Radiotherapy is an important treatment for patients with stage III/IV non-small cell lung cancer (NSCLC), and due to its high incidence of radiation pneumonitis, it is essential to identify high-risk people as early as possible. The present work investigates the value of the application of different phase data throughout the radiotherapy process in analyzing risk of grade ≥ 2 radiation pneumonitis in stage III/IV NSCLC. Furthermore, the phase data fusion was gradually performed with the radiotherapy timeline to develop a risk assessment model.This study retrospectively collected data from 91 stage III/IV NSCLC cases treated with Volumetric modulated arc therapy (VMAT). Patient data were collected according to the radiotherapy timeline for four phases: clinical characteristics, radiomics features, radiation dosimetry parameters, and hematological indexes during treatment. Risk assessment models for single-phase and stepwise fusion phases were established according to logistic regression. In addition, a nomogram of the final fusion phase model and risk classification system was generated. Receiver operating characteristic (ROC), decision curve, and calibration curve analysis were conducted to internally validate the nomogram to analyze its discrimination.Smoking status, PTV and lung radiomics feature, lung and esophageal dosimetry parameters, and platelets at the third week of radiotherapy were independent risk factors for the four single-phase models. The ROC result analysis of the risk assessment models created by stepwise phase fusion were: , , , and , respectively. The nomogram based on the final fusion phase model was validated using calibration curve analysis and decision curve analysis, demonstrating good consistency and clinical utility. The nomogram-based risk classification system could correctly classify cases into three diverse risk groups: low-, intermediate- and high-risk group .In our study, the risk assessment model makes it easy for physicians to assess the risk of grade ≥ 2 radiation pneumonitis at various phases in the radiotherapy process, and the risk classification system and nomogram identify the patient’s risk level after completion of radiation therapy. Non-small-cell lung cancer (NSCLC) accounts for 85% of all lung cancer cases . Many NSNumerous studies have been conducted to investigate clinical risk factors for RP, such as pulmonary function, performance status, smoking history, tumor location, an interstitial pulmonary disorder, pulmonary emphysema, and concurrent chemotherapy, all of which are strongly associated with the occurrence of RP –11. PrevThe present work investigated the potential risk factors for RP at different phases of radiotherapy for stage III/IV NSCLC, then fused the data of different phases based on the radiotherapy timeline to improve the effectiveness of the model, and finally established the risk classification system and nomogram according to fusion model of all phases data. In the age of precision radiotherapy, these tools can help physicians identify patients with RP as early as possible, allowing them to customize follow-up treatment strategies and interventions.The present retrospective study included 91 cases between June 2019 and June 2021. All patients were diagnosed with stage III/IV NSCLC according to the AJCC 8th edition. Inclusion criteria: (1) No contraindication to RT and estimated survival greater than 6 months after RT. (2) No intolerance or interruption of RT for more than a week. (3) Absence of acute infectious or autoimmune disease. (4) Complete follow-up information. The gross tumor volume (GTV), planning target volume (PTV), and clinical target volume (CTV) as defined in ICRU 50 and 62 were measured in this study. Furthermore, this study described risky organs and target volumes based on RT and oncologic group guidelines. The prescribed RT doses were 50–66 Gy at 1.8–2 Gy/fraction/day for five fractions/week. Each RT plan was obtained from the Eclipse system , which was delivered with 6 MV photon beams and 2-arc VMAT. Patients were given either simultaneous chemoradiation or sequential chemoradiation. The chemotherapy regimens contained Carboplatin-based doublet, Cisplatin-based doublet, Platinum-based triplet, Single agent and Other which were applied in a widespread manner inclinical settings. Doses and regimens were modified according to the National Comprehensive Cancer Network (NCCN) and the Chinese Society of Clinical Oncology (CSCO). Informed consent was not required as this is a retrospective, unicentric cohort study.All cases were assessed every week during the process of RT. Follow-up visits were made 1 month after RT and every 2–3 months for the next 6 months. RP was graded by one senior radiologist and two senior oncologists. RP severity was assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events 4.03 (CTCAE 4.03). A grade ≥ 2 was considered symptomatic RP, which required steroids or limiting instrumental activities of daily living. Therefore, the endpoint was Grade ≥ 2 RP (RP ≥ 2) in our study.This study was used to investigate RP ≥ 2 risk by collecting data at four different phases, as shown in Fig. All cases were subjected to free-breathing CT scans using a Philips Brilliance Big Bore CT scanner  to develop treatment plans. The following parameters were used in CT scans: tube current (200 mA), voltage (120 kVp), pixel size (0.911 mm), slice thickness (5 mm), and image matrices . This work utilized the Pyradiomics library in Python for extracting radiomic features. One hundred five Original features were extracted, including 18 first-order features, 14 shape features, and 73 texture analysis features  were extracted. A total of 1183 transformation features based on shape and first order were extracted. Eight wavelet filters  and five Image algorithms  were used. Prior to calculating radiomics features, each image was resampled (size: 3 × 3 × 3) and normalized . We obtained 2576 features in PTV and lungs by performing the above operations.P-values for continuous and categorical variables, respectively. Subsequently, parameters of P < 0.05 were selected for multivariate analysis. This work utilized the least absolute shrinkage and selection operator (LASSO) algorithm for Phase II data for the sake of selecting significant features. Meanwhile, this work reduced coefficients of the unrelated radiomics feature to 0, while those (non-0) of the rest features closely associated with RP ≥ 2 were selected for multivariate analysis. The four Phases (I/II/III/IV) data were analyzed by multivariate analysis to establish the risk analysis model, and the significant risk factors of a single-phase model were included in the fusion phases (I ~ II/I ~ III/I ~ IV) model. The stepwise logistic regression was utilized in multivariate analysis. This work determined Spearman’s correlation coefficients in all models, with a result greater than 0.8 indicating potent correlation. For two closely related features, the feature with an larger univariate analysis p-value was removed [Univariate analysis was performed on Phase I/III/IV data. T-test and chi-square tests were used to calculate  removed , 23. VarThis study developed a visual nomogram based on the fusion model of all phases data. As revealed by calibration curves (resampling of 1000 bootstraps), for RP ≥ 2, the nomogram-predicted probability was consistent with the actual value. Moreover, this work utilized the decision curve analysis (DCA) for testing nomogram utility in the clinic. The total risk point was assessed using our nomogram; then, recursive partitioning analysis was performed to develop the risk classification system for the accurate and effective classification of cases in diverse RP ≥ 2 risk levels.P = 0.01), BMI (P = 0.03), and smoking status (P = 0.004) showed significant differences of RP ≥ 2 when compared with RP < 2 groups. Lasso regression of Radiomics features (Phase II) is shown in Fig. P < 0.05) between the RP ≥ 2 group and RP < 2 group. Hematological indexes (Phase IV) are shown in Table P = 0.011) between the groups.The general clinical characteristics (Phase I) are shown in Table I P = 0.0, and smo P = 0.00 showed sr > 0.8). Since smoking status (P = 0.004) was more significant than sex (P = 0.01) in the univariate analysis, sex was disregarded. The stepwise logistic regression result illustrated that smoking status was an independent risk factor . Similarly, OSMAL_PTV , LFMin_lung , Lungs_V5 , Esophagus_V10 , PLT_3W  were significant risk factors in Phase II/III/IV model. The independent risk factors of the four single phase models were fused by the RT timeline. Stepwise logistic regression was then performed for Phase I ~ II/I ~ III/I ~ IV models. Notably, the independent risk factors in the Phase I ~ II model comprised only two radiomics features without smoking status . Factors independently predicting RP risk in Phase I ~ III model involved clinical, radiomics, and dosimetry features. As PLT_3W  was eliminated from the Phase I ~ IV model, the components of independent factors were consistent with Phase I ~ III. The discriminatory ability of all model-independent risk factors was analyzed using ROC. The model area under curve (AUC), specificity, and sensitivity can be obtained from Table The variable correlation coefficient after univariate analysis and feature selection is shown in Fig.  P = 0.00 was moreOur nomogram based on Phase I ~ IV model is presented in Fig. P < 0.05). In this study, the percentage of smokers or non-smokers with RP ≥ 2 was 12.31% (8/65) and 38.46% (10/26), respectively. These data suggested that smokers may be more tolerant to RT than non-smokers, which was in line with the related studies signifying the relation of smoking with a decreased hypersensitivity pneumonitis risk, possibly due to the immunosuppressive effect [P < 0.05) and possibly associated with a much smaller female lung volume than the male lung volume . Under similar dose and radiation field conditions, with the smaller lung volume and the larger the relative volume dose in female. However, sex was strongly correlated with smoking status (r > 0.8), with 0% (0/20) of women smoking and 91.5% (65/71) of men smoking. Sex was not involved in the multivariate analysis, therefore, further research was desired to determine the association of sex as an influential factor in RP ≥ 2.Smoking status was an independent risk factor in Phase I/I ~ III/I ~ IV models, which was supposed to be the protective factor for RP ≥ 2  of Phase II/I ~ II models that directly reflected the length information of the target area in the principal axis direction. Under similar conditions, the longer the target area, the larger the lung volume involved in RT, and the higher the risk of RP ≥ 2. However, the statistical significance of osmal_ptv for Phase I ~ III/1 ~ IV models was not significant (P > 0.05), possibly due to the introduction of the dosimetry parameters, particularly esophagus_V10 parameter. Presently, no literature has reported that esophagus dose was the direct influencing factor of RP. According to the anatomical relationship between the esophagus and lung, we predict that Esophagus_V10 can indirectly reflect the length information of the overlapping area of the target area and lung in the transverse position.The osmal_ptv, which was a PTV shape feature extracted from the target area by using the radiomics method, was an independent risk factor  of Phase II/I ~ II//I ~ III/I ~ IV models. Therefore, we supposed that these radiomics feature extracted from lung CT images might express the RT sensitivity in lung tissues and differentiate susceptible groups with RP ≥ 2 that cannot be obtained from clinical characteristics or dosimetry parameters.In many reports –31 that With the free-breathing mode used for the CT scanning modality in this study, it has been suggested that respiratory motion may simply be random noise that influences radiomic features and that features that predict symptomatic RP may be robust and reproducible features of the free-breathing protocol . HoweverP < 0.05) in Phase III/I ~ III/1 ~ IV model. We also conducted a univariate ROC analysis on lung_V5. The best cut-off value was 52.7% . The reason why the cut-off value was only 52.7%, which was less than the dose parameter (v5 < 65%) of guidelines revealed by NCCN to reduce RP risk-limiting lung, might be that our institution has strict restrictions on lung_V5 in clinical practice (v5 < 60%).Studies have reported a close relationship between whole lung_V5 and RP in NSCLC –42. NotaP = 0.01) in Phase IV model but not in Phase I ~ IV model . However, it does not signify that platelets are not important because the difference was significant in RP ≥ 2 compared with RP < 2 groups upon univariate analysis , with PLT_3W being lower in the RP ≥ 2 group. Similar results have also been reported in some studies [PLT_3w was considered an independent risk factor (OR = 0.98,  studies  where pl studies , 48. HowThe lung cancer radiotherapy process typically includes admission examination, target area delineation, plan design, and radiotherapy implementation. The time required for the entire process slightly varied from hospital to hospital. For example, it usually took 8–10 weeks in our institution. Thus, we collected data at different phases based on the radiotherapy timeline and conducted a Longitudinal analysis of the risk of RP ≥ 2 with RT for NSCLC of stage III/IV. Nevertheless, data regarding this topic remained missing. This work attempted to identify RP ≥ 2 risks as early as possible. With the introduction of data at different phases, the AUC values of the model gradually increased, eventually gaining a high AUC value of 0.9 in Phase I ~ III/I ~ IV models, higher than any single-phase model. Furthermore, the nomogram and risk classification system established based on the final model are helpful for individualized assessment of RP ≥ 2 risk and differentiation of RP ≥ 2 population. In the interpretation of our nomogram, we should consider internal validation from the statistical aspect. Apart from ROC survival analysis, this work performed DCA and calibration curves, and these were bootstrap validation approaches. As suggested by clinical statisticians, bootstrap validation is advantageous when the sample size is relatively small . The intThis study had several shortcomings, as follows. Firstly, it had a small sample size. More data are necessary for developing and validating our study. Moreover, this was a retrospective study, so there may be selection bias in our data. Third, at present, in our study, only common and important parameters in clinical practice were selected, including other valuable variables such as genomics and inflammatory markers that may be associated with RP. Therefore, we are also conducting studies in this area.In conclusion, the RP ≥ 2 risk study based on the radiotherapy timeline found that the RP ≥ 2 risk analysis model effect was more accurate as the radiotherapy process had advanced. Finally, we developed a new nomogram and risk classification system by including smoking status, radiomics feature of lungs, and lung and esophageal dose. Our results showed that the model has good performance, which can help doctors recognize high-risk RP ≥ 2 NSCLC cases of III/IV stage and guide personalized treatment and clinical decision-making.


Pseudomonas aeruginosa (P. aeruginosa) is a widespread, gram-negative, pathogenic bacterium that causes serious internal and external infections in humans and other animals. The increasing antibiotic resistance has complicated bacterial infection treatment, and current antibiotic therapies cannot cure all infections. Owing to this, bacteriophages (phages) have regained attention as potential therapeutics for bacterial infections. In this study, the phage “PaVOA” was isolated from hospital sewage and characterized. Next, a New Zealand rabbit skin infection model was used to determine the therapeutic efficacy of PaVOA as compared to a phage cocktail or the cephalosporin antibiotic ceftriaxone. Characterization results demonstrated that phage PaVOA belongs to the Myoviridae family, has a double-stranded DNA genome, is resistant to low temperatures (−20°C), is most optimal at 40°C, has good acid–base tolerance, and remains stable for 30 min under 20 W ultraviolet (UV) intensity. The optimal multiplicity of infection of PaVOA was 0.1, and a one-step growth curve showed a short latency period (10 min), thus demonstrating its ability to rapidly kill bacteria. Furthermore, the addition of calcium (Ca) and magnesium (Mg) ions significantly increased the PaVOA titer. An in vivo phage kinetic curve showed that PaVOA was rapidly inactivated within the blood of New Zealand rabbits (undetectable after 12 h), and no animals died due to phage treatment. Wound healing studies showed that the phage cocktail induced a high healing rate and an acceleration of the skin remodeling process, and was more efficacious than ceftriaxone. Therefore, phage cocktail therapy represents a novel therapeutic approach in the treatment of traumatic skin infections caused by multi-drug resistant P. aeruginosa. Pseudomonas aeruginosa (P. aeruginosa), a gram-negative bacterium, is a common opportunistic pathogen in hospitals that can cause serious infections such as pneumonia, urinary tract infections, burn infections, and bacteremia  are viruses that are small in size, do not have a complete cellular structure, and contain only a single nucleic acid. Phages have an estimated population of over 10on Earth  and can on Earth . Importaon Earth . The apphe study , thus suPseudomonas aeruginosa is one of the most prevalent causative pathogens of wound infections in hospitals  and cultured on a shaking table at 37°C for 12 h. Bacterial DNA was isolated using the TIANamp Bacteria DNA Kit . All strains were identified as P. aeruginosa by PCR experiments.Twenty-eight clinically isolated P. aeruginosa drug susceptibility testing provided by the National Committee for Clinical Laboratory Standards (NCCLS) for drug selection. A total of 22 antibiotics , including ciprofloxacin , amikacin , ceftriaxone , meropenem , gentamicin , doxycycline , imipenem , amoxicillin , cefepime , ofloxacin , compound sulfamethoxazole , enrofloxacin , ampicillin , azithromycin , chloramphenicol , tetracycline , nincomycin , norfloxacin , ceftazidime , mezlocillin , cefoperazone , and tobramycin  were used for the antibacterial sensitivity testing of 29 P. aeruginosa strains using the paper diffusion method. The diameter of inhibition circles was used to evaluate the sensitivity of P. aeruginosa to all antibiotics tested.We referred to the recommendations for P. aeruginosa. The double-layer agar plate method was then used to separate phages. Individual phage plaques were chosen for purification once their size and morphology were consistent (purified single phages). One of the lytic phages with transparent plaques was selected, and P. aeruginosa (PA/18) was used as the host bacteria to further study the biological characteristics of the selected phages. Moreover, the host profile of the phage was assessed using the spotting method.Two different bacteriophages were isolated from the sewage of Nanfang Hospital of the Southern Medical University of China. For water sampling, a 0.22 μM filter membrane  was used to remove residual bacteria, followed by centrifugation of the filtered filtrate at 12,000 rpm for 15 min at 25°C, with the resulting supernatant enriched with 11 PFU/mL were loaded onto a copper grid for 1 min, followed by negative staining with uranyl acetate (2% w/v) for 1 min and subsequent aspiration of excess liquid. After drying, the Talos™ F200S TEM  apparatus was used to observe the morphology of phages and to capture images.Purified phage particles with a titer of 10Purified phage concentrates were prepared using the PEG precipitation extraction method . Phage gPseudomonas aeruginosa was cultured in LB broth for 16–18 h. Overnight cultures were then diluted with LB broth to a concentration of 108 CFU/ml. Phages were added at MOIs of 1 × 10−4–1 × 102 and incubated for 4 h at 37°C in a warm oven after shaking and mixing. Cocktails were centrifuged at 12,000 rpm for 10 min followed by isolation of the supernatant to determine phage titers using the double-layer agar plate method. The experiment was repeated thrice.Pseudomonas aeruginosa was cultured to the logarithmic growth phase, at which point the PaVOA phage was added according to the optimal MOI ratio determined previously. Cultures were placed in a 37°C incubator for 15 min prior to centrifugation at 8,000 rpm for 5 min. After discarding the supernatant, sediment was resuspended with preheated sterile LB broth. The suspension cocktail was cultured on a shaking table at 37°C, 200 rpm. Samples were taken at intervals of 10 min in the first 30 min and then every 15 min. Phage titers of samples were determined using the double-layer agar plate method. The experiment was repeated thrice, and one-step growth curves were plotted using GraphPad Prism 8  software. The burst size of the phage is equal to the amount of phage at the end of lysis divided by the initial number of bacterial cells at the time of infection  for 1 h. Three parallel controls were set up for each temperature, and titers were measured using the double-layer agar plate method. Additionally, the PaVOA phage was exposed to sterile Petri dishes at a distance of 40 cm from UV light (20 W) for 1 h, and samples were taken at 5 and 10 min intervals to determine phage stability. The titers of PaVOA phages were determined using the double-layer agar plate method at a pH range from 1 to 14, with pH conditions controlled using SM buffer. Experiments were repeated thrice.Host bacteria (PA/18) were inoculated in LB, LB-Ca, LB-Mg, and LB-Ca-Mg liquid medium  and then cultured in a shaking table at 37°C, 200 rpm until the OD600 was approximately 0.3. PaVOA phages were added at the optimal MOI as previously determined and cultured for 3 h. The resulting supernatants were collected by centrifugation at 12,000 rpm for 15 min at 4°C, with phage titers being determined by the double-layer agar plate method.9 PFU/mL with normal saline. New Zealand rabbits underwent shaving and disinfection of their ears, followed by slow injections of 1 ml diluted phage preparations through the ear marginal vein. Volumes of 500 μl whole blood were collected into anticoagulation tubes at different points  throughout the experiment. Whole blood samples were centrifuged at 12,000 rpm for 10 min at 4°C with the resulting supernatants being diluted in PBS. Phage titers at each time point were determined by the double-layer agar plate method to evaluate phage survival rate.New Zealand rabbits (3 months old) were purchased from Guangdong Provincial Medical Laboratory Animal Center . Purified PaVOA phage samples were diluted to a concentration of 10P. aeruginosa. Twenty-five New Zealand rabbits (3 months old) weighing approximately 1.9–2.1 kg were housed in sterilized cages and provided with adequate water and rabbit food. After 7 days of adaptive feeding, New Zealand rabbits were depilated at approximately 2 cm on the left side of the spine of their back, followed by local anesthesia using 0.5% lidocaine. Surgical scissors were then used to create square allograft wounds with a side length of approximately 2 cm  by syringe, after which wounds were covered with sterile dressings and adhesive bandages. Successful replication of the previously described model should result in purulent secretion on the wound surface, mild tissue erythema and edema, and slightly elevated skin temperature.The efficacy of phages in the treatment of traumatic skin bacterial infection was evaluated using phages and antibiotics to treat full-thickness skin excision wounds of New Zealand rabbits inoculated with ely 2 cm . Wound i8 PFU/mL), bacteriophage cocktail , and ceftriaxone groups (0.002%) received 2 ml of relevant solutions onto their sterile gauzes. Sterile adhesive dressings were then used to cover and fix all gauzes, followed by 4 days of treatment. Wound healing effects were evaluated at fixed points  using a digital camera and Vernier Calipers. Wound healing (%) was calculated using the following equation:Following the successful replication of the wound infection model, New Zealand rabbits were randomly divided into five groups: negative control (infection-free), positive control (infection), and three treatment groups , with five animals in each group. The administration methods for each group were as follows: negative and positive control groups were treated with 0.9% NaCl dropped onto their sterile gauzes, whilst single bacteriophage .All experimental data were collected and organized using Microsoft Excel and then plotted and analyzed using GraphPad Prism 8. Data are presented as mean ± standard deviation (SD).P. aeruginosa showed that all strains were highly resistant to cotrimoxazole, amoxicillin, and lincomycin. Additionally, more than 75% of the strains were highly sensitive to amikacin, ceftriaxone, cefepime, meropenem, ofloxacin, gentamicin, imipenem, azithromycin, tetracycline, ceftazidime, mezlocillin, cefoperazone, and tobramycin. The remaining 25% showed no obvious regularity concerning antibiotic resistance. Additional data showed that the host strain PA/18 was resistant to six antibiotics and was an MDR strain.The drug sensitivity results of the 22 antibiotics tested on 29 strains of Myoviridae family. Additionally, the host spectrum of PaVOA was determined by the spotting method, and the cleavage rate reached 8/29, indicating that the host spectrum of PaVOA was narrow.TEM showed that each PaVOA virus particle had an icosahedral head with a diameter of 66 ± 1 nm and a contracted tail with a length of 120 ± 7 nm , which iThe results of nuclease-mediated digestion of the phage genome revealed no bands in the DNase I treatment group, whilst the size and position of the bands in the negative control, RNase A, and the Mung Bean Nuclease treatment groups were effectively identical, indicating that the PaVOA genome is only sensitive to DNase I, thus proving that PaVOA possesses a double-stranded DNA (dsDNA) genome.An MOI of 0.1 resulted in the largest phage lysate titer . The resThe results of stability tests of PaVOA showed that the phage was able to tolerate low temperatures, and the survival rate did not change significantly between −20°C and 4°C. The highest survival rate was observed at 40°C. Decreasing survival was observed at temperatures above 40°C, and most notably at 70°C . The phap < 0.05). The addition of magnesium ions alone could improve the titer (p < 0.05), whilst the addition of calcium ions alone would reduce the titer (p < 0.05).The simultaneous addition of calcium and magnesium ions to growing PaVOA had the greatest effect on phage activity , which cAfter the phage was injected into rabbits, phage activity decreased rapidly within 12 h. As shown in The wound healing of the treatment and control groups on days 0, 3, 7, 12, 17, and 22 are shown in As shown in P. aeruginosa strains and produce plaques with a diameter of 2–3 mm. According to plaque morphology and TEM image identification, it is a lytic phage belonging to the Myoviridae family.Bacterial infections are a global public health issue , and treP. aeruginosa strains, whereas PaVOA only infected 27.6% of the tests strains. Additionally, phage PPaMa1/18 induced an 85.7% lysis of P. aeruginosa clinical isolates  that is resistant to six antibiotics to establish a New Zealand rabbit skin infection model for the comparison of phage (single or combined) and antibiotic (ceftriaxone) therapies for MDR wound infections. Overall, rabbits treated with ceftriaxone exhibited poorer wound healing than those treated with phages. Notably, treatment with a combined phage cocktail resulted in the greatest degree of wound healing. A previous study confirmed that phage cocktail treatment is effective against antibiotic-resistant Staphylococcus aureus diabetic foot ulcer infections  and Guangdong Province Modern Agricultural Industry Technology System, China (2019kj127).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The intake of stigmasterol, β‐sitosterol, β‐sitostanol and campestanol were associated with the lower risks of obesity, whereas no significant correlationss were found between campesterol intake and any subtype of obesity in the multivariable‐adjusted model. Interestingly, the stigmasterol intake was inversely related with the prevalence of central obesity in female, while the β‐sitostanol intake was found in male . The multiple linear regression models showed that fruits, vegetable‐oil, nuts and seeds may be important diet sources of PSs. The intake of total PSs, β‐sitosterol, stigmasterol, β‐sitostanol and campestanol were inversely associated with the prevalence of obesity. Moreover, the lower obesity risk for total PSs and PSs subgroups differed for the gender. The firm results deserve to be further verified in cohort studies.To investigate the associations between different phytosterols (PSs) intake and subtype of obesity in Chinese. Total 6073 adults aged ≥18 years was enrolled from China. General characteristics were completed by the validated dietary questionnaire. For total phytosterols intake, comparing Q4 with Q1 was inversely associated with the risks of overweight [odds ratio (OR) 95% confidence interval (CI), 0.82 ,  The present study suggests that the intake of total phytosterols (PSs), stigmasterol, ß‐sitosterol, ß‐sitostanol and campestanol were inversely associated with the prevalence of obesity. In addition, lower obesity risk for total PSs and PSs subgroups differed for the gender. These results deserve to be further verified in cohort studies. Finally, the sample of 6073 participants were available for the analysis.We used data from the validated internet‐based dietary questionnaire for Chinese  in the Chinese food composition table were chosen for measurement. The contents of stigmasterol, β‐sitosterol, campesterol, β‐sitostanol and campestanol in food were analyzed at Institute of Nutrition and Food Safety, Chinese Centre for Disease Control and Prevention, Beijing, China, using gas chromatograph methods by Han et al. , 2009. T2.32 was calculated as body weight (kg) in kilograms divided by the square of the height (m). According to the 2006 Guidelines on Preservation and Control Overweight and Obesity in Chinese Adults classification  and WC ≥ 85 cm , respectively.Bodyweight, height, and waist circumference (WC) of participants were measured by well‐trained nurses. Participants were asked to wear light, thin clothing and no shoes. Bodyweight, height and WC were measured to the nearest 0.1 kg, 0.1 cm and 0.1 cm, respectively. Body mass index (BMI) in kg/m2.4Other covariates involved age, gender, education, incomes, physical exercise and smoking status. These data were also gained by the IDQC. For instance, education was divided into college and postgraduate and above, senior high school, junior high school, primary school and below. Income was divided into <2000 Yuan, 2000–4000 Yuan, >4000 Yuan. Smoking was divided into >20 times/day, 10–20 times/day, 1–9 times/day, < once/day, quit smoking and never smoking. Quit smoking was defined abstinent for at least 30 days before the enrollment to the study.2.5p < .05.All continuous variables and categorical variables are presented as means ± SD and the percentage, separately. Chi‐square test was used to compare the differences in frequency of categorical variables. One‐way analysis of variance (one‐way ANOVA) or Kruskal‐Wallis test was used to compare the means of continuous variables. Multivariable logistic regression analyses were used to exploring relationships between dietary phytosterols intake and different types of obesity. Age, gender, education, incomes, physical exercise and smoking status were adjusted in models. All analyses were carried out with SPSS Statistics ver. 22.0 (IBM). The level of significance was set at 33.1p < .05 for all).The characteristics and dietary PSs intake of participants were summarized in Table 3.2p < .05]. For stigmasterol, we found higher dietary stigmasterol intake was linked with lower prevalence of overweight/obesity, overweight and central obesity. For β‐sitosterol, participants in Q2 and Q4 were less likely to have overweight/obesity and overweight, respectively. Participants in Q3 of β‐sitostanol tended to have lower prevalence for central obesity  but campestanol for overweight/obesity and overweight . However, no significant associations were found between campesterol intake and any subtype of obesity in the multivariable‐adjusted model.As shown in Table 3.3p < .05). However, compared with the 1st quartile, the multivariable‐adjusted ORs of central obesity of the 3th quartile were 0.71  for β‐sitostanol and of overweight 0.75  for campestanol in male (All p < .05).Tables 3.4R = .91, F = 4151.28, p < .001).Table 4We applied an internet‐based dietary questionnaire to in a large northern Chinese population to investigate the associations between PSs intake and the prevalence of obesity incidence. Our findings indicated: (1) The intake of total PSs, β‐sitosterol, stigmasterol, β‐sitostanol, campestanol were associated with lower risks of obesity, whereas no significant associations were observed between campesterol intake and any subtype of obesity; Besides, the reverse relationships were observed between dietary PSs and central obesity. (2) total PSs and subgroups PSs intake were different for female and male in prevention of obesity risks. The higher levels of campestanol were associated with the lower risk of overweight/obesity and overweight in female and male. Interestingly, the stigmasterol intake was inversely related with the prevalence of central obesity in female, while the β‐sitostanol intake was found in male. (3) The fruits, vegetable‐oil, nuts and seeds may be important diet sources of PSs.In line with our previous findings, PSs intake was associated with the lower risk of obesity. Similarly, the recent meta‐analysis including 79 randomized controlled trials suggested PSs intake in subjects with BMI ≥25 and hyperlipidemic significantly decreased body weight and BMI . The average daily intakes of total PSs usually range from 200 to 400 mg in general population and high daily intake of 500–1000 mg can be obtained by vegetarians .None.This study was approved by the Human Research Ethics Committee of the Harbin Medical University ([2015] 006).Written informed consent was obtained from all participants.


We aimed to investigate whether (1) psychological and social indicators influence survival in patients diagnosed with cancer or haematologic malignancies when important biological aspects are controlled for, (2) psychological, social and biological indicators can be utilised to design one collated index for survival, usable in clinical practice to identify patients at risk of shorter survival and to improve personalised healthcare provision.In this cross‐sectional study, 2263 patients with cancer or haematologic malignancies participated. We analysed 15 biological, psychological and social indicators as risk factors for survival with a Cox proportional hazards model. Indicators significantly associated with survival were combined to compute models for the identification of patient groups with different risks of death. The training sample contained 1122 patients. Validation samples included the remaining 1141 patients, the total sample, as well as groups with different cancer entities.p < 0.001). Post hoc analysis of the influence of depression on survival showed a mediating effect of the following four factors, related to both depression and survival: previous psychiatric conditions, employment status, metastatic disease and haemoglobin levels.Five indicators were found to significantly impact survival: Cancer site (HR: 3.56), metastatic disease (HR: 1.88), symptoms of depression (HR: 1.34), female sex (HR: 0.73) and anaemia (HR: 0.48). Combining these indicators to a model, we developed the Cancer Survival Index, identifying three distinct groups of patients with estimated survival times of 47.2 months, 141 months and 198.2 months (Psychosocial and biological factors impact survival in various malignancies and can be utilised jointly to compute an index for estimating the survival of each patient individually—the Cancer Survival Index. We analysed 15 biological, psychological and social indicators as risk factors for survival in 2263 cancer patients with a Cox proportional hazards model. Five indicators, that is cancer site, metastatic disease, depression, female sex and anaemia, were significantly associated with survival and combined to compute the Cancer Survival Index. Cancer incidence is rising worldwide, due in part to the growing and ageing global population. Statistically, overall survival (OS) of cancer patients is constantly improving.Not considering psychosocial variables in study design can bias the results of clinical trials. If groups differ in important psychosocial indicators, the apparent association between the respective factor of interest and the outcome can be flawed.Research shows that psychosocial indicators influence adherence to screening and compliance with cancer treatment, are related to comorbidities, and ultimately impact survival.Growing financial constraintsIncorporating psychosocial factors into clinical oncology supports the aim of personalised medicine, which is to implement the most appropriate treatment and healthcare strategy for each patient based on their respective genetic and environmental characteristics.In the present study we aimed to investigate two aspects: First, the influence of psychosocial indicators on OS in cancer patients when important biological aspects are considered simultaneously. Second, whether and how psychosocial and biological indicators can be utilised to design one collated index for survival. Such an integrated approach could improve assessment of patient survival, patient management as well as clinical study design.Indicators of socioeconomic status, including household income, education level, and social support,22.1www.ccc.ac.at) after approval by the Ethical Committee of the Medical University of Vienna (EC number: 473/2006). Patients’ characteristics are shown in In total, 2263 patients with various malignancies (1097 men and 1166 women) were included. All patients gave written informed consent and were tested between March 2006 and November 2010 at the Department of Medicine I with its Clinical Divisions of Haematology and Oncology of the Comprehensive Cancer Centre Vienna  was used to assess anxiety and depression. The HADS is a 14‐item self‐administered rating scale, specifically developed for non‐psychiatric medical patients.2.3k = 5), psychological (k = 4) and sociodemographic variables (k = 6) were included in the analysis of OS among 2263 patients diagnosed with various malignancies.Fifteen parameters including biological  indicators impacting OS were selected based on published data and feasibility.2.4The influence of 15 somatic and psychosocial variables on OS was analysed with a Cox proportional hazards model. For identification of independent prognostic factors impacting OS, we used a training sample containing 1122 patients tested within 12 months after diagnosis. The prognostic model was then applied to the validation samples, which consisted of the remaining 1141 patients tested 12 and more months after diagnosis as well as the entire patient cohort. Variables independently associated with OS were identified with multivariate step‐by‐step regression.Statistical analyses were performed using SPSS 19.0. In the regression analysis, the cut‐off point for haemoglobin was defined as 11 g/dL based on previous studies. Age was dichotomised using a cut‐off of 60 years. Depression and anxiety were dichotomised based on the established criteria of the HADS score (≥7 for depression and ≥9 for anxiety). Education was dichotomised in low  and high (secondary school/university degree) education level, the cut‐off being high school graduation, income was grouped below and above 1300 € monthly family net income.33.1n = 1166) was 57.5 years (range 18–92 years) and of men (n = 1097) 58.6 years (range 18–88 years). The mean duration of follow‐up was 62.6 months (range 1 to 490 months). The OS among all patients at 5 years was 65.7%. Information on 15 factors analysed  was complete for all 2263 patients. As determined by HADS, the prevalence of suspected depression in the sample was 32.9% (HADS cut‐off ≥7), the prevalence of suspected anxiety 24.3% (HADS cut‐off ≥9) . Mean age of women (‐off ≥9) .3.2The impact of the 15 individual factors on OS in multivariate analysis is shown in Figure 3.3p < 0.001).Using these five variables, we designed a model—the cancer survival index (CSI)––for prediction of an individual patient’s risk of death. Patients were assigned to one of the three risk groups based on their number of risk factors: 0, low risk; 1 and 2, intermediate risk, 3–5, high risk, female breast (n = 414), lung (n = 241), colorectal (n = 146) and ‘other’ (n = 959) cancer patients. The last group includes various cancer entities that could not be analysed separately due to the small number. Patients were assigned to one of the three risk groups based on their number of risk factors: as lung or colorectal cancer constitute already one risk factor, no patients were included in the low risk group in those two entities. The CSI was predictive for OS in all five cancer subgroups tested, with ps ≤ 0.003. Predicted survival times are depicted in Table Next, we validated the CSI in each of the following cancer entities: lymphoma  and presence of distant metastases  were significantly associated with shorter OS, haemoglobin levels above 11  and employment  were associated with longer OS. Using these variables, we designed a model, the cancer depression index (CDI), to predict an individual patient’s risk of death. Patients were assigned to one of two risk groups based on their number of risk factors: 0 and 1 low risk; 2–4 high risk. The survival curves and death rates over time for the two risk groups in the all cancer patients sample are shown in Figure p < 0.001).Depression was shown to be significantly associated with OS. To further corroborate the influence of psychosocial factors on OS, we analysed which of the other 14 parameters are associated with depression and developed a model depicting the influence of those factors on survival. After step‐by‐step regression analysis, previous psychiatric disorders  and low education level (p <0.001)  contains aspects easy to asses and is therefore especially usable in clinical practice. Of the 15 factors included in this study, five different parameters are related to OS. Cancer site, metastatic disease, anaemia and sex are well established parameters and their impact on OS is recognised.Our study results indicate that the influence of depression on OS is mediated by the association of depression with other aspects relevant to survival, including previous psychiatric disorders, employment status, metastatic disease and haemoglobin levels. Combining those factors into one biopsychosocial cancer scoring system is novel and represents the importance of psychosocial aspects—the tumour macroenvironment—for survival.Data presented in this study demonstrate that patients with low socioeconomic status, measured by household income and education level, are more prone to show symptoms of depression. However, these patients are also less likely to express a need for psychological treatment or psychosocial support, and they are less likely to receive such support. This reflects a highly relevant social problem, as it is related to unequal quality of care based on patients’ social indicators. This disparities in cancer care have been further exacerbated by the recent COVID‐19 pandemic.Recent publications demonstrate (1) a correlation between lower education and high body mass index in the highly developed and industrialised countries, (2) the impact of high body mass index on all‐cause mortality and (3) that poverty and low education are associated with higher mortality.Natural selection describes the process of interplay between somatic and environmental factors resulting in evolution. In a biological concept, selection pressure on the malignant clone might not be restricted to its genetic profile, the tumour microenvironment and immunological factors but might extend to comorbidity, medical infrastructure, patients’ ability to adhere to complex screening and treatment programmes, society’s ability to make such programmes widely accessible etc.—the tumour macroenvironment.Another hypothesis addressing the ‘mind–body’—interplay includes epigenetic changes. Recent data indicate that psychological and social stressors can induce epigenetic changes.4.1The strengths of this study include its large sample size, unicentricity and the availability of simultaneous data regarding somatic, socioeconomic and psychological aspects from each individual. Nonetheless, the following limitations have to be pointed out: First, part of the data used in the present analysis is based on patients’ self‐reports, which may lead to misclassification. Though, research indicates that self‐reported data on cancer and chronic disease can be regarded as reliable.Second, we used a screening tool, the HADS, to assess depression and anxiety. Screening tools can be over‐inclusive compared to clinical interviews. However, there are studies supporting the reliability and validity of the HADS for detection of anxiety and depression in patients with a somatic illness.Third, the diagnosis of depression was not based on the ‘gold standard’ of clinical interview. However, the HADS is a widely accepted, valid and reliable tool developed to identify anxiety and depression in somatically ill patients.4.2Considering the importance of psychosocial factors for the survival of patients with cancer, these aspects should be included in study design of clinical trials as well as in screening and treatment approaches for individual patients. Not considering psychosocial variables in study design can bias the results of clinical trials. If groups differ in important psychosocial indicators, the apparent association between the respective factor of interest and the outcome can be flawed. There is conflicting data, whether therapeutic approaches targeting psychosocial factors improve OS.4.3To provide optimal cancer care to each patient, healthcare providers need to be more attentive to the tumour macroenvironment. This includes psychological and social factors; most importantly depressive disorders, previous psychiatric conditions and socioeconomic factors like household income, educational level and employment status. We recommend the CSI to be used in routine clinical practice for the identification of cancer patients at risk of shorter survival.The authors declare no conflict of interest.Alexander Gaiger: Conceptualization, methodology, validation, writing ‐ original draft, supervision, and project administration. Simone Lubowitzki: Formal analysis, investigation, data curation, writing ‐ review & editing, and project administration. Katharina Krammer: Formal analysis, investigation, data curation, writing ‐ review & editing, and project administration. Elisabeth L. Zeilinger: Formal analysis, investigation, data curation, writing ‐ review & editing, and project administration. Andras Acel: Formal analysis, investigation, data curation, writing ‐ review & editing. Olivera Cenic: Formal analysis, investigation, data curation, writing ‐ review & editing. Andrea Schrott: Formal analysis, investigation, data curation, writing ‐ review & editing. Matthias Unseld: Formal analysis, investigation, data curation, writing ‐ review & editing. Anahita Paula Rassoulian: Formal analysis, investigation, data curation, writing ‐ review & editing. Cathrin Skrabs: Investigation, writing ‐ review & editing. Peter Valent: Investigation, writing ‐ review & editing. Heinz Gisslinger: Investigation, writing ‐ review & editing. Christine Marosi: Investigation, writing ‐ review & editing. Matthias Preusser: Investigation, writing ‐ review & editing. Gerald Prager: Investigation, writing ‐ review & editing. Gabriela Kornek: Investigation, writing ‐ review & editing. Robert Pirker: Investigation, writing ‐ review & editing. Günther G. Steger: Investigation, writing ‐ review & editing. Rupert Bartsch: Investigation, writing ‐ review & editing. Markus Raderer: Investigation, writing ‐ review & editing. Ingrid Simonitsch‐Klupp: Investigation, writing ‐ review & editing. Renate Thalhammer: Investigation, writing ‐ review & editing. Christoph Zielinski: Conceptualization, methodology, writing ‐ original draft, and supervision. Ulrich Jäger: Conceptualization, methodology, validation, writing – original draft, and supervision.The study was approved by the institutional ethics committee of the Medical University of Vienna, Austria .Informed consent was obtained from each study participant.Figure S1Figure S2Click here for additional data file.Table S1‐S2Click here for additional data file.


Adroctenes horvathi from Kenya and South Africa, as well as Hypoctenes faini from Rwanda. We present an updated list of published polyctenid records in the Afrotropical region indicating their host specificity and their geographical distribution. We report global infection patterns and sex ratio of polyctenids based on previously published data, including Old and New World species. Lastly, we demonstrate the first molecular phylogeny of Polyctenidae, showing their phylogenetic relationship with the closely related family Cimicidae.Polyctenidae bugs are rarely studied, hematophagous, and highly specialized ectoparasites of bats. There are only 32 described species worldwide, including six species in the Afrotropical region. Knowledge on these parasites is limited, and most studies are restricted to the New World polyctenid species. Here we report additional records of  Polyctenidae bugs are very rare, hematophagous, highly specialized ectoparasites of bats. In this study, we demonstrate the first molecular phylogeny of the family Polyctenidae, showing their phylogenetic relationship with the closely related family Cimicidae. Additionally, we report global infection patterns and sex ratio of polyctenids based on previously published data, including Old and New World species. Bat bugs (Hemiptera: Cimicidae and Polyctenidae) are blood‐sucking parasites, belonging to the superfamily Cimicoidea. Cimicids ]. Eoctenes intermedius is the most widespread species with several records from Australia, Africa, and Asia  , whereas Hesperocteninae is restricted to the Western Hemisphere (South and North America)  and/or stenoxenous  Maa, . An expeHesperoctenes fumarius showed prevalence of 21% on Molossus rufus as well as intensity of infestation (mean number of bat bugs on infected hosts) of 2.22 ± 2.86  of 0.5 ± 1.14 and 0.4 ± 1.49 as well as mean intensity of 2.0 ± 1.43 and 3.2 ± 3.00 on M. molossus and M. rufus, respectively , keeping whole specimens from external damage. Specimens were placed in separate tubes at 56°C for overnight digestion, using 20 μl Proteinase‐K and 180 μl ATL buffer (per sample) (Qiagen). DNA was extracted using DNeasy Blood and Tissue Kits (Qiagen) based on the protocol provided by the manufacturer. We targeted the COI gene (658 bp long fragment) for the molecular analysis, and we used the following primers: Lep1F (5′‐ATT CAA CCA ATC ATA AAG ATA TTG G‐3′), Lep1Fdeg (5′‐ATT CAA CCA ATC ATA AAG ATA TNG G‐3′), and Lep3R (5′‐TAT ACT TCA GGG TGT CCG AAA AAT CA‐3′)  were concatenated in the Geneious Prime 2019.2.3  and Hypoctenes faini , from one female of Rhinolophus simulator  and one female of Otomops martiensseni , respectively.Three polyctenids  were found belonging to two species: Adroctenes horvathi in the collection of the California Academy of Sciences in San Francisco, CA (USA). The specimens were collected by James D. Hawkins  from Rhinolophus spp. We included these records in Table Five specimens of previously unidentified and unpublished polyctenids were recorded, representing 3.2A. horvathi and H. faini are the second published occurrence of these species to both Rwanda and South Africa. Finally, H. faini and A. horvathi are reported for the first time from Otomops martiensseni and Rhinolophus simulator, respectively. We excluded records with unspecified data, when exact country was not given .We collected distributional data of all six African polyctenid species, which have been reported from 14 countries to date Figure , Table 13.3Hesperoctenes. Sex ratio is often female biased in both New and Old World species; however, there is no clear evidence for strong female biased occurrence due to low sampling effort and lack of data. In total, 645 females and 381 males were reported from previous works, indicating female biased sex ratio  (Scutelleridae) and 83.18% Ceratocapsidea (MW984087), respectively. The 16S sequences of H. fainii and A. horvathi showed the highest similarity of 84.29% Tetraphleps aterrimus (NC_042679) (Anthocoridae) and 83.65% Primicimex cavernis (MG596876) (Cimicidae), respectively. For the 18S fragment, H. fainii and A. horvathi showed the highest similarity to 97.37% and 95.50% Latrocimex spectans (MZ378786) (Cimicidae), respectively. Lastly, the BLAST search of the 28S gene fragment of A. horvathi (28S) showed a 90.12% similarity with Cimex lectularius (KJ461188) (Cimicidae). Amplification and sequencing of the 28S rRNA gene of H. faini were unsuccessful with two different primer sets.Based on BLAST search, for the COI gene fragment the closest match for Overall, within Cimicoidea, as reflected by the topology of the Bayesian tree based on three genetic markers  Figure , Table 344.1Adroctenes horvathi has been recorded in the African continent only and has the widest distribution, being present in Eastern and Southern Africa and is the most common species among all the known African polyctenids. The primary host species of A. horvathi belong to the family Rhinolophidae, which are widely distributed in continental Africa and A. horvathi may be present in additional countries where its presence has not yet been observed.Currently, six species of polyctenids are known from the African region. Eoctenes is the most species‐rich genus in Africa, with three different species. Nevertheless, E. coleurae seems to be the most rarely collected polyctenid species among all the African Polyctenidae as it has been recorded only once in Sudan and has not been reported since its description . Future studies focusing on family Emballonuridae and its parasitic fauna should give more insights to the distribution of E. coleurae.ion Maa, , making Eoctenes nycteridis is also endemic to the African continent and has been mostly reported from the central countries with some additional records, such as Eritrea and Liberia; therefore, it is expected to occur in other regions within the distribution range of its hosts, family Nycteridae. Species belonging to family Nycteridae occur in Africa but some parts of Asia as well.Eoctenes intermedius is a widely distributed species with several records from Asia  to the base of the tree. Polyctenid species cluster close to Primicimicinae, forming a separate clade at the base of Cimicidae. Based on these results, Polycteninae is a sister clade to Primicimicinae. Subfamily Cacodminae appears to be monophyletic, which has been shown before  suggesting that Curaliidae is not a sister group of Polyctenidae  may be considered as a subfamily of Cimicidae.4.5Trypanosoma, Bartonella, and Kaeng Khoi virus  parasites, which have been shown to infect, e.g., Rhinolophidae and Nycteridae species ; data curation ; formal analysis ; investigation ; methodology ; project administration ; resources ; supervision ; visualization ; writing – original draft ; writing – review and editing . Sándor Hornok: Conceptualization ; data curation ; methodology ; supervision ; writing – original draft ; writing – review and editing . Áron Botond Kovács: Formal analysis ; methodology ; writing – review and editing . Nóra Takács: Methodology ; writing – review and editing . Miklós Gyuranecz: Formal analysis ; software ; writing – review and editing . Wanda Markotter: Data curation ; funding acquisition ; investigation ; supervision ; writing – review and editing . Philippe Christe: Conceptualization ; project administration ; supervision ; validation ; writing – original draft ; writing – review and editing . Olivier Glaizot: Conceptualization ; project administration ; supervision ; validation ; writing – original draft ; writing – review and editing .The authors declare no competing interests.Ethical approval was obtained from the University of Pretoria  and Research was performed under Section 20 approval of the Department of Agriculture, Land Reform and Rural Development, South Africa.


HIV‐positive patients whose viral loads are successfully controlled by active antiretroviral therapy (ART) show no clinical signs of AIDS. However, their lifespan is shorter compared with individuals with no HIV infection and they prematurely exhibit a multitude of chronic diseases typically associated with advanced age. It was hypothesized that immune system aging may correlate with, and provide useful biomarkers for, this premature loss of healthspan in HIV‐positive subjects. Here, we tested whether the immune correlates of aging, including cell numbers and phenotypes, inflammatory status, and control of human cytomegalovirus (hCMV) in HIV‐positive subjects on long‐term successful ART (HIV+) may reveal increased “immunological age” compared with HIV‐negative, age‐matched cohort (HIV−) in participants between 50 and 69 years of age. Specifically, we expected that younger HIV+ subjects may immunologically resemble older individuals without HIV. We found no evidence to support this hypothesis. While T cells from HIV+ participants displayed differential expression in several differentiation and/or inhibitory/exhaustion markers in different T cell subpopulations, aging by a decade did not pronounce these changes. Similarly, while the HIV+ participants exhibited higher T cell responses and elevated inflammatory marker levels in plasma, indicative of chronic inflammation, this trait was not age‐sensitive. We did find differences in immune control of hCMV, and, more importantly, a sustained elevation of sCD14 and of proinflammatory CD4 and CD8 T cell responses across age groups, pointing towards uncontrolled inflammation as a factor in reduced healthspan in successfully treated older HIV+ patients. Proinflammatory markers, such as sCD14, in plasma and proinflammatory responses of T cells were elevated in successfully treated HIV+ compared with HIV− older adults age‐independently. The higher number of naïve CD8 T cells, higher expression of inhibitory/exhaustion markers  were detected on T cells of HIV+ with or without stimulation. The higher expression of exhaustion markers decreased with age and differences diminished in older populations. Human CMV (hCMV) is a widely distributed human herpesvirus that infects 60%–90% of the human population depending on the age and socioeconomic conditions  as well as HIV‐negative (HIV−) age controls. The impact of controlled HIV infection and age on immune homeostasis and function, including immune responses to hCMV latent infection were assessed in this cohort. To avoid sex at birth bias, we focused on male participants, and took advantage of the fact that nearly all HIV+ participants were CMV seropositive. We compared their immune and inflammatory phenotypes to those of HIV− control groups with similar age, gender and CMV positivity. Consistent with prior studies, we found that the some of the measured parameters were significantly different in HIV+ subjects compared to HIV− controls. While many changes were not age‐sensitive, we found age‐dependent differences as well. Moreover, certain HIV‐associated disturbances persisted in ART‐treated participants into the advanced age, suggesting a prolonged impact of long‐term chronic viral infection on proinflammatory immune status in older adults. These phenotypes may provide clues to overcome morbidity and mortality in successfully treated HIV‐positive populations.22.1Our cohort consisted of 88 male participants aged 50 and older with 42 HIV+ and 46 HIV− participants, with very close medians between the comparing groups. We selected age of 50 years and older, since the clinical symptoms of immune aging phenotypes become more noticeable after age of 50 and accelerate thenceforth . However, the mean levels of those markers by age were not statistically significantly different  compared with HIV− . Of interest to our hypothesis, similar to the inflammatory marker changes, the changes in absolute numbers of CD4 and CD8 between HIV+ and HIV were less significant in the older age group, probably due to the overall age‐related lymphopenia. The fact that aging did not potentiate the effects of HIV, but rather ameliorated the phenotype observed in HIV+, was surprising, and could suggest the frequency of cell phenotypes are affected differently by HIV infection and by age.To evaluate T cell homeostasis in HIV+ participants on ART as a function of aging, we first compared the absolute numbers of total T cells and their subsets in the peripheral blood mononuclear cells (PBMCs) from HIV+ and HIV− . A similar pattern was observed in CD8, although this was not statistically significant. MFI of TIM3 estimates demonstrated an opposite pattern from the frequencies, in both CD4 and CD8, TIM3 MFI in HIV+ was positively correlated with age, while negatively correlated in HIV−; these correlations were not statistically significant from zero.Expression of functional activation and inhibitory/exhaustion markers on CD4 and CD8 T cells was examined to investigate the status of T lymphocytes in successfully treated HIV+. CD38 and HLA‐DR have been recognized as activation markers expressed on activated cells during active microbial infection , and positively correlated with age in HIV− , although not statistically significant  with increasing age.2.5p = 0.0224).We stimulated PBMC with the CD3/CD28/CD49d antibody cocktail and labeled with CFSE to analyze T cell proliferative ability as well to evaluate functional characteristics of T cell subsets in successfully treated HIV+ population as a function of aging Figure . Approxip = 0.0093) as observed in PD‐1  probes. Telomeres are repeating hexametric sequences of nucleotides at chromosomal ends that provide the stability and that shorten with each replication. The mean fluorescence index (MFI) of PNA signals in both CD4 and CD8 T cells were not statistically significant Figure .As conclusion, we did not observe aging phenotypes at the DNA levels in HIV+ individuals compared with HIV− in this study.2.7R = 0.219, p = 0.143) but were significantly correlated in HIV+   Figure ; we noteGiven that the primary control of reactivating hCMV is under purview of T cells, we examined T cell cytokine secretion after both hCMV‐specific (IE1 and pp65 peptide pools) and polyclonal, non‐specific stimulation with phorbol ester and calcium ionophore (PMA and ionomycin). We measured IFN‐γ and TNF‐α expression by intracellular cytokine staining and scored the cells expressing either one or both cytokines as responsive. Cytokine responses of CD4+ cells against IE1 were at the background level (without stimulation). No significant difference was observed in % T cell reactivity to CMV peptides in either CD4 or CD8 T cells from HIV+ and HIV− participants Figure , and theThe response of T cells to PMA/ionomycin revealed higher cytokine responses in HIV+ than the HIV− participants, a result that was consistent in both CD4 and CD8 Figure . This br2.8Finally, we analyzed the correlation between inflammatory markers and other variables to explore the landscape of immune status in HIV+ participants on successful ART. Figure 3HIV infection causes a massive and catastrophic disruption in the host immune system and mucosal homeostasis, which in subjects on ART resemble some of the immune changes found in physiological aging. It remains difficult to prove whether those homeostatic disturbances in HIV+ participants actually represent accelerated aging or whether they only result in phenotypes similar to aging. Active HIV infection causes many changes in immune phenotypes such as CD4 T cell death, T cell activation and exhaustion and expression of inflammatory markers. Those changes are significantly reduced with ART, yet chronic diseases abound in this group of patients and appear earlier than in their HIV‐negative counterparts. Some of diseases were attributed to ART toxicity especially in the early days of ART  HIV+ participants and age‐matched HIV‐negative controls, all seropositive for hCMV. Our focus in this study was to understand how virologically undetectable HIV infection affects immune aging under successful ART. We were somewhat surprised to find that systemic inflammatory markers in those individuals were subtly and not very predictably elevated, and in particular that IL‐6 and CRP, the two stalwart markers of elevated inflammation with aging, did not change in an age‐related manner over the span of two decades in our cohort. However, our data were similar to the findings of de Armas et al., who compared plasma inflammatory cytokines from successfully treated HIV+ with those from HIV− in different age groups and found only TNFR2 was elevated in HIV+ in all age groups while IL‐6 and IL‐8 were actually decreased in HIV+ compared with HIV−  or elevated  with successfully treated HIV infection, and these changes showed no age‐sensitivity. T cell phenotypes in successfully treated HIV+ participants were not very different from those in HIV−, lacking signs of massive activation or massive cellular exhaustion, and only showing increase in number of inhibitory marker positive cells. The increase in those markers at homeostatic T cells diminished in older population in both groups. In contrast, response to polyclonal stimulation were generally decreased in HIV+ compared with HIV+, exception of TIGIT, which is increased in HIV+. Again, contrary to homeostatic T cells, the magnitude of the difference between HIV+ and HIV− in stimulated T cells were greater with increasing age.Immune response to hCMV was more informative and insightful and suggested impaired control of hCMV in HIV+ participants, with possible increased rate of virus reactivation based on the fact that HIV+, but not HIV−, participants exhibited significant increase in anti‐hCMV neutralizing antibodies, and that this increase was more pronounced with increasing age. T cell responses to hCMV immediate‐early antigen 1 (IE1) regardless of the HIV status or age. As its name states, IE1 is among the earlies transcripts of hCMV and is transcribed early both in the course of primary infection and reactivation  on CD8 cells, and negatively correlated with CD4 counts, consistent with damage to CD4 cells, exhaustion of CD8 cells, and incompletely repaired gut barrier. This pattern of correlation was dramatically different in HIV− participants, where inflammatory cytokines positively correlated with T cell responses to polyclonal stimulation and to expression of CD57, suggesting qualitative difference in immune system regulation.Limitations of this study are primarily twofold. First, the study is of relatively low power, with 42–46 subjects/group, which impacted finding statistical significance even when differences were visually apparently. Second, the age‐related conclusions and the results on age‐sensitive traits are limited by a relatively narrow span of ages, from 50–69 years of age. The fact that over this range of ages we did not observe changes in certain well‐known age‐sensitive parameters, like IL‐6 and CRP levels, may highlight that type of limitation. We also would like to note that the difference we see in this paper may not directly be caused by HIV infection but caused by secondary changes due to the HIV infection, such as more frequent reactivation of CMV in HIV+ as the higher anti‐CMV antibody titers in HIV+ suggest. However, even with these limitations, we have identified two sustained and mechanistically potentially different contributors to increased systemic inflammation in HIV+ participants, with a potential to exacerbate multiple chronic diseases. These include (i) the persistent significantly higher elevation of sCD14; and (ii) increased frequencies of T cells producing inflammatory cytokines (IFN‐γ and TNF‐α) upon polyclonal stimulation. Both were elevated across both ages examined, suggesting prolonged disturbances in gut mucosal integrity and potential microbial translocation, and a linked, or independent/additive, chronic “trigger‐happy” inflammatory T cell accumulation, both of which could contribute to the adverse effects of poorly controlled inflammation and its impact on various chronic diseases  and cryopreserved in fetal bovine serum (FBS) + 10% DMSO.This study was approved by the Institutional Review Boards (IRB) at the University of Arizona (IRB protocol#2102460536). HIV‐positive subjects, who are treated successfully with ART (HIV RNA <50 copies/ml in plasma), were recruited from Banner‐University Medicine North HIV‐positive study cohort was selected from HIV‐positive males, who diagnosed more than 5 years ago, and are over 50 years old of age. Age‐ and sex‐matched controls are healthy community‐dwelling individuals, recruited in Arizona. CMV seronegative individuals were removed from the cohort since CMV infection affects many aspects of immune phenotype. Demographic information of the cohort is shown in Table 4.2Interleukin‐6 (IL‐6), Interleukin‐8 (IL‐8) and tumor necrosis factor (TNF)‐α (HCYTOMAG‐60 K and HSTCMAG‐28SK), TNF receptor (TNFR) 1 and 2 (HSCRMAG‐32 K), soluble CD14 (sCD14) (HCVD6MAG‐67 K), and C‐reactive protein (CRP) (HNDG2MAG‐36 K) in plasma were quantified by Millipore MagPix kit (Millipore) and soluble CD163 in plasma was quantified by ELISA kit (Invitrogen EHCD163) according to the manufacturer's protocol.4.3Serum samples with high IFA‐scored antibody titers , obtained from prior studies, were used as the top standards for CMV as previously described . Cutoff value was calculated as 20% of no plasma control, which represent 80% reduction of the infection. The highest dilution rate, which exceeded 20% positive, was read as a neutralizing titer.Human foreskin fibroblast (HFF)‐1 was purchased from ATCC (#SCRC‐1041). HFF‐1 cells were grown in complete DMEM . GFP‐expressing hCMV virus was kindly provided by Dr. Felicia Goodrum (University of Arizona) , rested overnight in X‐Vivo medium (Lonza) supplemented with 5% human male AB serum. Antibodies used for flow cytometry is listed in Table intCD95low; central memory (Tcm): CD28highCD95high; effector memory (Tem): CD28lowCD95highCCR7−CD45RA− terminally differentiated EM (Te); CD28lowCD95highCCR7−CD45RA+ : CD28+ Figure . The gat4.6Experiment was performed as described before  under a null hypothesis of zero correlation. Software included R version 4.4.2 and IBM SPSS version 28.Unpaired t‐test was used to compare means and Chi‐Square test was used to analyze categorical values in the demographic table. Analysis of covariance was used to evaluate HIV status moderation of the relationships between immunologic measures and age. The F‐test statistic was used in a stepwise fashion to test interactions, then common slopes with different intercepts and a common slope models. The z‐test statistic was used to test Pearson correlations (M.W., M.J., L.D., M.J.S., and R.P.S. conducted experiments and acquired data. M.J., M.J.S., B.J.L., and J.N.Z. contributed to study design. M.W. and B.J.L analyzed and interpreted the data. M.W. Y.C. and C.M. performed recruitment, specimen collection and database maintenance. M.W., E.K.H., B.J.L, and J.N.Z. contributed to writing the manuscript.Supported by the USPS Awards AG054317 and AG020719 and the Bowman Professorship in Medical Sciences to J.N‐Ž.The authors declare that there is no conflict of interest.All patients provided written informed consent to the study.Appendix S1Click here for additional data file.


Persistence involves the intention to maintain efforts when faced with obstacles and challenges, in order to achieve a specific goal. The Rigid and Flexible Persistence Scale (RFPS) is a self-report measure that assesses persistence that is theoretically derived from the premises of the Dualistic Model of Passion. The aim of the present research was to adapt the RFPS to Brazilian Portuguese and to estimate its evidence of validity and reliability in the context of work. Participants were 400 professionals, 55.8% women, aged between 18 and 68 years. The results indicate that the RFPS presented validity evidence based on the content. Corresponding to the theoretical expectations, exploratory and confirmatory factor analyses demonstrated adequacy of the structure composed of two factors, explaining 75% of the data variance, with good levels of reliability. The RFPS also revealed strong invariance across gender and work conditions (in-person vs remote). Flexible persistence showed positive association with harmonious passion and occupational self-efficacy. Conversely, rigid persistence showed positive association with obsessive passion. It was observed a mediational role of occupational self-efficacy in the relationship between harmonious passion and flexible persistence. Overall, the findings suggest that the RFPS is an adequate measure of persistence in a Brazilian occupational sample. Aiming to consider healthy and potential issues of individuals, Positive Psychology has focused on topics such as optimism, well-being and character strengths, demonstrating the importance of acting in both the promotion of mental health and the prevention of risks  was developed by Vallerand et al. , in the p < 0.001) and negatively associated flexible persistence , whereas harmonious passion was related with flexible persistence  and, to a lesser extent, rigid persistence . Of interest, the two types of persistence were found to predict different consequences. Specifically, both RP and FP were found to predict adaptive outcomes within the confines of the activity at hand , whereas only FP was found to predict adaptive life outcomes  outside of the activity  provided support on the role of passion as a determinant of the two types of persistence. Specifically, the results from structural equation modeling suggest that obsessive passion positively associated rigid persistence  in the Brazilian Portuguese language and estimate its validity evidence based on content, internal structure, and on relationship with external variables, namely, passion for work and occupational self-efficacy.The present study was based on the hypothesis that the content of the Brazilian Portuguese RFPS would yield psychometric properties equivalent to the original scale (H1) and that a structure composed of two correlated factors would be found in Brazilian samples (H2). Flexible persistence was also expected to present a moderate positive correlation with harmonious passion and a moderate negative correlation with obsessive passion (H3). Furthermore, rigid persistence was expected to be positively correlated with obsessive passion and, to a lesser extent, with harmonious passion (H4). Hypothesis 5 was that there would be a positive and moderate relationship between occupational self-efficacy and flexible persistence. However, there would be a null relationship between rigid persistence and occupational self-efficacy. Finally, in line with Feng and Chen , the conM = 35.6; SD = 10.5). Individuals were from the Southeast (68.5%), South (19.5%), Northeast (4.8%), Central-west (5.5%), and North (1.7%) of the country. In addition, they were attending or had completed postgraduate studies (54.0%), undergraduate (37.8%), high school (7.5%), or elementary education (0.7%). The professionals held different positions in which they had been for a mean of 64.8 months  and worked a mean of 33.1 h (SD = 17.3) per week in private (62%) or public (32.5%) institutions or autonomously (5.5%), in person (59.7%) or remotely (40.3%).A non-probabilistic sample was composed of 400 Brazilian workers , 18 to 68 years of age  and flexible persistence . The instrument is of the self-report type, in which participants must indicate how much they agree with each statement using a seven-point Likert-type scale, in which 1 corresponds to “do not agree at all” and 7 to “very strongly agree”. Results of both exploratory and confirmatory factor analyses supported the dual structure of the scale reflecting rigid and flexible persistence. The internal consistencies of the dimensions of the original scale  and six for obsessive passion  answered on a Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree). Internal consistency showed adequate reliability both dimensions, harmonious passion (α = 0.90) and obsessive passion (α = 0.86). The two-factor model showed adequate fit for instrument’s internal structure (χ2/df) = 3.96, TLI = 0.94, CFI = 0.96, RMSEA = 0.08, AIC = 23,992.86, BIC = 24,225.10).The Passion Scale has been fully validated and shown to possess high levels of validity and reliability , which are answered on a Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The single-factor structure was demonstrated by means of confirmatory factor analysis , and internal consistency showed adequate reliability (α = 0.78).The OSS-SF refers to the reduced form of the OSS  was accessed to evaluate the scale content intelligibility. None of the participants had difficulty interpreting the instructions or items of the instrument since the RFPS had clearly and objectively drafted items. Finally, the Brazilian version of the scale was back-translated into English by a native translator, which made it possible to verify the equivalence between the content of the original and the Brazilian version.With the authorization of the author of the original version, Robert J. Vallerand, the RFPS was independently translated from English into Portuguese by four bilingual professionals . Subsequently, a synthesis version was obtained by an expert committee composed of four researchers specializing in psychological assessment and psychometrics. In a subsequent step the instrument was analyzed based on four criteria: clarity of language, practical relevance, theoretical relevance, and theoretical dimensions by three judges that were experts in Organizational and Work Psychology. A group composed of five professionals, two doctors, a salesperson, a seamstress and a process engineer , aged between 25 and 37 years  was used to verify evidence of validity based on the content of the instrument, considering values above 0.70  was used to verify the factor structure through EFA, while sample 2 (n = 250) was selected for the CFA. In spite of the extensive and inconclusive debate over sample size in factor analysis, both samples could be considered adequate as they fit most of the classical rules-of-thumb suggested in the literature, as subject to item ratios of 10:1 and 10–20:1, or number of observation greater than 100  was performed using the statistical software Factor, with a parallel analysis method, as an indicator for the retention of the factors, polychoric correlation, diagonally weighted least squares (DWLS) estimation, and Promin oblique rotation Hongyu, . To veri2/df, RMSEA, CFI, and TLI. The reference values commonly used in the specialized literature were used as adequacy parameters: χ2/df < 5, RMSEA < 0.08, CFI and TLI > 0.90  estimation method. The fit of the measurement model to the data was evaluated using the indices recommended by Muthén and Muthén , namely,r) was calculated, using the Jamovi software, to assess the degree of correlation between the constructs and their directions (whether positive or negative). Significance levels of p < 0.05 were considered. The magnitudes of the correlations were interpreted according to Cohen’s classification  estimated through a bootstrap procedure, a method that allows for more robust estimates for the confidence limits of these effects, as well as for estimates of the standard errors (SE) associated with these statistics. Using the a priori sample size calculator for Structural Equation Models , practical relevance (PR), theoretical relevance (TR) and theoretical dimension (TD) through the content validity coefficient (CVC) procedure  = 554.5; p < 0.0001), indicating the possibility of performing EFA. Accordingly, the parallel analysis suggested the retention of two factors, since both presented values higher than those observed in the factors allocated in the 95% percentile of the randomly estimated data . Table At first, using the Factor software, the EFA was performed with sample 1. In a preliminary analysis it was observed that there were no missing values on the database, the factorability of the data matrix was verified using the Kaiser–Meyer–Olkin criteria (KMO = 0.67) and Bartlett’s test of sphericity . The factor loadings of the items varied between 0.492 (item 8) and 0.975 (item 1), and the model was able to explain 75% of the total variance of the data. Regarding the reliability of the RFPS indicators, both the FP factor  and the RP factor  presented adequate levels of internal consistency. Additionally, good fit indices were observed for the saturated model (χ2 (df) = 23.039 (13); NNFI = 0.96; CFI = 0.98; RMSEA = 0.07, 95% CI [0.000–0.0972]).The correlation between the two factors was positive, significant, but low (χ2 (df) = 27.824 (19); CFI = 0.97; TLI = 0.96; RMSEA = 0.04; 90% CI [0.000–0.075]), as well as adequate levels of reliability for the factors . The factor loadings of items 1, 2, 3, and 4 corresponding to FP ranged from 0.54 to 0.82. Items 5, 6, 7, and 8 related to RP had factor loadings between 0.60 and 0.95. Additionally, there was a correlation of low magnitude between the factors , and Fig. Confirmatory factor analysis (CFA) was performed using the statistical software Mplus, with WLSMV estimation, with the data from 250 participants (sample 2), also it was observed that there were no missing values on the database. Satisfactory fit indices were found for the model  was verified with both samples. The results are presented in Table The results suggest strong equivalence of the measurement model across groups since there was no decrease in the fit indices exceeding the literature recommended cut-offs, as the model restriction increased. Once this evidence was estimated, the validity evidence based on the relationship with an external variable was evaluated considering the relationship between persistence, passion for work, and occupational self-efficacy. The results are shown below.Using the Jamovi software, correlation analyses and structural equation modeling were performed with the entire sample of 400 participants. According to Table χ2 (df) = 891.838 (289); CFI = 0.956; TLI = 0.951; RMSEA = 0.072 90% CI = 0.067–0.078. As can be seen in Fig. β = 0.580 (CI = 0.517–0.641), SE = 0.038 p < 0.01), whereas that between OP and OS is negative β =  − 0.105 (CI =  − 0.179 to − 0.017), SE = 0.049 p < 0.05). In turn, OS positively predicted FP β = 0.273 (CI = 0.177–0.368), SE = 0.058 p < 0.01) but not RP. In addition, direct effects were also observed. The direct effect of HP on FP was significant, β = 0.485 (CI = 0.329–0.579), SE = 0.057 p < 0.01), as was the direct effect of OP on FP β =  − 0.261 (CI =  − 0.347 to − 0.175), SE = 0.052 p < 0.01) and on RP β = 0.605 (CI = 0.542–0.667), SE = 0.038 p < 0.01). Therefore, significant mediation effects (indirect effects) were observed HP-OS-FP β = 0.158 (CI = 0.099–0.217), SE = 0.036 p < 0.01) and OP-OS-FP β =  − 0.027 (CI =  − 0.051 to − 0.003), SE = 0.015 p = 0.047).Structural equation modeling was performed to estimate the mediating effect of the occupational self-efficacy variable on the association between dimensions of passion and persistence. The model showed good fit indices to the available data: β = 0.643 (CI = 0.571–0.715), SE = 0.044 p < 0.01) and non-significant on RP β = 0.063 (CI =  − 0.014–0.140), SE = 0.04 p = 0.181). On the contrary, there was a significant negative total effect of OP on FP β =  − 0.288 (CI =  − 0.376 to − 0.200), SE = 0.054 p < 0.01), and a significant positive total effect on RP β = 0.605 (CI = 0.542–0.667), SE = 0.038 p < 0.01). These results suggest that the occupational self-efficacy mediated approximately 24.6% of the relationship between HP and FP. and approximately 9.4% of the relationship between OP and FP. Finally, it should be highlighted that the model was able to explain 42.0% of the variance in the FP variable, 40% in RP and 31% of the variance in OS.Additionally, a significant total effect of HP on FP was observed The aim of the present work was to cross-culturally adapt the RFPS to the Brazilian context and estimate the first validity evidence based on content, internal structure, reliability, and the relationship with an external variable. The results indicate that the adapted version of the RFPS  of the EPRF for the Brazilian context was therefore achieved . In fact, people with HP can fully focus on the task at hand and experience positive results both during the engagement with the activity  and afterward . Additionally, when prevented from engaging in passionate activity people with this type of passion are able to focus their energy and attention on other tasks that need to be performed, therefore they are people who are in control of the activity and prove to be efficient in deciding when to participate or not  that FP would be positively correlated, with moderate magnitude, with HP and negatively, inversely correlated with OP was partially confirmed, since no statistically significant correlation was observed between FP and OP, only between FP and HP (The hypothesis (H4) that RP would be positively correlated with both types of passion, although with greater intensity with OP was confirmed. With OP, the worker is involved in a restricted way in the activity with an uncontrollable desire to perform the task they consider important. The worker cannot stop doing or thinking about the passionate activity because it dominates him or her. As such, OP leads the worker to persist rigidly on work goals. Although this rigid persistence in performing the activity can have beneficial results, such as high performance, it can also generate conflicts with other goals since frustrations and ruminative thoughts can accompany the individual when they are not involved in the passionate activity  in which HP would positively predict FP, and OP would negatively predict FP and positively predict RP was confirmed. These results suggested that the way someone engages in a task that they are passionate about dictates the quality of that persistence, therefore, HP can lead to the development of FP, which allows the individual to persist in different goals and activities as well as the main one in a more pleasant and consonant way. On the other hand, obsessive passion is capable of providing a more restricted type of action in the involvement with the activity, being positively associated with RP and negatively associated with FP  occupational self-efficacy partially mediated the relationship between HP and OP on FP. This corroborates the theoretical expectation, since as professional experience allows the internalization of the professional activity and identity in a harmonious way the individual tends to present higher levels of engagement and performance at work  on self-report instruments, especially in high stakes contexts. In this sense, it is suggested the use of methods that could mitigate the effects of these response biases. Research investment is also recommended to estimate the instrument’s potential using other psychometrics methods, such as item response theory, with the goal of evaluating the difficulty and discrimination properties of the items, as well as the establishment of interpretative norms that allow the attribution of psychological meaning to the RFPS scores. Lastly, the psychometric properties of the RFPS can be assessed within the context of other activities besides work, such as education and sports.This study made it possible to confirm the potential of the Brazilian Portuguese version of the EPRF to assess Rigid and Flexible Persistence in the Brazilian population by demonstrating the stability of the instrument as well as the internal structure, reliability, generalizability across group and relationship with external variables. The findings of this first study provide support for the psychometric properties of the Brazilian version of the RFPS and stimulate the continuity of research into the construct of persistence using this instrument in future studies in order to assess the consequences of the two dimensions of persistence and the replication of results found in this study, what will contribute to the accumulation of validity evidence to support the interpretation of the RFPS scores.