality as reported by randomized controlled trials (RCTs). Methods: We searched Medline, Scopus, Web of Science, and CENTRAL Cochrane from inception to September 2021. Studies were eligible if enrolled adults with any health condition, compared beta-carotene supplements at any dose with placebo or no intervention, provided information on deaths from any cause, and were RCTs, in English. The risk of bias was assessed by the Cochrane risk of bias tool and the GRADE. Risk ratios and their 95% confidence intervals were used and a P-value less than 0.05 was considered statistically significant. Results: Among 3,942 articles searched, 44 articles on 31 RCTs, which included 216,734 total subjects, 108,622 in beta-carotene supplement groups, and 108,112 in the placebo or no-intervention groups, were involved in the final analyses. In a random-effects meta-analysis of all 31 trials, beta-carotene supplements were found to have no preventive effect on mortality (risk ratio 1.02, 95% confidence interval 0.98-1.05, I 2 = 42%). Further, the analysis showed no preventive effect on cancer, cardiovascular, cerebrovascular, and other mortality causes. Instead, beta-carotene supplementation significantly increased the risk of lung cancer mortality (RR 1.14, 95% CI 1.02, 1.27, I 2 = 3%) but decreased the risk of human immunodeficiency virus-related mortality (RR 0.55, 95% CI 0.33, 0.92, I 2 = 0). Conclusion: More studies should be performed to better define the role of beta-carotene on survival, to confirm or deny our results. Therefore, the possible beneficial or harmful effects of the beta-carotene supplementation on mortality must not be overstated. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=259354], identifier [CRD42021259354].

12.
Biotechniques ; 73(1): 25-33, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35698842

RESUMO

Background: Clinical and epidemiological studies suggest that analysis of the polyunsaturated fatty acids (PUFAs) is essential to evaluate nutritional requirements and disease risk. We describe a simple, sensitive and non-invasive method for estimating the n-3 index and arachidonic acid (AA)/eicosapentaenoic acid (EPA) ratio in dried blood spots (DBSs). Experimental: After obtaining DBSs on a spot card, PUFAs were transesterified (direct, acidic transesterification) and subsequently extracted with n-hexane. Gas chromatography with flame ionization detection (GC-FID) was used to analyze the extracted PUFAs, and then n-3 index and AA/EPA ratio were calculated. Method validation showed satisfactory precision and linearity. Conclusion: This analysis is simple and reliable to estimate PUFA status, and it was successfully applied to samples from 20 subjects, demonstrating its applicability.


Assuntos
Ácido Eicosapentaenoico , Ácidos Graxos Insaturados , Ácido Araquidônico , Cromatografia Gasosa , Humanos
13.
Medicina (Kaunas) ; 58(5)2022 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-35630109

RESUMO

Nowadays, novel oral anticoagulants (NOACs) have shown improved safety profile and efficacy compared to vitamin K antagonists in the prevention of thromboembolic events occurring during different pathological conditions. However, there are concerns and safety issues, mostly related to adverse events following interactions with other drugs, in real-world practice. We report the case of an 83-year-old woman who developed a non-bleeding leg ulcer not caused by trauma or other evident pathological conditions after 10 days of treatment with apixaban 5 mg/q.d. She was switched from apixaban to dabigatran and the leg ulcer rapidly improved and completely cicatrized in 40 days. The resolution of the ulcer and the toleration of dabigatran therapy suggest an apixaban-specific reaction; however, the pathological mechanism of ulcer onset is currently unclear. Careful evaluation of hospital databases of Molise region (Southern Italy) hospitals identified two similar cases between 2019 and 2021. These cases underline the necessity of careful post-marketing surveillance, considering the rapidly increasing number of patients treated with NOACs and patient's risk factors such as old age, high polypharmacy rate, co-morbidities, and peculiar genetic background related to NOACs pharmacokinetic features.


Assuntos
Fibrilação Atrial , Úlcera da Perna , Administração Oral , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/efeitos adversos , Feminino , Humanos , Úlcera da Perna/induzido quimicamente , Úlcera da Perna/tratamento farmacológico , Pirazóis , Piridonas , Úlcera/induzido quimicamente , Úlcera/tratamento farmacológico
14.
Diagnostics (Basel) ; 12(5)2022 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-35626434

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant outbreaks have highlighted the need of antigen-detecting rapid diagnostic tests (Ag-RDTs) that can be used at the point-of-care (POC). Although many Ag-RDTs have been approved for SARS-CoV-2 detection, studies demonstrating the clinical performance of Ag-RDTs against variants of concern, especially the new Omicron variant, are limited. The aim of this study was to evaluate the diagnostic sensitivity and specificity of the AMAZING COVID-19 Antigen Sealing Tube Test Strip (Colloidal Gold) in 584 early symptomatic and asymptomatic participants (age range 0-90 years). The performance of this Ag-RDT was assessed by comparing its results with reverse transcription RT-PCR (rRT-PCR). One hundred twenty positive samples were also analyzed with rRT-PCR to discriminate Omicron and Delta/Kappa variants (72.50% Omicron; 27.50% Delta/Kappa). Overall, the Ag-RDT showed high positive and negative percent values of 92.52% (95% CI, 86.61-95.95%) and 98.05% (95% CI, 96.41-98.95%), respectively, as well as an overall diagnostic accuracy of 96.92% (95% CI, 95.17-98.16%). Taken together, these data indicate that this inexpensive and simple-to-use Ag-RDT presents excellent analytical performance and can reliably detect Omicron and Delta/Kappa variants.

15.
Molecules ; 27(2)2022 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-35056816

RESUMO

Astaxanthin (AST) is a dietary xanthophyll predominantly found in marine organisms and seafood. Due to its unique molecular features, AST has an excellent antioxidant activity with a wide range of applications in the nutraceutical and pharmaceutical industries. In the past decade, mounting evidence has suggested a protective role for AST against a wide range of diseases where oxidative stress and inflammation participate in a self-perpetuating cycle. Here, we review the underlying molecular mechanisms by which AST regulates two relevant redox-sensitive transcription factors, such as nuclear factor erythroid 2-related factor 2 (Nrf2) and nuclear factor κB (NF-κB). Nrf2 is a cellular sensor of electrophilic stress that coordinates the expression of a battery of defensive genes encoding antioxidant proteins and detoxifying enzymes. Likewise, NF-κB acts as a mediator of cellular stress and induces the expression of various pro-inflammatory genes, including those encoding cytokines, chemokines, and adhesion molecules. The effects of AST on the crosstalk between these transcription factors have also been discussed. Besides this, we summarize the current clinical studies elucidating how AST may alleviate the etiopathogenesis of oxidative stress and inflammation.


Assuntos
Regulação da Expressão Gênica/efeitos dos fármacos , Inflamação/tratamento farmacológico , Fator 2 Relacionado a NF-E2/metabolismo , NF-kappa B/metabolismo , Estresse Oxidativo , Animais , Humanos , Inflamação/metabolismo , Inflamação/patologia , Fator 2 Relacionado a NF-E2/genética , NF-kappa B/genética , Transdução de Sinais , Xantofilas/farmacologia
17.
Diagnostics (Basel) ; 11(7)2021 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-34359312

RESUMO

Hypertrophic cardiomyopathy (HCM) and heterozygous familial hypercholesterolemia (HeFH), two of the most common genetic cardiovascular disorders, can lead to sudden cardiac death. These conditions could be complicated by concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as in the case herein described. A young amateur soccer player died in late October 2020 after a fatal arrhythmia and the autopsy revealed the presence of HCM with diffuse non-obstructive coronary disease. The molecular autopsy revealed a compound condition with a first mutation in the MYH7 gene (p.Arg719Trp) and a second mutation in the LDLR gene (p.Gly343Cys): both have already been described as associated with HCM and HeFH, respectively. In addition, molecular analyses showed the presence of SARS-CoV-2 lineage B.1.1.7 (UK variant with high titer in the myocardium. Co-segregation analysis within the family (n = 19) showed that heterozygous LDLR mutation was maternally inherited, while the heterozygous MYH7 genetic lesion was de novo. All family member carriers of the LDLR mutation (n = 13) had systematic higher LDL plasma concentrations and positive records of cardiac and vascular ischemic events at young age. Considering that HCM mutations are in themselves involved in the predisposition to malignant arrhythmogenicity and HeFH could cause higher risk of cardiac complications in SARS-CoV-2 infection, this case could represent an example of a potential SARS-CoV-2 infection role in triggering or unmasking inherited cardiovascular disease, whose combination might represent the cause of fatal arrhythmia at such a young age. Additionally, it can provide clues in dating the presence of the SARS-CoV-2 lineage B.1.1.7 in Northern Italy in the early phases of the second pandemic wave.

18.
Artigo em Inglês | MEDLINE | ID: mdl-34204965

RESUMO

The study aim was to investigate the age, gender and technical level on motor coordination abilities of Taekwondo children. One hundred and fifteen children (83 male, 32 female), aged 7.76 ± 1.71 years, divided in three different groups, under 8 (5-7 years), under 10 (8-9 years) and under 12 (10-11 years), underwent three coordination skills tests: the ruler drop test (RDT), assessing visual reaction time, the hexagonal test (HT), assessing agility, and the target kick test (TKT), assessing kicking ability. MANOVA showed significant gender differences for TKT, in which females showed higher scores than males (p = 0.033). Significant differences were found in HT and TKT, where the under 12 group showed higher scores than younger athletes (p < 0.001). No differences amongst different age groups were found in RDT, showing that this could be a good predictor of Taekwondo performance, assessed at an early stage. High-level athletes showed better scores in all the tests than the low levels, as it was expected. Coordinative performance improves with age and is positively influenced by practicing a sports activity. The predisposition to a particular sport with a well-planned training may lead to a motor proficiency comparable to that reached by older athletes and better than same-age athletes.


Assuntos
Desempenho Atlético , Artes Marciais , Atletas , Criança , Feminino , Humanos , Masculino , Destreza Motora , Tempo de Reação
19.
J Funct Morphol Kinesiol ; 6(2)2021 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-34198610

RESUMO

Intergenerational physical activity could be a pleasant method to prevent elderly sedentary behaviors. The aim of this study is to provide a basis to develop an intergenerational physical activity between preschool children and elderly people. An assessing enjoyment three questionnaire survey was administered to 140 participants (aged 67.8 ± 9.1): the global physical activity questionnaire (GPAQ) assessing the sedentariness degree; the physical activity enjoyment scale (PACES-Q) assessing enjoyment for the physical activity usually practiced; the physical activity enjoyment scale (PACES-INT) assessing the enjoyment for a hypothetical intergenerational program. Successively, the sample was divided into subgroups based on age, gender, marital status, education, employment, sports background, sedentariness level and residential location. Four multichoice questions, aiming to have guidelines in organizing an intergenerational program, were used. A total of 44.3% of the sample found the physical activity practiced pleasant, whereas 81.5% enjoyed the intergenerational program (only 7.1% expressed a negative judgment). A separated one-way ANOVA showed significant differences in PACES-INT for gender, (p = 0.009), residential location, (p < 0.001) and employment (p = 0.004). About 80% of the sample would adhere to the intergenerational programs, despite the fatigue fear and logistic or family relationship problems.

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