Low levels of physical activity (PA) and prolonged sitting time (ST) increase the risk of non-communicable diseases and mortality, and can be influenced by socio-demographic characteristics. The aim of this study was to use self-report data to characterise socio-demographic patterns of PA and ST in eight Latin American countries.n = 9218, aged 15–65 years), collected from September 2014 to February 2015. Transport and leisure PA and ST were assessed using the International Physical Activity Questionnaire–long version. Overall and country-specific mean and median levels of time spent in transport and leisure PA and ST were compared by sex, age, socioeconomic and education level.Data were obtained from the Latin American Study of Nutrition and Health (ELANS), a household population-based, multi-national, cross-sectional survey (p < 0.005) in men than women with mean differences of 58.0 and 34.0 min/week. The mean and median for transport PA were similar across age groups . The median time spent in transport and leisure PA between three strata of socioeconomic and education levels were similar. The prevalence of not meeting PA recommendations were 69.9% (95% CI: 68.9–70.8) for transport and 72.8% (95% CI: 72.0–73.7) for leisure. Men, younger people (15–29 years), individuals with higher socioeconomic and education levels spent significantly (p < 0.001) more time sitting than women, older people (30–59 years and ≥ 60 years) and those in the middle and low socioeconomic and education groups, respectively.Mean levels of transport and leisure PA were 220.3 min/week (ranging from 177.6 min/week in Venezuela to 275.3 min/week in Costa Rica) and 316.4 min/week (ranging from 272.1 min/week in Peru to 401.4 min/week in Ecuador). Transport and leisure PA were higher (Transport and leisure PA and ST range widely by country, sex, and age group in Latin America. Programs for promoting leisure and transport PA and reducing ST in Latin America should consider these differences by age and gender and between countries.NCT02226627. Retrospectively registered on August 27, 2014.ClinicalTrials.Gov  The incidence of cardiovascular diseases (CVD) is increasing throughout the developing world; causing more than 16 million deaths each year, 80% of which occur in low and middle-income countries . PhysicaSedentary behavior, as distinct from physical activity, encompasses a broad range of behaviors that involve a sitting or reclining posture and do not increase energy expenditure above 1.5 metabolic equivalents during waking time . SedentaOn the basis of this evidence the World Health Organization (WHO) has developed global recommendations for physical activity and an action plan for increasing physical activity and decreasing time spent in sedentary behavior . Policy In recent decades, Latin America has experienced accelerated demographic and epidemiological transitions, and many countries are facing the double burden of communicable and non-communicable diseases . In LatiEstudio Latinoamericano de Nutrición y Salud; ELANS) is a cross-sectional, multinational representative sample conducted in 8 of the 33 Latin America countries . Only urban populations were included to enhance comparability across countries and for reasons of feasibility [The Latin American Study of Nutrition and Health  . The IPAwww.ipaq.ki.se). IPAQ assesses walking separately. Thus, IPAQ physical activity data are reported as min/day of walking, moderate, and vigorous physical activity. Total time (min/week) and time spent in each of the physical activity modes  were estimated and used as analysis variables. We analyzed transport physical activity  and leisure physical activity  separately. In addition, the IPAQ contained two items capturing sitting time. Sitting time was assessed from the questions in the IPAQ long-form [Data were analyzed in accordance with the IPAQ scoring protocol , and three age groups  were defined to ensure adequate sample sizes. Sex, socioeconomic and educational level were categorized using standard questionnaires. Socioeconomic level was evaluated by questionnaire using country-specific definitions based on national norms, laws, and the questionnaires used on national surveys in each country –31. GiveDescriptive analyzes are presented as arithmetic mean, median, frequency, percentage, and 95% confidence intervals (95% CI) for physical activity (transport and leisure time) and sitting time for each country and for the entire sample (sum of the eight countries). Since minutes of physical activity (transport and leisure time) and sitting time were not normally distributed, values for the 25th, 50th and 75th percentile were also obtained. A Kolmogorov-Smirnov test was applied to evaluate the data distribution. Differences between groups were analyzed using Wilcoxon or Kruskal-Wallis tests.The main outcomes were the mean and median time, in min/week, spent in the two modes of physical activity  and sitting time (min/day). Results were stratified by sex, age group, socioeconomic level, and educational level. We also reported the proportion of each group meeting the WHO physical activity guidelines  in transport and leisure. Data analyses were performed with IBM SPSS, version 22 for Windows . The samThe proportion of women  was higher than men . In terms of age, 39.4% (95% CI: 38.5–40.5) of participants were aged < 30 years, 53.9% (95% CI: 52.9–55.0) aged 30–59 years, and 6.7% (95% CI: 6.1–7.2) aged ≥60 years. About half were classified as having a low socioeconomic level  and/or low educational level  , and the highest average was in Costa Rica . The difference between these two countries was 97.7 min/week. For leisure physical activity, the highest values were in Ecuador  and the lowest was in Peru , with a mean difference of 129.3 min/week between these two countries. For sitting time, the mean difference between Argentina (highest sitting time) and Ecuador (lowest sitting time) was 196.3 min/day (Table p < 0.001), leisure (p = 0.011) physical activity and sitting time (p < 0.001).The levels of transport physical activity were higher for men  than for women  overall, with a mean difference of 58 min/week. The largest sex difference was in Colombia (88.9 mean min/week), followed by Chile (88.6 mean min/week) and the smallest sex difference was in Venezuela (2.4 mean min/week). For leisure physical activity, the largest sex difference was in Venezuela (148.9 mean min/week) and the smallest was in Argentina (5 mean min/week). Men  spent more time sitting than women . The mean difference between sex was 36.4 mean min/day. In overall, men had a significantly higher values than women for transport (p = 0.027) between age group for transport physical activity was found only in the Ecuador . Significant difference (p = 0.011), Venezuela (p = 0.001) and in overall (p < 0.001) than for those 30–59 and ≥ 60 years old, and the higher difference between 15 and 29 and ≥ 60 years was in Venezuela (217.7 mean min/week). For sitting time, the time spent was significantly higher in 15–29 years old than for those 30–59 and ≥ 60 years in overall and in five countries . In leisure physical activity, we found significant differences in Brazil  and in Peru  between strata socioeconomic level. The results do not show a clear association between socioeconomic level and transport or leisure physical activity. There are no significant differences between socioeconomic levels for transport and leisure physical activity. Overall, individuals with higher socioeconomic (p < 0.001) and education levels (p < 0.001) spent more time sitting than those in the middle and low socioeconomic and education groups  and 72.8 (95% CI: 72.0–73.7); ranging from 59.8% (Chile) to 81.0% (Venezuela) for transport and 46.1% (Ecuador) to 83.8% (Venezuela) for leisure  compared to those aged <30 years  and those aged ≥60 years . Insufficient leisure physical activity prevalence was lower among those aged < 30 years compared to those aged 30–59 and ≥ 60 years  had a lower prevalence of insufficient leisure physical activity overall compared with those of middle socioeconomic level  or low SES  , Venezuela (p = 0.001) and overall (p < 0.001). Sitting time was highest among those with higher socioeconomic and education levels. In contrast, the relationships between physical activity and socioeconomic and education levels were more variable across countries.The aim of this study was to quantify and characterise socio-demographic patterns of physical activity and sitting time in eight Latin American countries. On average, participants spent 220.3 min/week (median: 120.0 min/week) in transport physical activity, 316.4 min/week (median: 180.0 min/week) in leisure physical activity and 460.2 min/day (median: 420.0 min/day) in sitting time. When all countries were analyzed together, transport and leisure physical activity and sitting time were higher in men than women. The mean and median of transport physical activity were similar across age groups, but leisure physical activity was higher in the 15–29 group than for those 30–59 and ≥ 60 years old in Brazil  . Our anaThe presence of “ciclovías” improved the participation of adults in active transportation by walking . ResultsSex differences in transport and leisure physical activity have been reported in studies from countries with different income levels . OverallOverall, physical activity (transport and leisure) and sitting time showed high variability across countries. There was, however, no clear pattern in the time spent in physical activity and sitting in relation to differences at the socioeconomic and education levels. The current patterns of physical activity and sitting time by socioeconomic strata are closely related to urban development in Latin America characterized by social and environmental inequalities, unplanned and disorganized growth, and underlying political and socioeconomic factors , 55. FacThe differences in physical activity with socioeconomic level are clearer when evaluated at the level of the transport and leisure domains . We founEach country in our study had a mean level of sitting time higher than 7 hours/day. Van Dyck et al.  reportedOur study showed that in most countries, younger participants (<30 years) spent more time sitting time than older participants (≥30 years). This behaviour indicates more frequent sedentary occupations in the use of passive transport among younger adults. It is possible that this pattern could signal a future increase in for poor health outcomes . While tELANS provides data allowing comparisons across eight countries from Latin American for the first time. Major inputs included the production of comparable physical activity values in eight countries using a common protocol. Many manuscripts showed moderate correlations between IPAQ and accelerometers , 63. QueThe study findings show wide variation in transport and leisure physical activity and sitting time by sex and age group in eight Latin America countries. The results do not show significant difference in transport and leisure physical activity by socioeconomic and education levels. The observed variability across countries sets the stage for future investigations to inform interventions at the national and regional levels. Future studies should seek to better understand the challenges of promoting transport and leisure physical activity and reducing sitting time in urban regions. Such studies may help in gaining a deeper understanding of the factors that can be targeted to increase physical activity in Latin America.Additional file 1: Figure S1. Prevalence  of insufficient physical activity from eight Latin America countries.Additional file 2: Figure S2. Prevalence  of insufficient physical activity by sex from eight Latin America countries.Additional file 3: Figure S3. Prevalence  of insufficient physical activity by age group from eight Latin America countries.Additional file 4: Figure S4. Prevalence  of insufficient physical activity by socioeconomic level from eight Latin America countries.Additional file 5: Figure S5. Prevalence  of insufficient physical activity by education level from eight Latin America countries.


Elevated levels of cardiac troponin T (cTnT) have been associated with unfavorable outcomes in cardiac patients. However, no studies, to date, have discussed the prognostic value of high‐sensitivity cTnT (hs‐cTnT) in thrombolyzed patients with acute ischemic stroke (AIS).We hypothesized that elevated levels of hs‐cTnT would be associated with poorer clinical outcomes in AIS patients treated with intravenous tissue‐type plasminogen activator (IV tPA).From January 2017 to February 2018, a total of 241 AIS patients treated with IV tPA within 4.5 hours of onset were recruited. On admission, patients were stratified into either normal or elevated hs‐cTnT groups according to a cutoff value of 14 ng/L. Multivariable logistic regression analyses were conducted to identify determinants of hs‐cTnT elevation and to detect whether elevated hs‐cTnT was associated with disability and/or mortality.P < .001) and stroke etiology (P = .024) were significantly associated with elevated hs‐cTnT levels. After adjusting for demographic and clinical characteristics, hs‐cTnT elevation was still significantly associated with 14‐day major disability  3‐5, model 1, P = .019, odds ratio [OR] 2.677; model 2, P = .015, OR 2.834), 14‐day composite unfavorable outcome , 30‐day mortality  and 90‐day mortality .In multivariable regression analysis, older age (Elevation of hs‐cTnT at admission is associated with an increased risk of 90‐day mortality in AIS patients treated with IV tPA. ACSacute coronary syndromeAISacute ischemic strokeBNPbrain natriuretic peptideCIconfidence intervalcTncardiac troponinDNTdoor‐to‐needle timeECASSEuropean Cooperative Acute Stroke StudyECGelectrocardiogrameGFRestimated glomerular filtration rateENDearly neurological deteriorationhs‐cTnhigh‐sensitivity cardiac troponinHThemorrhagic transformationIV tPAintravenous tissue‐type plasminogen activatorMMP‐9matrix metalloproteinase‐9mRSmodified Rankin ScaleNCCTnon‐contrast computed tomographyNIHSSNational Institute of Health Stroke ScaleODTonset‐to‐door timeONTonset‐to‐needle timeORodds ratioROCreceiver operating characteristicsrPHremote parenchymal hemorrhagesICHsymptomatic intracerebral hemorrhage1Cardiac complications, such as congestive heart failure, acute coronary syndrome (ACS), and arrhythmia occur in 20% of acute ischemic stroke (AIS) patients and are associated with unfavorable outcomes.22.1Consecutive AIS patients who underwent IV tPA at the Departments of Emergency Medicine or Neurology at Shenyang Brain Hospital, Shenyang Medical College, were prospectively recruited from January 2017 to February 2018. Patients were eligible for enrolment if they were diagnosed with AIS on admission and treated with IV tPA within 4.5 hours after onset. Patients were excluded from the study if increased levels of hs‐cTnT at admission were primarily attributed to an acute cardiovascular event, verified by two cardiologists. Patients younger than 18 years or beyond 4.5 hours were also excluded Figure .Clinical profiles of patients, such as demographics and previous medical history, were obtained upon admission. Clinical durations, such as onset‐to‐door time, door‐to‐needle time, and onset‐to‐needle time, were recorded by stroke nurses. Previous medical histories included smoking, alcohol consumption, hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease (CAD), myocardial infarction, atrial fibrillation (AF), congestive heart failure (HF), stroke, chronic obstructive pulmonary disease, and epilepsy.Stroke severity was assessed by certified raters using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) scores. Stroke etiology was determined with the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification.In this study, we defined symptomatic intracerebral hemorrhage (sICH) as per European Cooperative Acute Stroke Study II (ECASS II) criteria.This study was approved by the ethical review committee of Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital. All patients were informed that data may be used for research purposes, and their rights to decline participation. Written consents were not collected because of the nature of the observational study and being routine clinical practice suggested by AHA/ASA guidelines. The waiver of written consent was approved by the ethical committee. All patient‐related information was de‐identificated when subject to statistical analysis.Levels of serum hs‐cTnT ≤14 ng/L were defined as a Reference Characteristics of study conduction, examination of CT scan, laboratory tests, and IV tPA protocol were summarized in Appendix 2.2t test, Pearson χ² test, and Cochran Mantel Haenszel χ² were used to compare the differences between the elevated hs‐cTnT and normal hs‐cTnT groups. Univariate and multivariate logistic regression models were used to explore the influence factors of elevated hs‐cTnT and the association between elevated hs‐cTnT and functional outcomes. We used two multivariate regression models to analyze unfavorable outcomes. In model 1, we adjusted for age, gender, estimated glomerular filtration rate (eGFR), insular cortex involvement, and NIHSS on admission. In model 2, we adjusted for CAD, AF, HF, and those included in model 1. Because death was a low‐incidence event in this study, we adjusted for only age and admission NIHSS for this endpoint. To assess the discriminative capacity of serum hs‐cTnT for mortality at 30 and 90 days, the area under the receiver operating characteristics (ROC) curves were calculated. Survival analysis were estimated by the Kaplan‐Meier method and compared by the log‐rank test. All statistical inferences were two‐sided and P < .05 was defined as significant. STATA version 15.0 and SAS 9.3 were used for all statistical calculations.Quantitative variables were expressed as the mean and SD or median and interquartile range (IQR), and categorical variables were expressed as frequencies (%). The Student 33.1A total of 349 patients were consecutively admitted. Patients with onset‐to‐door time exceeding 4.5 hours (n = 68), failure to receive thrombolytic therapy (n = 32), and unavailability of troponin results (n = 8) were excluded. As a result, a total of 241 AIS patients who underwent intravenous thrombolysis were included. Figure P < .001), while sex was equally distributed in each group. The severity of stroke assessed with admission NIHSS score was significantly higher in hs‐cTnT elevated group . Patient comorbidities, such as diabetes mellitus (P = .015), CAD (P = .008), and AF (P = .002), as well as laboratory abnormalities, such as higher serum creatinine levels (P = .008) and lower eGFR  were more frequent in the hs‐cTnT elevated group. Insular cortex lesion, but not specifically right insular involvement, was significantly associated with hs‐cTnT elevation . TOAST etiology differed between hs‐cTnT normal and elevated patients (P = .001). Etiology was more often considered cardioembolic in the elevated hs‐cTnT patients and more often macroangiopathic in the normal hs‐cTnT patients. Table Of the 241 patients analyzed, 65 had hs‐cTnT levels above the reference . Patients in hs‐cTnT elevated group were significantly older than the normal group  demonstrated END in the elevated hs‐cTnT group compared with eight patients (4.5%) in the normal hs‐cTnT group, showing no statistical significance. Since hemorrhagic transformation (HT) is an important cause of END, we also assessed the occurrence of asymptomatic hemorrhage, symptomatic hemorrhage, HT types, and remote parenchymal hemorrhage. Similarly, we failed to observe statistical significance in any of these categories, despite the overall HT showing an increasing trend in hs‐cTnT elevated patients , 30 days , and 90 days  after thrombolysis. Major disability (mRS 3‐5) similarly increased in hs‐cTnT elevated patients at 14 days , but not at 30 days (P = .134) or 90 days (P = .054). Conversely, patients with increased levels of hs‐cTnT demonstrated an increased occurrence of the composite unfavorable outcome (mRS 3‐6) at 14 days , 30 days , and 90 days   and 90 days , major disability at 30 days , and 90 days  showed no difference between the two groups , did not reach statistical significance at 90 days  was found to be significantly associated with hs‐cTnT elevation. We also found that stroke etiology, according to TOAST criteria, showed a statistical difference between the two groups, after multivariable regression analysis , indicating that patients with elevated hs‐cTnT were more prone to present with cardioembolic etiology  for 30 and 90 days mortality were 0.778 (95% CI 0.611‐0.945) and 0.737 (95% CI 0.554‐0.920), respectively. With Youden index of 0.523 for 30 days and 0.491 for 90 days, an identical optimal cutoff value of hs‐cTnT 15.39 ng/L  was determined, giving specificity of 0.796 and sensitivity of 0.727 for 30 days and specificity of 0.798 and sensitivity of 0.692 for 90 days  elevation of serum hs‐cTnT was associated with 90‐day mortality after treatment, (b) elevation of hs‐cTnT was not associated with END or any type of HT, (c) older age and TOAST etiology (more cardioembolic etiology) were associated with hs‐cTnT elevation, and (d) hs‐cTnT ≥15.4 ng/L predicts mortality with acceptable sensitivities and specificities.Stroke‐heart syndrome, in particular, ischemic stroke‐related cardiac alteration, may well be related to mechanisms of the brain‐heart connection , which is the cortical modulation of the cardiovascular system.d‐dimers, MMP‐9, and S100 β protein was also shown to be valuable in detecting increased mortality after stroke.Prognosis of AIS is critical for not only patients and relatives but also physicians who have critical decision‐making power to optimize and allocate stroke care and resources.In patients without ACS, the prognostic performance of hs‐cTnT for all‐cause mortality seems superior to that of hs‐cTnI,Serial measurement of cTn is the preferred examination of differentiating ACS and other confounding conditions.Many factors influence the level of cTnT in patients with AIS. In our multivariable regression analysis, the independent association between older age and cTnT elevation in stroke patients is in line with previous studies.Some limitations of this study need to be mentioned. First, the recruited patients were mostly minor to mild stroke  groupClick here for additional data file.APPENDIX S1 Supplement with respect to methodologyClick here for additional data file.


Mindfulness has transdiagnostic applicability, but little is known about how people first begin to practice mindfulness and what sustains practice in the long term. The aim of the present research was to explore the experiences of a large sample of people practicing mindfulness, including difficulties with practice and associations between formal and informal mindfulness practice and wellbeing. In this cross-sectional study, 218 participants who were practicing mindfulness or had practiced in the past completed an online survey about how they first began to practice mindfulness, difficulties and supportive factors for continuing to practice, current wellbeing, and psychological flexibility. Participants had practiced mindfulness from under a year up to 43 years. There was no significant difference in the frequency of formal mindfulness practice between those who had attended a face-to-face taught course and those who had not. Common difficulties included finding time to practice formally and falling asleep during formal practice. Content analysis revealed “practical resources,” “time/routine,” “support from others,” and “attitudes and beliefs,” which were supportive factors for maintaining mindfulness practice. Informal mindfulness practice was related to positive wellbeing and psychological flexibility. Frequency (but not duration) of formal mindfulness practice was associated with positive wellbeing; however, neither frequency nor duration of formal mindfulness practice was significantly associated with psychological flexibility. Mindfulness teachers will be able to use the present findings to further support their students by reminding them of the benefits as well as normalising some of the challenges of mindfulness practice including falling asleep.The online version of this article (10.1007/s12671-018-0951-y) contains supplementary material, which is available to authorized users. Mindfulness practice has become increasingly popular in recent years, and training in mindfulness skills is now widely available through a variety of courses, workshops, internet programmes and apps, and through one-to-one sessions. Despite this, we know little about how people first begin to practice mindfulness, how often people practice, difficulties they experience, and how people support their practice. There are also uncertainties about how much mindfulness practice is required to produce beneficial effects and regarding the role of informal mindfulness. Understanding these issues is important in order to support the maintenance of mindfulness practice and to promote resilience and wellbeing in the long term.Mindfulness has been defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgementally” , including difficulties and supportive factors. Additionally, the present study investigates the relationship between mindfulness practice and the current wellbeing and psychological flexibility of participants, and whether attending a face-to-face taught course is associated with more frequent formal mindfulness practice. Increased understanding of these areas will provide potential avenues for future research as well as informing the delivery of MBIs and providing insights to support the maintenance of long-term mindfulness practice, thus promoting improvements in health and wellbeing.Participants were recruited through the social and professional networks of the first author and via online advertising . Volunteers were requested who currently practice mindfulness or who had practiced mindfulness in the past but were not practicing at the moment and who would be willing to take part in an online questionnaire about their experiences and current wellbeing. No incentives were offered for taking part.Two hundred and eighteen participants 174 female) took part in the study. The mean age of participants was 44.5 years . Fifty-two participants (23.9%) identified themselves as mindfulness teachers with experience of delivering a range of mindfulness-based approaches . Participant characteristics are shown in Table 74 femaleParticipants were asked to select one of seven options to describe how they first began to practice mindfulness, as illustrated in Fig. Of the 11 participants who originally followed a structured programme either from a book or online, five went on to attend a face-to-face taught course. Of the 138 participants who did not initially attend a face-to-face taught course or follow a structured programme from a book or online, 24 people later followed a structured course from a book, online, or by telephone, and 41 people later attended a face-to-face taught course. The sample for the present study therefore comprised 115 people (52.8%) who had attended a face-to-face taught course, 30 people (13.8%) who followed a course from a book or online, and 73 people (33.5%) who had not attended or followed any type of structured mindfulness course.This project included participant involvement in the design of the study. Experienced and novice mindfulness meditators reviewed the study questions and changes were made based on their feedback.The study was given ethical approval by the University of Derby and participants gave informed consent before participating. Two hundred and seventy-four survey responses were submitted. Data were screened for duplicate IP addresses and any incomplete or duplicate responses were removed, leaving 218 responses eligible for analysis. Several items of categorical data were coded for quantitative analysis including the method of introduction to mindfulness, frequency, and duration of formal and informal mindfulness practice (coded 0 = not practicing to 5 = every day/1 h). Scores for the Acceptance and Action Questionnaire  measures aspects of psychological flexibility, particularly acceptance and experiential avoidance  and duration in years of mindfulness practice. It was suspected that these variables may affect wellbeing and psychological flexibility. Several scores were missing from the AAQ-II and SWEMWBS responses and so ten participants were excluded from analyses involving these measures. Three participants had one score missing, which was resolved using imputation through interpolation and extrapolation.Responses to open-ended questions regarding sleep during practice and support for practice were analysed using inductive content analysis (Elo and Kynga The 145 participants who had attended a face-to-face course or followed a course from a book or online provided further information about the course and their experience. Sixteen participants (11%) attended courses delivered by the NHS: 14 face-to-face and two online. Sixty-eight people (46.9%) paid for their face-to-face taught course and eight people (5.5%) paid for their online course. Most participants 90; 62.1%) attended or followed courses consisting of eight sessions. One hundred and thirty-five participants answered the question “Why did you attend the mindfulness course?” Responses were categorised and can be found in Table .1% attenFalling asleep during practice was common: 62 people (42.8%) reported falling asleep during practices in the course sessions and 49 of these were attendees of a face-to-face course. Of these 62 participants, 54 (87.1%) said they fell asleep during the body scan (42 were attendees of a face-to-face course). Ninety-six people (66.2%) reported falling asleep during their home practice (77 were attendees of a face-to-face course). One hundred and thirty-nine participants answered the question about home practice and 22 (15.8%) said they completed the home practice all of the time, 72 (51.8%) said they completed the home practice most of the time, and 34 (24.5%) said they completed the home practice some of the time. Eighteen participants (12.9%) said they did not feel able to discuss difficulties with home practice with the course teachers compared to 107 (77%) who did feel able to discuss this. Fifty-nine participants (53 who attended a face-to-face taught course) were offered a reunion/top-up session, and 35 (32 who attended a face-to-face taught course) attended a reunion/top-up session. One hundred and thirty-five people (96.4%) said they found the mindfulness course helpful, compared to five (3.6%) who did not (five people did not answer this question). When asked if they thought the mindfulness course made any difference to their life, 141 participants answered as follows: significant positive change: 90 (63.8%), some positive change: 46 (32.6%), no change: three (2.1%), and some negative change: two (1.4%).Of the 218 participants, 198 reported that they were currently practicing formal mindfulness, and 207 reported that they were currently practicing informal mindfulness. In a free-text comment field, some participants gave examples of their informal mindfulness practice. These included washing the dishes, eating, driving, brushing teeth, walking the dog, drinking coffee, and watching a wild bird or flower. Self-reported frequency of formal and informal mindfulness practice is illustrated in Fig. U = 5346.50, z = − 1.29, ns, r = − 0.09.For the purpose of inferential statistics, frequency of practice was coded from 0 (not practicing) to 5 (practicing every day) and a Mann-Whitney test revealed that there was no significant difference in the frequency of formal mindfulness practice between those who had attended a face-to-face taught course (Mdn = 4) and those who had not attended a face-to-face taught course (Mdn = 4), The mean wellbeing (SWEMWBS) score for the sample of 208 participants was 23.75 , and the mean psychological flexibility (AAQ-II) score was 19.08 . These scores are consistent with norms of 23.7 for SWEMWBS  = 2.098, β = .159, SE = .165, B = .345, p = .037) and frequency of informal practice (t(204) = 3.72, β = .254, SE = .154, B = .574, p < .001) were significantly related to wellbeing, and frequency of informal mindfulness was the most important variable in this model. Duration of formal mindfulness practice (t(204) = 1.62, β = .118, SE = .212, B = .344, p = .106) was not significantly related to wellbeing. Model 2 included mindfulness teacher status and duration of mindfulness practice in years. Neither of these variables were significantly related to wellbeing (teacher status: t(202) = 1.49, β = .110, SE = .598, B = .892, p = .138; years of practice: t(202) = .459, β = .033, SE = .037, B = .017, p = .647). However, including these variables affected the relationships between wellbeing and frequency of formal mindfulness practice (t(202) = 1.96, β = .149, SE = .166, B = .324, p = .052) and wellbeing and duration of formal mindfulness practice (t(202) = 1.25, β = .093, SE = .217, B = .272, p = .212), resulting in there no longer being a significant relationship between wellbeing and frequency of formal mindfulness practice. In model 2, frequency of informal mindfulness practice was the only variable significantly related to wellbeing (t(202) = 3.18, β = .222, SE = .158, B = .503, p = .002). The combined influence of mindfulness practice (model 1) accounted for 15.9% of the variation in wellbeing . This increased slightly to 17.3%  when the other variables were added (model 2). Although ANOVA results indicated that both models were significant predictors of wellbeing (p = .000), model 1 (F = 12.890) was a better predictor than model 2 (F = 8.477). Both models showed small effect sizes .Hierarchical regression tested the relationship between mindfulness practice and wellbeing. For model 1, frequency of formal mindfulness practice (t(204) = − 3.395, β = − .241, SE = .352, B = − 1.197, p = .001) was significantly related to psychological flexibility. Frequency of formal practice (t(204) = − .446, β = − .035, SE = .376, B = − .168, p = .656) and duration of formal mindfulness practice (t(204) = − 1.296, β = − .098, SE = .484, B = − .627, p = .197) were not significantly related to psychological flexibility. Again for model 2, neither mindfulness teacher status (t(202) = − 1.161, β = − .089, SE = 1.36, B = − 1.580, p = .247) nor years of mindfulness practice (t(202) = − 1.478, β = − .111, SE = .084, B = − .124, p = .141) were significantly related to psychological flexibility. Adding these variables to the model did not significantly affect the sizes of the relationships between psychological flexibility and the three aspects of mindfulness practice. Again, frequency of informal mindfulness practice was the only practice variable significantly related to psychological flexibility (t(202) = − 2.763, β = − .201, SE = .360, B = − .995, p = .006). The combined influence of mindfulness practice (model 1) accounted for 8.7% of the variation in psychological flexibility . This increased to 11.2%  when the other variables were added. Although ANOVA results indicated that both models were significant predictors of psychological flexibility, model 1  was a better predictor than model 2 . However, the models only explained that a small amount of the variance and effect sizes were small .Hierarchical regression also tested the relationship between mindfulness practice and psychological flexibility. For model 1, frequency of informal mindfulness practice , sitting practice , breathing space , mindful movement , all of the above , and other . In the free-text option for “Other,” participants stated a variety of additional practices including mindfulness of sound and loving-kindness meditation. Seventy-six participants (38.4%) said that there were some practices they disliked or found difficult and so did not do. The most common of those listed by participants were the body scan  and mindful movement or walking . Participants were then asked to select the options that best described their experiences of mindfulness practice, and responses were as follows: easy , interesting , practice reluctantly , irritating , practice willingly , difficult , enjoyable , boring , relaxing , ok , it is what it is , and blissful . There were a number of free-text comments about practice varying from day to day. Other comments touched on the usefulness of practice as well as difficulties with practice including perceptions of how practice “should be,” such as “can occasionally be hard to stay sitting if the mind is pre-occupied - useful still to sit and be with boredom or irritation and come back to focusing anchor.” “Can sometimes make me aware of things I hadn’t known I was feeling, which can annoy me when I don’t feel ready to deal with them emotionally.” “Sometimes guilt-inducing because I think I’m not doing them right and I should be better by now.” “Each meditation is different. Sometimes being with the uncomfortable is challenging. Whatever the moment brings … can be blissful and easy one day then difficult and uncomfortable the next.”Of the 198 participants currently practicing formal mindfulness, 112 (56.6%) reported falling asleep during practice. Seventy of these (62.5%) said that they did not fall asleep regularly and 11 (9.8%) said that they had a medical condition that they thought made them more likely to fall asleep during practice. Participants reported falling asleep most frequently during the body scan  and breathing/sitting practice . One-hundred and five participants answered the open question “How do you feel about falling asleep?” Responses were analysed in line with Elo and Kynga  and cateParticipants were asked to select all that applied from a range of options to describe how their current practice is supported. One-hundred and ninety-six participants responded as follows: CD , app , self-guided , guided by others , practice in a group with guidance , and practice in a group without guidance . Responses to the open question of what is or would be supportive were analysed in line with Elo and Kynga ; four maParticipants stated tools such as apps, CDs, and emails from websites helped to support practice. Evidence and reminders that mindfulness can be helpful were seen as supportive. Some participants created their own practice reminders in the home or using cues from their environment. For example: “a reminder bracelet, pic on my desk, the school bell is when I breathe etc.” “Following mindful accounts on twitter & newsletters.” “An understanding of the basis for mindfulness and examples of success in using mindfulness more than it made me feel better.” “CDs, downloads, and apps are great, a nice voice is important either male or female, good books with website/links are very useful.”Participants highlighted the importance of finding time to practice and stated that this wasn’t always easy. Being able to incorporate practice into a daily routine or form a routine for practice was also important.Being part of a mindfulness community was highly valued. Fourteen participants explicitly stated that they attend regular group practice sessions or course refresher/reunion sessions in order to support their practice. Contact with mindfulness teachers, attending workshops, group practice sessions, and talking to others who practice all helped to support ongoing mindfulness practice. Support from friends, family, and the workplace was also seen as important. For example: “I buddy up with a friend and we text each other when we have completed a formal practice. I taught her mindfulness and now offer informal supervision. This monthly connection keeps me on track ….” “Regular opportunities to formally practice with others and share ideas or experiences about practice. It inspires and reinvigorates.” “Mindfulness at workplace, in a work culture where mindfulness is valued.” “More connection with community of other practitioners.”Some participants stated that their own beliefs and experience supported them to continue to practice; feelings during and following practice and feeling a benefit. Attitudes of acceptance and kindness were also important, particularly if practice had lapsed. For example: “the experience of life being easier, more fulfilling, having resources to cope with difficulty when I practice.” “Knowing the benefits I gain from doing. Knowing that if I stop it’s like a muscle and weakens. Knowing that I can always begin again, which is very kindly and forgiving.” “Knowing that you can do anything mindfully and you can’t get it wrong.” “The encouragement to trust that every moment can be mindful without having to use a formal approach.”The current study explored how participants first began to practice mindfulness and how they continued, difficulties they experienced, and how they supported their ongoing practice. The study also investigated associations between formal and informal practice and wellbeing and psychological flexibility.The participants in this study first began to practice mindfulness in a wide variety of ways, which reflects the range in methods of delivery of mindfulness outside health services. Remarkably, almost half the sample had not attended a face-to-face taught course.In line with previous research . This suggests that increased sleep was sometimes viewed as a positive outcome. The acceptance of sleep by participants in this study could be indicative of a general attitude of acceptance which could be a contributory factor to the AAQ-II scores, discussed further below.Practical resources, time/routine, support from others, and attitudes and beliefs were identified as common themes that supported home practice. Technology  and cues in the environment helped participants to remember to practice as well as form a routine. These findings are in line with suggestions for practice support made by Hindman et al.  in respoSupport from friends, family, and others practicing mindfulness was an important factor in continuing to practice, and some participants attended regular group practice sessions or course refresher/reunion sessions. This support and being part of a “mindfulness community” could also have been a confounding factor that contributed to wellbeing. For example, one participant stated: “I really enjoyed the class mostly because of the interactions with other people. I’d like to be a part of a regular formal practice community.” For this participant, the social aspect of attending a course appears to be more important than the practice itself. Continuing to be part of a community, in contact with others who practice, could therefore impact on wellbeing.Knowledge and beliefs about practice were also identified as supportive factors. Embedded in these qualitative responses were attitudes of trust, beginner’s mind, and acceptance. These attitudes were both implied and explicit in the language, for example: “Knowing that I can always begin again, which is very kindly and forgiving” and “The encouragement to trust that every moment can be mindful.” Kabat-Zinn  describeThe majority of participants in this study were female; however, a larger proportion of female participants is not uncommon in mindfulness research conducted online ESM 2(PDF 12 kb)


Restriction of dietary salt is widely recommended in the management of hypertension, but assessment of individual salt intake has drawn little attention. Monitoring nutritional salt intake through sodium excretion has been popular, because the main route for sodium (Na) excretion is through the urine. Nonetheless, direct measurement of dietary salt intake is time consuming and lacks accuracy. To collect a 24-h urine and measure the content is difficult method for most patients. In this review paper, we would like to explore the usefulness of measuring urinary salt excretion by using a self-monitoring device at home. Measuring daily overnight urine by the self-monitoring device at home will be useful for the management of hypertension suitable for each individual. From the recent increase of processed foods, the term “salt intake” would not accurately be equal to “sodium intake”. Devices measuring urinary sodium excretion have been developed and evaluated on their accuracy and correlation with sodium intake. They must be handy, simple and capable of measuring large populations to be useful for monitoring of daily salt intake and to guide salt restriction as well as the long-term effects by dietary salt intake. Hypertension (HTN) is one of the foremost non-communicable diseases (NCDs) in the world , which sFor developing and onset of HTN, excess dietary salt intake plays a significant role , 10. As Nonetheless, some medical institutions estimate salt intake by using a 24 h urine sample. But repeated measurements to evaluate daily salt intake are quite difficult. Further, salt intake estimation using spot urine  or the s0.53 g/day. Careful comparison of overnight with 24 h urine collection methods have developed the above converting formula making these devices more reliable [Excess intake of dietary salt is estimated to be one of the leading risks to health worldwide. Major national and international health organizations, along with many governments around the world, have called for reductions in the consumption of dietary salt. In developed and developing countries, salt added during food processing is the dominant source of salt and largely outside of the direct control of individuals , 19. Howreliable . There iVoid completely and discard the urine before going to bed.Collect the overnight urine (including the first urine after awakening) in the 1 L urine cup. About 8 h urine is preferable.Set the salt monitor and push the source button Daily salt excretion is shown on the panel. (after about 15 s).Remove the salt monitor from the cup and void the urine. Wipe the urine on the sensor by tissue or toilet paper.Put the clean water in the cup and discard the water. Add water again.Set the salt monitor. After cleaning the censor by the water, wipe the water on the sensor by tissue or toilet paper. (Never wash the device except sensor).Discard the water of the cup. Set the salt monitor until next morning.Next day, remove the salt monitor from the cup and collect the overnight urine again .A KME-03 salinity checker  might be used to determine the estimated daily salt intake. This device consists of a 1 L urine cup and an electrical device with volume and conductivity sensors. The volume sensor, which consists of 50 small resistant chips, measures overnight urine volume in the cup. The conductivity sensor consists of two gold-plated nickel metal plates. A temperature compensating circuit is used because conductivity changes with temperature. In this method, urine have to collect for 24 h, and salt intake will be assessed by determining the urinary Na excretion. This method is considered to be reliable and is used in many clinical and epidemiological studies . These aNumerous studies have shown that some people are not sensitive to salt. Sensitivity and resistance to the effects of salt have been evaluated by the degree of blood pressure change between high-salt intake and low-salt diet –28. ReceEvaluation of sodium intake by urine sodium level needs precautions such as ruling out some diseases  and other related factors. Measurement of 24 h urine sodium excretion has been used as a golden standard for evaluating sodium intake. However, 24 h urine samples are inconvenient, costly for a large population. Alternative methods, such as spot, overnight, daily, timed urine samples have been taken into concern whether it can reflect sodium intake of individuals as well as large populations. There were studies showing correlation between spot and 24 h urine collection . NeverthP < 0.001) [P < 0.01. Mean estimated daily salt intake of all participants was 9.9 g/day [However, several studies had been conducted for urinary salt monitor from 24 h urinary sample or from overnight urine sample. Among them Yasutake K et al. (2016) found that the estimated 24 h urinary salt excretion from the overnight urine samples reflected salt intake from the previous day. The average 24 h urinary salt excretion  estimated from the overnight urine samples was as follows: 8.01 ± 1.15 g (0.73 ± 0.11) on days 2–6, 5.86 ± 0.85 g (1.01 ± 0.15) on days 7–9, 9.69 ± 1.64 g (0.74 ± 0.13) on days 10–12, 6.51 ± 1.56 g (1.03 ± 0.25) on day 13, 8.60 ± 3.25 g (0.71 ± 0.14) on day 14, and 6.28 ± 1.31 (1.05 ± 0.22) on day 15 . Concern< 0.001) . Ohta et.9 g/day , which w.9 g/day . In factHowever, there is strong and consistent evidence from animal studies, clinical trials and epidemiological data both within and across populations implicating high salt intake as an important risk factor for high BP among both hypertensive and normotensive individuals –45; highDetection and treatment of hypertension is a major component of cardiovascular risk reduction. However, the underlying causes of hypertension, such as poor diet, are often left ‘untreated’. Patients with drug treated hypertension are at higher risk of CVD than individuals with normal BP. Similarly, amongst drug-treated hypertensives, those with unhealthy lifestyle are at a higher risk of CVD than those with healthy lifestyle , 53. TheHistorical improvement of devices on salt-intake are still on their way to prevent devastating cardiovascular, cerebrovascular diseases. Recent development of devices that measure urinary salt excretion correlate well with sodium intake making them promising tools for preventing these diseases. First, they will evoke awareness of high-salt intake in regions where high-salt intake prevails. Second, these tools will be helpful in evaluating salt intake on various upcoming trials on high salt intake-induced diseases. The devices must be developed to evoke awareness of deadly consequences of high-salt intake in regions where high-salt intake prevails. Cardiovascular diseases are not only deadly, but once diagnosed; also have undesirable impact on the individual as well as health economics.Although there are several methods for the assessment of salt intake, the precise determination of salt intake in individual patients is difficult. Reliable methods are difficult to perform, and simpler methods are less reliable. However, the assessment of salt intake is strongly recommended, because it is useful for informing patients of their salt intake and conducting salt restriction. In addition, further interventional study can be approached for established this home monitoring device. Moreover, public health initiatives, in tandem with efforts by the food industry, are urgently needed to lower salt consumption and consequently lower CVD burden and increase life expectancy. Such public health approaches can be simple, low-cost and effective.


There is no consensus on the optimal anesthesia method for intertrochanteric fracture surgeries in elderly patients. Our study aimed to compare the hemodynamics and perioperative outcomes of general anesthesia with endotracheal intubation, combined spinal-epidural anesthesia, and general anesthesia with laryngeal mask airway (LMA) and nerve block for intertrochanteric fracture surgeries in elderly patients.n = 25), combined spinal-epidural anesthesia (n = 25), and general anesthesia with LMA and nerve block (n = 25). The intraoperative hemodynamics were recorded, and the maximum variation rate was calculated. Postoperative analgesic effect was evaluated using the visual analog scale (VAS). Postoperative cognitive status was assessed using the Mini-Mental State Exam (MMSE).This is a retrospective study of 75 patients aged > 60 years scheduled for intertrochanteric fracture surgeries with general anesthesia with intubation . The VAS scores postoperative 2 h, 4 h, 6 h, and 8 h also differed significantly between the three groups . The VAS scores postoperative 24 h were significantly lower in the general anesthesia with LMA/nerve block group than the general anesthesia with intubation group and the combined spinal-epidural anesthesia group. The MMSE scores postoperative 15 min and 45 min differed significantly between the three groups . The MMSE scores postoperative 120 min in the general anesthesia with intubation group were the lowest among the three groups. There was no significant difference in the incidence of respiratory infection postoperative 24 h, 48 h, and 72 h between the three groups.Compared to general anesthesia with intubation and combined spinal-epidural anesthesia, general anesthesia with LMA and nerve block had better postoperative analgesic effect and less disturbances on intraoperative hemodynamics and postoperative cognition for elderly patients undergoing intertrochanteric fracture surgeries. The global population aging has led to increasingly more elderly patients with hip fractures. Aging is associated with decreased hemodynamic stability, hypertension, poor physical status, risk of cognitive impairment, and osteoporosis –3. ProviIt has been shown that regional anesthesia is comparable to general anesthesia for hip fractures in adults . HoweverOur study aimed to compare intraoperative hemodynamics, postoperative pain, postoperative cognitive function, and respiratory infection between general anesthesia with endotracheal intubation, combined spinal-epidural anesthesia, and general anesthesia with LMA and nerve block for elderly patients undergoing intertrochanteric fracture surgeries.A total of 75 patients scheduled for closed reduction or open reduction with internal fixation for intertrochanteric fracture between January 2017 and November 2018 were included in this retrospective study. The inclusion criteria were age > 60 years and < 90 years, intertrochanteric fracture diagnosed by radiology, and American Society of Anesthesiologists (ASA) physical status I–III. Patients with the following conditions were excluded: cognitive impairment, allergy to anesthetic agents, operation time > 4 h, conversion to general anesthesia with intubation.n = 25), combined spinal-epidural anesthesia (n = 25), and general anesthesia with LMA and nerve block (n = 25). All patients fasted preoperatively for 8 h. Hypertension and diabetes mellitus were controlled before the surgery. All anesthesia procedures were performed by one anesthesiologist.The patients were matched by sex, age, and weight and received general anesthesia with intubation  was used to deliver electric stimulations at 2 Hz, with a starting current of 1 mA and a pulse time of 0.1 ms. Contraction of the quadriceps femoris and the gastrocnemius in response to a current < 0.3 mA indicated that the injection site had been reached. After confirming no aspiration of blood or cerebrospinal fluid, ropivacaine 0.5% 30 ml was injected respectively for lumbar plexus block and sciatic nerve block. Anesthesia was induced using etomidate 0.1–0.3 mg/kg, vecuronium bromide 0.1 mg/kg, and fentanyl 2–4 μg/kg. Then an LMA was inserted. General anesthesia was maintained using propofol 3–5 mg/h·kg. No postoperative analgesics were used.Patient data was from a previous clinical trial in which intraoperative heart rate, systolic blood pressure, and diastolic blood pressure were recorded using a ventilator. Hemodynamic changes were evaluated using the maximum variation rate, which was calculated using the formula:maximum variation rate = (maximum – minimum)/pre − anesthesia value.Postoperative pain was evaluated at 2 h, 4 h, 6 h, 8 h, and 24 h using the visual analog scale (VAS). The VAS scores range from 0 to 10, with 0 indicating painless and 10 indicating the worst pain imaginable.Patient cognitive function was assessed preoperatively, postoperative 15 min, 45 min, and 120 min using the Mini-Mental State Examination (MMSE). The MMSE assesses orientation to place and time, calculation, memory, language, reading, writing, and drawing. A reduction of 3 points in the postoperative MMSE score suggested postoperative cognitive dysfunction .Postoperative respiratory infection was tested by bacteria culture using the respiratory secretions collected postoperative 24 h, 48 h, and 72 h.P-value < 0.05 was considered statistically significant.Continuous data were presented as means and standard deviations. Categorical data were presented as percentages or frequencies. Comparisons were made using the one-way analysis of variance analysis followed by post-hoc analysis or the chi-square test. Ordinal data was compared using the Kruskal-Wallis test. All statistical analyses were performed using the SPSS 18.0 software . A n = 7), allergy to anesthetic agents (n = 4), operation time > 4 h (n = 2), conversion to general anesthesia with intubation (n = 3). The patients included 33 men and 42 women . There was no significant difference in sex, age, weight, and ASA physical status between the three groups (Table A total of 91 patients were eligible for inclusion and 16 patients were excluded for cognitive impairment (P < 0.001, Table The maximum variation rate of heart rate, systolic blood pressure, and diastolic blood pressure differed significantly between the three groups (general anesthesia with intubation > combined spinal-epidural anesthesia > general anesthesia with LMA and nerve block, all P < 0.001, Table The three groups showed no significant difference in preoperative VAS scores. The VAS scores postoperative 2 h, 4 h, 6 h, and 8 h differed significantly between the three groups (general anesthesia with intubation > combined spinal-epidural anesthesia > general anesthesia with LMA and nerve block, all P < 0.001, Table There was no significant difference in preoperative MMSE scores between the three groups. The MMSE scores postoperative 15 min and 45 min differed significantly between the three groups (general anesthesia with intubation < combined spinal-epidural anesthesia < general anesthesia with LMA and nerve block, all There was no significant difference in the incidence of respiratory infection postoperative 24 h, 48 h, and 72 h between the three groups Table .Table 5Our study found that general anesthesia with LMA and nerve block was associated with less significant intraoperative hemodynamic variations compared to general anesthesia with intubation and combined spinal-epidural anesthesia. In addition, patients receiving general anesthesia with LMA and nerve block also had significantly less postoperative pain and significantly better postoperative cognitive function than those receiving the other two anesthesia methods.Hemodynamic instability during intubation and extubation, such as changes in heart rate and blood pressure, can increase the risk of vascular events, especially in elderly patients . In our Our study found that patients receiving general anesthesia with LMA and nerve block had generally less postoperative pain compared to those receiving general anesthesia with intubation or combined spinal-epidural anesthesia. Spinal anesthesia and nerve block both can effectively stop the peripheral afferent pain pathways and provide good analgesic effect. However, spinal anesthesia was not as good as lumbar plexus/sciatic nerve block in terms of analgesic effect and duration in our study. This might be explained by the relatively small doses of anesthetic agents used in spinal anesthesia, which was resulted from controlling the level of anesthesia.The MMSE is widely used for screening cognitive dysfunction. It is easy to use and has a sensitivity of 87% and a specificity of 82% in diagnosing postoperative cognitive dysfunction , 13–15. During postoperative 72 h, there were 3 cases of respiratory infection in the group of general anesthesia with intubation. However, none of the patients had respiratory infection in the general anesthesia with LMA/nerve block group, and only 1 patient had this condition in the combined spinal-epidural anesthesia group. Although no airway device was used in the combined spinal-epidural anesthesia group, still 1 case of respiratory infection occurred in this group. This might be related to the high level of anesthesia and respiratory paralysis. Intratracheal intubation is more invasive than LMA and may increase the risk of respiratory infection. Two meta-analysis showed that LMA is superior to, or as good as, intratracheal intubation regarding respiratory infection , 24.Our study is not without limitations. First, the sample size is small. Second, our study is a single-center study and may lack representativeness. Third, data was collected from a short postoperative period.In conclusion, general anesthesia with LMA and nerve block was associated with less postoperative pain and less disturbances on intraoperative hemodynamics and postoperative cognitive function for elderly patients undergoing intertrochanteric fracture surgeries. LMA might also be associated with reduced risks of respiratory infection.


Some studies have suggested that blood glucose fluctuation and C-peptide level were considered as predictive factors for carotid artery intima–media thickness (CIMT). However, the relationships of these variables are unclear. This research was aimed to identify the potential effects of blood glucose fluctuation, C-peptide level and conventional risk factors on CIMT.A total of 280 type 2 diabetes mellitus (T2DM) patients were enrolled into this study. Population characteristics were obtained through medical history and clinical parameters. The patients were divided into two groups according to the critical value of CIMT (0.9). Research data were analyzed to identify risk factors of CIMT between the two groups.p = 0.0002 and p = 0.0063). Logistic regression analysis results indicated that smoking, uric acid (UA) levels, 2 h C-peptide and standard deviation of blood glucose (SDBG) were the influence factors for CIMT thickening . Blood glucose fluctuation could affect the risk of some complications. In largest amplitude of glycemic excursions (LAGE) > 4.4 group, the CIMT abnormal rate was 27.10%, which was significantly higher than 12.12% in the LAGE ≤ 4.4 group (p = 0.012). The CIMT abnormal rate of SDBG > 2.0 group was 27.81%, which was significantly higher than that of the SDBG ≤ 2.0 group (p = 0.018).The comparison results of basic information showed that differences in age and illness years between the two groups were statistically significant (Blood glucose fluctuation is an independent risk factor associated with CIMT in T2DM patients, in addition to conventional risk factors, such as smoking, high UA level and 2 h C-peptide. Therefore, more attention should be given to the change of CIMT and the complications. Diabetes mellitus (DM) is a serious chronic and harmful disease, which threatens human health all over the world . The incAt present, the pathogenesis of diabetic chronic complications has not been thoroughly clarified. It may be affected by genetic susceptibility, insulin resistance, hyperglycemia, inflammatory reaction and other factors –8. CardiSome studies indicate that C-peptide causes human atherosclerotic lesions in diabetic patients, because it induces smooth muscle cell proliferation , 23. It A total of 280 Chinese patients with type 2 diabetes, who were hospitalized in Shanghai Jiading District Central Hospital from January 2016 to December 2017, were recruited in this study . The diagnosis of type 2 diabetes mellitus was based on the WHO diagnostic criteria in 2013. All the enrolled patients were of Han nationality and had no diabetic ketosis or nonketotic hyperosmolar coma. The patients in the following conditions were excluded: severe hepatic and renal dysfunction, heart deficiency and serious infection. The basic information such as age, gender, body mass index (BMI), smoking status, family history and other medical history were collected to identify risk factors of CIMT. All patients agreed to participate in this study and signed the medical informed consent. Meanwhile, this study was also approved by our local ethics committee.Venous blood samples were obtained through venipuncture. Then the blood samples were freezed (− 70 °C) to test the levels of fasting blood glucose (FBG), 2-h post-load glucose, C-peptide levels, creatinine, HbA1c, uric acid (UA), serum cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride (TG) and so on. Serum biochemicals were measured by automatic biochemical analyzer  and HbA1c was measured by high-performance liquid chromatography .Patients’ finger blood glucose levels before and after three meals and before sleep were recorded to calculate sugar fluctuation parameters including PPGE, LAGE and SDBG within 24 h after admission. PPGE is equal to the mean value of the absolute differences between the blood glucose level 2 h after each meal and the corresponding pre-prandial blood glucose level. LAGE corresponds to the differences between the maximum and minimum blood sugar levels of a day. SDBG is the standard deviation of the total blood glucose within 1 day.CIMT is located on the vertical dimension between carotid intima and media. It was measured by color Doppler flow imaging with a probe of 9–12 MHZ . Bilateral carotid arteries of patients were checked by a professional ultrasound doctor. The measurements were repeated three times and the average value was recorded. When CIMT ≥ 0.9 mm, it was considered to be abnormal according to the “the guidelines for prevention and control of hypertension”.t test or analysis of variance (ANOVA). The possible relationships between CIMT and variables were evaluated by logistic linear regression analysis. The multivariable-adjusted model was used, including age, sex, BMI, smoking, the presence or absence of hypertension, cerebral infarction, HDL cholesterol, LDL cholesterol, triglycerides, creatinine, serum urea, uric acid, C-peptide level, homocysteine and HbA1c. It can give an assessment of the independent association of each possible variable and CIMT. p < 0.05 was considered as an indicator of significant difference. Data were evaluated by the software STATA version 12.0 .Data consistent with the normal distribution and homogeneity of variance are presented as mean ± SD. The skew distributional data are expressed as median (IQR). Enumeration data and categorical variables were compared by Chi square analysis or Fisher’s exact test. Differences of continuous variables were tested by Student’s p = 0.0002 and p = 0.0063).A total of 280 T2DM patients were enrolled in this research. The study population was divided into CIMT ≥ 0.9 group and CIMT < 0.9 group according to the “2013 European Guidelines for Hypertension Management”. The basic information of the study population is shown in Table Logistic regression analysis was used to identify the risk factors for CIMT thickening.p = 0.042). Smoking was a risk factor for abnormal CIMT. The OR value was 133,860.6 and the differences were statistically significant (p = 0.032). The level of 2 h C-peptide was a risk factor for abnormal CIMT and it was statistically significant . In addition, UA level was an influence factor for CAD .All the influence factors such as age, gender, smoking habits and clinical parameters were included in the multivariable model. After adjusting the confounding factors, the results indicated that smoking, UA levels and SDBG were the influence factors for CIMT thickening and the results are shown in Table p = 0.012, Fig. p = 0.018, Fig. The “diabetes blood sugar fluctuation management expert consensus” was published by Chinese Medical Association Endocrinology Branch in 2017. PPGE > 2.2, LAGE > 4.4 and SDBG > 2.0 were considered as abnormal blood glucose fluctuations in this consensus. The study population was divided into abnormal blood glucose fluctuation and normal group. Then we compared the differences in major complications of diabetes between the two groups. In this research, no significant differences in the prevalence rates of HBP and cerebral infarction were observed in any blood sugar fluctuation group Figs. . Howeverp = 0.032, p = 0.047, p = 0.049 and p = 0.042, respectively).Previous studies had focused on the harmful effect of high blood sugar and its relationship with complications in diabetes. Traditional risk factors such as smoking also have a significant impact on the abnormal changes in CIMT , 25. In p = 0.047). But the OR value of UA was 0.95, meaning that UA level was a protective factor, which may be caused by a lack of sample size. C-peptide could increase the risk of CAD via a pathway that increases TG or decreases HDL-C levels, which was confirmed by some researches [According to researches, there exists a close relationship between UA and endothelial dysfunction, which causes the abnormal CIMT and increased risk of CAD . High lesearches , 29. Ourp = 0.012 and p = 0.018).Blood glucose fluctuation beyond a certain range  was a risk factor associated with abnormal CIMT. To reveal the relationship between blood glucose fluctuation and diabetic complications, grouping and stratification analysis was conducted. The results indicated that there was no relationship between blood glucose fluctuation and cerebral infarction and no evidence showed that blood glucose fluctuation could directly affect the incidence of HBP. People whose LAGE > 4.4 or SDBG > 2.0 were at high risk of abnormal CIMT. The differences between blood glucose abnormal fluctuation groups and normal groups were statistically significant (One limitation of this study is that the sample size is not large enough. The impact of blood glucose fluctuations to abnormal CIMT and incidence of diabetic complications needs larger sample size to be confirmed. In future work, sample size needs to be expanded and more accurate relationships could be explored.Blood glucose fluctuation beyond a certain range is an independent risk factor associated with CIMT in patients with type 2 diabetes mellitus. T2DM patients, whose blood glucose fluctuation range is wide, should be given more attention to the change of CIMT and cardiovascular system complications. CIMT is a predictor of CAD, which is the most serious complication of diabetes. Early diagnosis and treatment of CAD are beneficial to relieve their pain and improve their quality of life.


ATM and BMI‐1 genes can alter the risk of breast cancer through genotyping 6 variants among 524 breast cancer cases and 518 cancer‐free controls of Han nationality. This was an observational, hospital‐based, case–control association study. Analyses of single variant, linkage, haplotype, interaction and nomogram were performed. Risk was expressed as odds ratio (OR) and 95% confidence interval (CI). All studied variants were in the Hardy‐Weinberg equilibrium and were not linked. The mutant allele frequencies of rs1890637, rs3092856 and rs1801516 in ATM gene were significantly higher in cases than in controls . Two variants, rs1042059 and rs201024480, in BMI‐1 gene were low penetrant, with no detectable significance. After adjustment, rs189037 and rs1801516 were significantly associated with breast cancer under the additive model . In haplotype analysis, haplotypes A‐C‐G‐G  and A‐C‐A‐A in ATM gene were significantly associated with 1.98‐fold and 6.04‐fold increased risk of breast cancer . Nomogram analysis estimated that the cumulative proportion of 3 significant variants in ATM gene was about 12.5%. Our findings collectively indicated that ATM gene was a candidate gene in susceptibility to breast cancer in Han Chinese.We tested the hypothesis that genetic variation in  Recruitment was conducted in 4 hospitals of Heilongjiang province, China, that is, Daqing Oilfield General Hospital, The 2nd and 3rd Affiliated Hospitals of Qiqihar Medical University and Qiqihar Jianhua Hospital. This study was conducted during the period from January 2013 to August 2015.2.3The conduct of this study was approved by the Ethics Committee of Qiqihar Medical University. Written informed consent was obtained from all study participants at the time of recruitment. This study complied with the Declaration of Helsinki.2.4A patient was recorded to have breast cancer if he or she had either newly diagnosed or histopathologically confirmed or previously untreated breast cancer.2.5Control participants had no clinical evidence of any types of cancer except non‐melanoma skin cancer. All controls reported to have no family history of cancer. No restriction was placed on age and tumour stage at the time of recruitment.2.6In total, 1042 female participants were eligible for inclusion. There were 524 cases with breast cancer and 518 controls free of cancer.2.7The following information was collected from cases with breast cancer, including age of first onset, age of menarche, menopausal age, family history of cancer, invasion depth (T1‐T4), tumour stage (I‐III) and lymph node. From controls free of cancer, age at enrolment and age of menarche were recorded.2.83‐EDTA tubes from each participant. Plasma was separated by centrifugation at 4°C and kept frozen in a deep freezer at −80°C until assayed.Venous blood samples (3 mL) were drawn into 5‐mL vacutainer tubes containing K2.9Genomic DNA was extracted from leucocytes using the phenol‐cholesterol method according to a standard procedure.2.10https://www.ncbi.nlm.nih.gov/gene/). In this study, no restriction was placed on the cut‐off point of minor allele frequency of selected variants, as available linkage analyses only identified some rare variants of genes involved in DNA repair, including ATM gene under investigation, and these variants were associated with a moderate risk of breast cancer.Four variants in ATM gene were selected, including rs189037 (A‐111G), rs3092856 (1380His>Tyr or C4138T), rs1801516 (1853Asp>Asn) and rs373759 126713G>A). Two variants were selected from BMI‐1 gene, including rs1042059 (18Cys>Tyr) and rs201024480 310Ser>Asn). The selection of these variants was based on published papers 713G>A. T0Ser>Asn.2.11Genomic sequences of 6 variants in ATM and BMI‐1 genes were amplified by polymerase chain reaction. Genotyping was determined using ligase detection reaction method.Using the same method, 60 randomly selected samples were re‐genotyped, and the results were completely identical.Genotyping was performed by laboratory workers in a manner blind to the case–control status and related characteristics of study participants.2.12t test or Mann‐Whitney U test depending on its distribution. Categorical variable expressed as percentage were compared using the χ2 test. Testing Hardy‐Weinberg equilibrium in control participants, as well as genotype and allele differences between cases and controls was completed by the χ2 test or Fisher's exact test. Breast cancer risk conferred by genetic variants was calculated using logistic regression analysis after adjusting for age and age of menarche. Effect size was indexed as odds ratio (OR) and 95% confidence interval (95% CI). In addition, given the limited sample size of this study, an internal validation was performed by evenly and randomly splitting all study participants into 2 groups, viz. training group (n = 512) and testing group (n = 512). Risk prediction for breast cancer was, respectively, conducted in both groups.Continuous variables expressed as mean (standard deviation) were compared between cases and controls using https://www.broadinstitute.org/haploview/haploview, and linkage magnitude was expressed as D prime (D’).Linkage analysis was performed using the HaploView software Release 4.2 available at https://www.r-project.org/.Haplotype analysis was performed using the HAPLO.STATS program after controlling for age and age of menarche. This program was realized using the R Project for Statistical Computing Release 3.4.3 available at http://www.multifactordimensionalityreduction.org/.Interaction analysis was performed using the open‐source multifactor dimensionality reduction (MDR) software Release 3.0.2 available at A risk nomogram calculator was produced based on baseline information and significant variants identified. The nomogram was depicted using regression modelling strategies (rms) program. This program also was realized using the R Project for Statistical Computing Release 3.4.3. Specifically, a nomogram is a 2‐dimensional diagram that allows the approximate graphical computation of a mathematical function, and its accuracy can be justified by the concordance index (C‐index).Unless otherwise indicated, analyses were performed with the STATA software Release 13.0 .33.1P < .001). In cases, mean menopausal age was 50.19 years and only a small proportion of cases had a family history of cancer (5.95%). In case of invasion depth, 49.69%, 42.77%, 3.77% and 3.77% of cases were in T1, T2, T3 and T4, respectively. Tumour stages II (49.27%) and III (46.10%) accounted for the majority of breast cancer cases, and 42.47% of cases had positive lymph nodes.This study involved 524 cases with breast cancer and 518 controls free of cancer. Table 3.2P > .01).All studied variants were consistent with the distributions predicted by the Hardy‐Weinberg equilibrium in controls . The genotype distributions differed remarkably significantly for rs3092856 and rs1801516 between cases and controls (both P < .001). The 2 variants, rs1042059 and rs201024480, in BMI‐1 gene belonged to low‐penetrance mutations, and there was no hint of significance with breast cancer risk. The genotype and allele comparisons of 6 studied variants between breast cancer cases, respectively, stratified by tumour stage, invasion depth, lymph node and controls are presented in Table Table P: .002 and .001) of breast cancer after adjusting for age and age of menarche  and rs1801516 (AA) were associated with the significant risk , whereas this association was marginally significant for rs189037 in training group  and for rs189037 and rs1801516 in testing group  (Table P: .031 and .048), and significance persisted in both training and testing groups  Table . In addips Table .3.5P < .001). A low‐penetrance haplotype A‐C‐A‐A was overrepresented in cases than in controls .Haplotype analysis was, respectively, conducted in ATM gene and BMI‐1 gene, as they are mapped on different chromosomes. The derived haplotype frequencies and risk estimates for breast cancer are presented in Table When taking the most common haplotype (G‐C‐G‐G) as the reference group, haplotypes A‐C‐G‐G and A‐C‐A‐A in ATM gene were significantly associated with 1.98‐fold and 6.04‐fold increased risk of breast cancer . Other haplotypes carried no significance in association with breast cancer.3.6The interaction of 6 studied variants is illustrated in Figure 3.7P = .011).A nomogram calculator is presented in Figure 4Our findings partly verified the hypothesis of this study, by showing that ATM gene might be a candidate gene of breast cancer in Han Chinese. In particular, we have identified 2 variants in ATM gene, rs189037 and rs1801516, which may play a dominant role, as well as a possible joint role, in susceptibility to breast cancer risk. Despite no detectable significance, this study represents the first attempt to study the association between BMI‐1 genetic variation and breast cancer.The association of ATM genetic variation with breast cancer has been widely evaluated in Western countries,Two variants in ATM gene were under wide investigations. A meta‐analysis of 9 studies indicated that ATM gene rs1801516 might not be a breast cancer‐susceptibility locus in populations of European and Amerindian origins.In further haplotype analysis, we observed that that haplotype A‐C‐A‐A carrying the mutations of both rs189037  and rs1801516  was overrepresented in cases relative to controls, and its association with breast cancer was statistically significant. This observation not only reinforced the results of our single variant analysis, but also suggested the joint contribution of different loci in ATM gene on the development of breast cancer. However, our interaction analysis of 6 studied variants in both ATM and BMI‐1 gene failed to reveal any synergistic effect. It is possible that the variants under study may be in linkage with other causative mutations in ATM gene. We agree that additional confirmation of our findings is necessary to unravel the genetic involvement of ATM gene in breast carcinogenesis.Besides the candidate ATM gene, we have assessed the association between BMI‐1 gene 2 variants and breast cancer risk. This is, to the best of our knowledge, the first attempt in the literature that has tested this association. However, as the 2 variants are low penetrant in nature, we did not detect any significant association with breast cancer in both single variant and haplotype analyses. So, we proposed that BMI‐1 gene might not be a breast cancer‐susceptibility candidate.Several limitations should be considered in this study. First, this is an observational case–control association study, and our data cannot be used to prove the cause–effect relationship between ATM gene and breast cancer risk. Second, the coverage of genetic variation in ATM and BMI‐1 genes was limited. Third, all participants were collected from 4 local hospitals, and multi‐centre confounding cannot be ruled out. Fourth, this study involved only Chinese women of Han nationality, and extrapolation of our results to the other nationalities was only speculative.Taken together, our findings indicated that ATM gene was a candidate gene in susceptibility to breast cancer in Han Chinese. This study suggests genetic heterogeneity in diverse racial groups and underscores the necessity for race‐specific variation screening. In addition, our findings might be useful for the identification of high‐risk youth women by genotyping ATM genetic variants before the cumulative exposure of obvious risk factors, and meanwhile this study offers some helpful hints in understanding the pathophysiology of breast cancer and other solid tumours.None declared.L.H.Z and H.M.P planned and designed the study, and directed its implementation; L.L.Y and F.H.W drafted the protocol; F.H.W and PC obtained statutory and ethics approvals; M.L.Z, PC and DL contributed to data acquisition; DL, P.H.L and Q.B.M. had access to all raw data; M.L.Z and Q.B.M did the data preparation, quality control and data analysis; L.H.Z and L.L.Y wrote the manuscript. Click here for additional data file.


The aim of this four waves 9-year longitudinal study was to examine aggressive/depressive symptoms trajectories in a sample of N = 90 children with overweight and a matched group of children with normal weight . Weight and height were measured by pediatricians to calculate body mass index (BMI). Aggressive/depressive symptoms were measured through the Child Behavior Check-List filled out by children’s parents. Multilevel modeling was used to obtain the best fitting curves describing the change over time in aggression and depression scores. These analyses were performed by sex and group.Children with overweight showed a general increase of aggressive symptoms over time, with a peak at 8 years of age in males, whereas scores of the control group decreased over time both in males and in females. Female children with overweight showed increasing levels of depressive symptoms, with a peak at 8 years of age; children with normal weight, instead, showed low scores at all assessment points. The results highlight the importance of considering the developmental trajectories of aggression and depression in children of different weight status. Childhood overweight (body mass index—BMI from 85th to less than the 95th percentile) is a major social and health issue , 2 that These evidence point to the importance of monitoring the possible problematic emotional-behavioral functioning associated with childhood overweight , 6. HowePrevious research has demonstrated that overweight in children can be associated with several biological and environmental aspects ; howeverTo respond to these gaps in the literature, this study aimed to examine the developmental trajectories of emotional-behavioral functioning in a sample of children with overweight and normal-weight peers matched for socio-demographic characteristics. In a previous study, we reported the trajectories of these two groups over three waves  and did not include pubertal age . Thus, wFollowing the procedure visible here [10.1371/journal.pone.0190731], children aged 11 (sd = 0.78) were recruited for the fourth wave of the study, thanks to the collaboration of pediatricians working in public and private kindergartens and schools in Central Italy. All subjects were followed up from the previous assessment points and their scores were considered to update the trajectories and aggressive/depressive symptoms considering two groups of children: with normal weight (NW) and with overweight (OW). Pediatricians assessed children’s BMI and children’s parents filled out a measure tapping emotional-behavioral functioning of their offspring (see below). The sample was not affected by attrition thanks to the collaboration of pediatricians and schools, which strongly supported the program.BMI is a composite measure of children’ weight and height considering age. To identify children with overweight, we used international cut-off points .Two versions of the Child Behavior Checklist (CBCL) were used . Based on these results, we performed the multilevel modeling analyses to model change over time in depression and aggression levels.packagenlme version 3.1-139 [ggplot2 version 3.1.1 [Data analyses were performed using R version 3.5.3 . The pac 3.1-139  was usedon 3.1.1  for datat(131) = − 2.84, p = 0.005, Mdif = − 0.18, 95% CI = − 0.30 to − 0.05), and at the second one (t(164) = − 2.99, p = 0.003, Mdif = − 0.19, 95% CI = − 0.32 to − 0.06).Exploratory analyses revealed statistical differences in age  = − 3.12, p = 0.002, Mdif = − 1.01, 95% CI = − 1.66 to − 0.37). In the group with overweight, there were not statistical sex differences in BMI. Regarding both aggression and depression scores, the OW group scored higher than the NW group in both measures and in all time points. Males scored higher than females in aggression at the third time point (t(133) = − 5.53, p < 0.001, Mdif= − 4.42, 95% CI = − 5.99 to − 2.84). This pattern was also observed within the OW group (t(65) = − 19.80, p < 0.001, Mdif = − 9.24, 95% CI = − 10.18 to − 8.31), but not within the NW group. Regarding depression, females scored higher than males in depression at the third time point (t(131) = 4.75, p < 0.001, Mdif = 2.36, 95% CI = 1.38 to 3.34). This pattern was also observed within the OW group (t(75) = 11.36, p < 0.001, Mdif = 4.42, 95% CI = 3.65 to 5.20), but not within the NW group.Regarding BMI, there were no differences between males and females. In the NW group, males were heavier than females at the first time point , the latter two both as time-invariant characteristics. The time-relevant predictor was time point and group was the main predictor of interest. Aggression and depression were the outcome variables. Aggression and depression scores were skewed . To lessen the skew, 0.5 was added to each value and the square root was taken. The resulting skewness was 0.38 for aggression and 0.34 for depression. For both outcome measures, we evaluated several models and ended up with a mixed-effects model with a mixed-effects polynomial (quadratic) regression model with random intercept and random slope, in both cases. The best-fitting models are shown in Table Figures As can be seen in the Table The present research note updates the results of a three waves previous longitudinal study , by addiFemales with normal weight showed a decreasing trajectory in aggressive symptoms from T1 to T4, as expected from previous literature , and it A similar pattern was found with regards to depressive symptoms. Children with normal weight showed low and constant levels of depressive problems . The subjects with overweight, instead, showed higher scores, with a peak in females’ symptoms around 8 years of age. After this peak, their symptoms followed a decreasing trend. However, females’ scores at T4 were higher than T1.Two further considerations are noteworthy. First, although aggressive symptoms were overall higher in males (both NW and OW), females’ scores were higher at 2 years of age in this study sample. Similarly, depressive symptoms were overall more problematic in females, but males showed higher scores at T1 and T4, especially in the group with overweight. Second, the specific developmental phase of T3 (8 years of age) seems to have and effect both on the emotional-behavioral functioning of NW and OW group (as described above). However, belonging to the group with overweight seems to magnify this effect, with high peaks in aggressive  and depressive  symptoms at that particular age.This study has several important implications. Given the above results, pediatricians should consider that children with overweight necessitate attention both from a biological and psychological point of view, being aware the period around 8 years of age seems to be crucial in children’s physical and emotional/behavioral development. This piece of data should be used to inform prevention and intervention programs. Importantly, as noted above, the results of this study showed marked differences in the trajectories of male and female children with overweight, also indicating that the classical view in which males are more aggressive than females and girls are more prone to depressive symptoms  does notThe study does not allow to define the causal links describing the association between symptoms and overweight.Further studies with larger samples are required to increase our knowledge on the influence of weight on children’s emotional-behavioral functioning, particularly with regard to gender differences between 8 and 11 years.Additional file 1: Table S1. Descriptive statistics of variables by group and time point.