Astragalus section Hymenostegis is one of the important characteristic elements of thorn-cushion formations in the Irano-Turanian floristic region. In this paper, we examined the chromosome number of 17 species (15 new reports) and provide estimates of genome size for 62 individuals belonging to 38 taxa of A. sect. Hymenostegis, some species outside this section, plus two Oxytropis species. Based on chromosome counts 11 species were found to be diploid (2n = 16), four species tetraploid (2n = 32) and two taxa hexaploid (2n = 48). From genome size measurements on silica-gel dried material, three ploidy levels  were inferred, with a majority of species being diploid. The 2C values reach from 2.07 pg in diploid Astragalus zohrabi to 7.16 pg in hexaploid A. rubrostriatus. We found indications that species might occur with different cytotypes. A phylogenetic framework using nrDNA ITS sequences was constructed to understand the evolution of ploidy changes and genome sizes. It showed that genome size values among the studied taxa differ only slightly within ploidy levels and are nearly constant within most species and groups of closely related taxa within the genus Astragalus. The results of this study show that there is a rather strong correlation between genome sizes and chromosome numbers in sect. Hymenostegis. The resolution of the ITS-based phylogenetic tree is too low to infer evolutionary or environmental correlations of genome size differences. Polyploidization seems to contribute to the high species number in Astragalus, however, in sect. Hymenostegis it is not the main driver of speciation. Astragalus L. comprises about 2500–3000 species worldwide , CCDB database  and Index to Plant Chromosome Numbers of Iran [A. sect. Hymenostegis are unknown, except for a few species [Astragalus species and their worldwide distribution, genome size analyses are still rare [https://cvalues.science.kew.org; accessed 22 November 2021), the genome sizes of only 39 taxa are available, which means that currently about 0.01% of the total number of species have been studied.Cytological work in several ublished ,24,25,26c number ,28,29. B of Iran  chromoso species ,32,33,34ill rare ,36,37,38Astragalus species we report here chromosome numbers and nuclear DNA content of A. sect. Hymenostegis species and some related taxa. To get insights on possible processes related to chromosome evolution, we put these data in a molecular phylogenetic framework for A. sect. Hymenostegis.Because of the rarity of cytogenetic data and also the knowledge gap concerning genome size variation in Astragalus species belonging to sect. Hymenostegis are provided in Hymenostegis chromosome numbers have been determined [Hymenostegis was established as x = 8 and the examined species belong to three ploidy levels: 11 taxa are diploid (2n = 2x = 16), four are tetraploid (2n = 4x = 32) and two were found to be hexaploid (2n = 6x = 48).Chromosome numbers and karyotype characteristics for 17 termined ,33,34,39A. chrysostachys to 3.5 μm in A. subrecognitus. The mean length for the long arms (P) of chromosomes varied from 0.81 μm in A. chrysostachys to 2.8 μm in A. subrecognitus. Mean lengths of short arms (q) ranged from 0.66 μm in A. chrysostachys to 1.44 μm in A. assadabadensis and the average values of chromosome arm ratios (r) ranged from 1.23 in A. pediculariformis to 1.77 in A. tabrizianus. TF% index has a perfect negative correlation with AsK%, and a perfect positive correlation with the Syi index. The Syi index has shown a perfect negative correlation with AsK%. Astragalus chrysostachys and A. pediculariformis have the highest values of TF% (45%) and A. pediculariformis has the highest Syi% (83%), as well as the lowest values of AsK% (54%), resulting in the most symmetric karyotype. The lowest value of TF% (36%) and Syi% (56%) and the highest value of AsK% (63%) belonged to A. tabrizianus. The total haploid chromosome lengths (CL) differed from 1.47 μm in Astragalus species and two Oxytropis taxa are provided here for the first time  were analyzed by maximum parsimony (MP) and Bayesian phylogenetic inference (BI). The sequences resulted in an alignment length of 607 base pairs (bp). Maximum parsimony analysis resulted in a single tree of 98 steps length (not shown) with a consistency index (CI) of 0.84 and a retention index (RI) of 0.91. Both MP and BI led to trees with matching topologies, so only the BI tree is provided in Hymenostegis are generally low except for the two main clades of sect. Hymenostegis, the larger one comprising 28 species, the smaller one six. The taxonomically distant Astragalus taxa and two Oxytropis species were regarded as outgroups for the analysis.To infer phylogenetic positions of the taxa with available chromosome number and/or genome size data, 40 n = 2x = 16) have 2C genome sizes of 2.17 to 2.5 pg, tetraploids (2n = 4x = 32) have about twice as much nuclear DNA with 4.5 pg, and hexaploids (2n = 6x = 48) were found to have a 2C genome size of 6.8 to 7.2 pg. The only exception in our dataset is A. melanostictus where the individual used for chromosome counts had 32 chromosomes, while one of the two individuals used in flow cytometry presented 1.54 pg/2C, the smallest value in our analysis, and the second individual 2.21 pg/2C. For values taken from the literature we see major deviations from this otherwise consistent pattern  have been detected with 16, 32, and 48 chromosomes, respectively. Within our own analyzed species, we found a strong correlation between ploidy level and genome size. Thus, Astragalus species have on average a 2C of 2.28 (±0.17) pg for diploids, 4.56 (±0.12) pg for tetraploids and 6.79 (±0.31) pg for hexaploids. However, in A. melanostictus we found 2n = 4x = 32 chromosomes in the individual that was used for chromosome counts, while the two individuals used for genome-size estimations resulted (i) in highly disparate 2C values (1.54 vs. 2.21 pg) that (ii) fit only for the latter value to the genome-size classes defined above. As no leaf material was left for these individuals, we were not able to verify our measurements. We assume, however, that the smaller value might be due to a wrongly collected different taxon, as the result of our second individual (2.21 pg/2C) fits at least into the class of diploid genome sizes. Still, this doesn’t solve the disparity we see in this species regarding the 4x chromosome count with the otherwise diploid 2C value. Currently we assume that in A. melanostictus different cytotypes might exist and that we, by chance, used two different types for karyotype analysis and flow cytometry. The occurrence of different cytotypes within plant species is well known [We established a comprehensive karyo-morphological analysis for ll known ,44. As wRegarding relationships between different geographical areas or habitat types and the distribution of ploidy levels and/or of genome sizes, we found no clear trend. However, this could be caused by low phylogenetic resolution of the phylogeny and overall low range of variation of genome size among the analyzed species.A. sect. Hymenostegis taxa, the estimated 2C values where rather similar within ploidy levels and seem internally consistent even taking into account the relatively large CV values obtained for most of the individuals  ploidy levels. While chromosome numbers are constant and genome sizes of A. sect. Hymenostegis did not show (larger) variation within the three ploidy levels, karyotype differences were more pronounced  leaves and/or seeds were collected from natural habitats throughout 2017 to 2019. To obtain young leaves and ripe seeds collections had to be done at least at two different time points in the vegetation period. Details concerning the examined taxa are accessible in v/v, 3:1) solution. Fixed root tips were washed three times in distilled water and kept at 4 °C in 70% ethanol for several months, until use. Then, meristems were hydrolyzed in 1N HCl at 60 °C for 14 min, stained, and squashed in a drop of aceto-orcein as follow. Fixed root tips were kept in 2% aceto-orcein for 3 h and incubated for 10–15 min in cellulase-pectinase enzyme solution at 37 °C. The stained roots were squashed in 45% acetic acid under a stereomicroscope and the best metaphase plates were photographed in an Olympus (BX40) microscope. Chromosome counts were made on well-spread metaphase plates. The karyotype was prepared according to metaphase plates. Designation of centromere position and chromosome type was done according to Levan et al. [Seeds of the plants were placed on filter paper in petri dishes and kept wet till germination. Root tips of up to ten germinated seeds per individual of about 0.5–1 cm in length were pretreated with 0.01% aqueous solution of colchicine for 3–4 h at 4 °C, and fixed in freshly prepared absolute ethanol-acetic acid  as standard [A. sect. Hymenostegis species are generally hard to cultivate and occur naturally at remote locations we used dried leaf material for genome size measurements. Silica-gel dried material has previously been shown to be suitable for measuring genome size in some cases [Astragalus species, we measured both silica-gel dried and fresh leaves to evaluated the impact of material type on flow cytometry measurements (data not shown). We found semiarid- to arid-adapted species  generally suitable for flow cytometry with silica-gel preserved material if leaves were collected at a young stage, dried fast and measured shortly afterwards or stored frozen at −20 °C. Given the CVs in the flow histogram peaks were often >5% (Genome size was determined using propidium iodide (PI) flow cytometry with a Cyflow Space , following the procedure described in Jakob et al. . We usedstandard  and the me cases , althougme cases . For somften >5%  and we dA. sect. Hymenostegis were based on our previous dataset [Astragalus species where we had chromosome counts and/or 2C genome-size values, ITS sequences of Astragalus (33 species from sect. Hymenostegis and seven species from other sections) plus two Oxytropis species as outgroups, were aligned and subjected to phylogenetic analyses. Bayesian phylogenetic inference (BI) was done in MrBayes 3.1 [http://tree.bio.ed. ac.uk; accessed 18 October 2021). The MP analysis was conducted in PAUP* using the heuristic search algorithm. To test clade support, a bootstrap analysis with 500 bootstrap resamples was conducted. A list of examined taxa and GenBank accession numbers of the ITS sequences are listed in Molecular phylogenetic analyses of  dataset , which uayes 3.1 . The seqayes 3.1 . For BI A. sect. Hymenostegis. We inferred three ploidy levels  with the majority of analyzed taxa being diploids. Genome sizes were quite similar within the di- and tetraploids, while larger variation was found in hexaploids. As sect. Hymenostegis species are quite young, the phylogenetic resolution of the ITS dataset is low. This, together with the relative uniformity of 2C values, prevents assigning genome sizes differences to specific clades in the section or to relate them to environmental parameters. Polyploidization is involved but seems not the major driver of species diversification in sect. Hymenostegis, as about one third of the analyzed taxa are polyploids.The current work presents the first set of genome size and chromosomal data for


Idiopathic premature adrenarche (IPA) is considered a normal variant of puberty, presenting more commonly in female patients. There are concerns as to whether IPA alters the final height of these girls. Our main objectives were to (a) compare the adult height of girls with IPA against their target height and (b) design a mathematical model to predict adult height at diagnosis in female patients with IPA.A cohort study of girls with IPA was conducted from the time of IPA diagnosis until adult height. The following data were collected: target height, perinatal history, anthropometric and biochemical variables and bone age at diagnosis, age at Tanner stage 2 and menarcheal age, and adult height. First, we performed a univariate statistical analysis after which we carried out a multiple linear regression analysis using adult height as the dependent variable.R2 value of 71%.We obtained data from 79 female patients diagnosed with IPA with a mean adult height of 164.6 cm (95% CI: 163.36–165.85 cm). The mean follow-up time was 6.60 years. Average age at Tanner stage 2 was 9.71 years. Mean menarcheal age was 11.64 years. There were no significant differences between target height and adult height. Of the several predictive models designed for these patients, one of them, which included bone age, obtained an Although slightly advanced puberty was observed among the girls with IPA, their adult height was preserved. The use of predictive models of adult height on diagnosis of IPA could facilitate closer follow-up of girls at risk of reduced adult height. As the zona reticularis develops in the adrenal cortex, at approximately 5 to 8 years of age, there is a simultaneous increase of androgen precursors with weak androgenic activity, such as dehydroepiandrosterone (DHEA), its sulfate (DHEA-S), and androstenedione. This biological process, called adrenarche, is typical of humans and higher primates –3. ClassIn girls, premature adrenarche (PA) is determined by the presence of clinical signs of androgen action before the age of 8 years in addition to androgen precursors that are abnormally high for the patient’s prepubertal stage (Tanner 1) and more suitable for more advanced Tanner stages Tanner 2-4) (-4 (2). OPA is a relatively frequent reason for pediatric endocrinology consultations. However, epidemiological data are scarce. An elegant Finnish study reported an 8.6% prevalence of PA as defined by DHEA-S ≥ 1 µmol/L and presence of any clinical sign of androgen action in girls under age 8 years as compared to a rate of 1.8% in boys under age 9 years  was measured in the Pediatric Endocrinology Unit. The target height was calculated as follows: father’s height + mother’s height/2 − 6.5 cm. Likewise, the SDS for target height was calculated according to Spanish reference values , birth weight (grams), and birth length (cm). We calculated birth weight and birth length SDS using Spanish reference values according to gestational age and sex  and age of pubarche/axilarche onset (years). Height (cm), weight (kg), and body mass index (BMI) [weight (kg)/height (m2)] were also recorded. We calculated height, weight, and BMI SDS using references tables for the Spanish population (- pulation . Bone agpulation  by the mpulation  in cm anpulation . Pelvic ⚬ Androstenedione levels were determined by CLEIA (chemiluminescence enzyme immunoassay), the intra-assay coefficient of variation was 6.2%, and the inter-assay coefficient of variation was 8.5%. Testosterone concentrations were determined by ECLIA (electrochemiluminescence immunoassay), the intra-assay coefficient of variation was 1.6%, and the inter-assay coefficient of variation was 3.5%. DHEA-S concentrations were determined by ECLIA, the intra-assay coefficient of variation was 3.2%, and the inter-assay coefficient of variation was 4%. 17-OH-progesterone levels were determined by ELISA (enzyme-linked immunosorbent assay), the intra-assay coefficient of variation was 2.8%, and the inter-assay coefficient of variation was 5.8%.Clinical follow-up: every 6 months. We collected the following data on each visit: height , weight , BMI , growth velocity , Tanner stage  (- ic hair) , and menDefinitions:- Small for gestational age: birth length and/or weight < −2 SDS .⚬ A total of 79 girls with IPA were followed up until they reached adult height. Baseline characteristics are summarized in This observational study was performed in accordance with the principles of the Declaration of Helsinki, as well as the prevailing Spanish legislation on clinical research in human subjects. The study protocol was approved by the Research Ethics Committee of the University Hospital Fundación Jiménez Díaz (protocol n°: PIC003-19/Date: 30/01/2019). The purpose of the study was explained to all participants and both written parental consent and written assent from minors >12 years were obtained.In the descriptive analysis, qualitative variables are shown in frequency tables and quantitative variables as mean and 95% confidence interval. The Kolmogorov–Smirnov test was applied to verify the normal distribution of the data. Those variables that did not follow a normal distribution were logarithmically transformed.t-test for unpaired data was used to compare the adult height of girls with IPA with respect to target height.Student’s R2). The 95% confidence interval (CI) was also calculated for the predictions of these models.Subsequently, the correlation between adult height and each of its potential predictive variables was evaluated, constructing a correlation matrix. Next, a multiple linear regression model was used, taking as the dependent variable adult height (cm) and as independent variables those that showed a significant relationship with adult height in the correlation matrix using a strategy of stepwise regression. Previously, the presence of collinearity between the independent variables included in the model was ruled out (correlation > 0.6). The best model was selected by obtaining the best adjusted coefficient of determination  method . The valp values <0.05 were considered significant.Associations or statistical differences with Analyses were performed using the SPSS version 25.0 software .The mean age at diagnosis was 7.63 years, and the mean age at assessment of adult height was 14.16 years. Thus, the mean time of follow-up was 6.60 years. None of the girls was required to re-evaluate the BA during this follow-up.Four girls out of a total of 79 met the criteria for small for gestational age (5%).Tanner stage 2 of breast development was reached at the age of 9.71 years. In addition, mean menarcheal age was 11.64 years. Notably, maternal menarcheal age was 12.13 years.The mean adult height of girls with IPA was 164.60 cm (163.36-165.85). When compared to their target height [163.56 cm (162.39–164.73)], no significant differences were observed see Table 2.The mean total growth from diagnosis until adult height was 32.95 cm. Otherwise, the total growth since Tanner stage 2 (B2) until adult height was 19.39 cm.We built a correlation matrix with the different quantitative variables analyzed in this study. The initial univariate analysis showed that adult height was significantly correlated with target height (cm and SDS), birth weight (SDS), birth length (SDS), height at diagnosis (cm and SDS), predicted adult height (cm and SDS), and basal 17-OH-P (ng/ml) at diagnosis. Afterwards, several multiple linear regression models were designed using adult height as the dependent variable.R2 of 68% after cross-validation (see The best fit model had an Adult height (cm) = 63.15 + target height (cm) × 0.23 + birth weight (SDS) × 0.63 + adult height prediction, taking in to account BA at diagnostic (cm) × 0.37 + height at diagnostic (SDS) ×2.28.This model displayed a 95% confidence interval for the prediction of ±2.6 cm.R2 after cross-validation of 63% with the following formula  = 85.71 + target height (cm) × 0.45 + birth lenght (SDS) × 0.94 + height diagnosis (SDS) × 3.37.This model showed a 95% confidence interval for the prediction of ±2.8 cm.n = 14). At the moment of adult height evaluation, this prevalence was 21.51% (n = 17). Moreover, the correlation of BMI Z-score at diagnosis and at adult height evaluation was 0.71 (p < 0.001). Besides, 64.28% of obese girls at IPA diagnosis continued to be obese at adult height, while 35.72% decreased their BMI below 2 SDS. In addition, 13.85% of girls with normal weight at diagnosis were obese when they reached adult height.The percentage of girls diagnosed as having IPA with obesity at diagnosis was 17.72% ; however, a high prevalence of SGA (birth weight < −2 SDS) was reported among the girls in the cohort (26.7%). This high percentage of SGA is only comparable to that reported by de Ferran et al.  between adult height prediction at diagnosis by BA and adult height in IPA girls. Moreover, the mean difference between adult height and adult height predicted at diagnosis by the Bayley–Pinneau average age method was 1.71 cm with a 95% CI of 0.59 to 2.83 cm. This means that the adult height prediction is not overestimated. As previously remarked, however, the accuracy of this prediction depends substantially on clinician expertise (We observed a significant positive correlation (xpertise .R2) of 71% and includes target height, birth weight, height at diagnosis, and predicted adult height taking into account BA at diagnosis. In addition, we have achieved a 95% confidence interval of 2.6 cm below to 2.6 cm above the predicted value. After removing the variable of predicted adult height taking into account BA at diagnosis from the original formula, the adjusted coefficient of determination diminishes to 67% and the new 95% confidence interval is ±2.8 cm. With this second model, we can avoid the interpretation of BA by less experienced clinicians. Taking into account all the above, we think that models for predicting adult height in girls with IPA may be useful in detecting cases in which the predicted adult height is far from the target height. Therefore, we can schedule more personalized clinical follow-up.The best model for adult height prediction shows an adjusted coefficient of determination  of the Familia Alonso Foundation.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 psychosocial risk assessment is a systematic intervention process for organizations that aims at improving psychosocial working conditions as well as employee health. Based on a screening of working conditions, interventions to reduce risk factors are implemented and evaluated. What is missing for most screening instruments however are cut-off values to categorize working conditions into uncritical vs. critical, whereas the latter indicates an elevated risk for illness. To estimate and evaluate cut-off values, two studies were conducted using the receiver operating characteristic (ROC) analysis.N = 295). It was tested for differences in the results of the two groups concerning the direct criterion of depressive symptoms and the indirect criterion of effort-reward imbalance.In Study 1, a sample of 229 participants answered an online survey on depression (PHQ) and psychosocial working conditions using a questionnaire (DYNAMIK) that covers five factors important to workers' health: workload, boundary permeability, participation, leader support, and usability. Using the ROC analysis, criterion-related cut-off values were generated to predict depressive symptoms. In Study 2, these cut-off values were used to classify working conditions in the two categories of ‘critical’ and ‘uncritical’ in an independent sample (In Study 1, cut-off values differed between the five scales and showed different values for sensitivity and specificity. In Study 2, participants exposed to critical working conditions reported more depressive symptoms as well as an effort-reward imbalance.Cut-off values are useful to identify working conditions as either critical or uncritical. This knowledge is important when deciding which working conditions should be optimized within the context of psychosocial risk assessment. The psychosocial risk assessment is a systematic intervention process for organizations that is aimed at improving psychosocial working conditions and thus employee health and well-being  and evaluate cut-off values based on two important health outcomes within an independent sample (Study 2).To demonstrate the procedure of developing cut-off values, we use the DYNAMIK questionnaire  in Germany, an online survey was circulated to people working in different organizations and areas of work. The participation was voluntary. Participants were asked to answer a questionnaire for the psychosocial risk assessment and one for the measurement of depressive symptoms. In total, 229 participants completed the survey.Of the 229 participants, 52% were female with a mean age of 35.46 years SD = 12.89). Most of the participants worked in sectors of human health and social work activities (30%), manufacturing (9%), education (8%), other service activities (8%), information and communication (7%), as well as public administration (6%). With regard to participants’ educational background, 17% had at least completed vocational training, 12% technical college, 13% held a polytechnic degree, 35% a university degree, and 6% a doctorate. An overview of sample characteristics is given in Table 2.89. MosThe project has been approved by the ethics committee at the Medical Faculty of Heinrich Heine University Düsseldorf (no. 5562) and has been performed in accordance with the ethical standards as laid down in the 2013 Declaration of Helsinki. All steps of the study including data collection, analyses, and interpretation contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation. All participants submitted written informed consent.The questionnaires were presented online. Participants filled in the DYNAMIK , boundary permeability (4 items), participation (3 items), leader support (3 items), and usability (2 items). Items were recoded so that a high value represented a high level of the corresponding stressor. All items were measured on a five-point scale with a response format of 1 (never/hardly ever), 2 (seldom), 3 (sometimes), 4 (often), and 5  or alternatively ranging from 1 (I strongly disagree), 2 (disagree), 3 , 4 (agree) to 5 (I strongly agree) depending on the content of the item. In addition, participants could choose “no response” if they neither wanted nor were able to give any meaningful answer. For each scale, a sum score was computed. Sample items are “I am unintentionally interrupted in my work” to measure workload or “The computer programs that I work with are easy to use” to measure software usability. Cronbach’s α was 0.77 for workload, 0.70 for boundary permeability, 0.78 for participation, 0.79 for leader support, and 0.61 for usability.Depression The nine items of the Patient Health Questionnaire (PHQ-9) were used to measure depression  with a minimum of 8 and a maximum of 20 . For boundary permeability, mean was 10.94 . Potential range of the scale was also between 4 and 20. For participation, observed values ranged between 3 and 15  with a mean of 10.42 (SD = 2.79). For leader support, the mean was 10.55 (SD = 2.47) with observed values ranging between 3 and 15 . For usability, the mean value was 6.88  with a potential range between 2 and 10.Descriptive statistics for study variables are presented in the following. For workload, mean value was 14.98 (SD = 4.40). Of the participants, 40% were classified as having only mild and 42% only moderate levels of depressive symptoms, while 12% reported having moderately severe, and 6% severe levels of depressive symptoms. Observed prevalence rates are higher than prevalence rates of a representative German sample for the mild (40% vs. 76%), moderate (42% vs. 18%), moderately severe (12% vs. 4.3%), as well as the severe (6% vs. 1.3%) levels of depressive symptoms . Participants with moderately severe and severe levels of depressive symptoms were grouped into the category ‘depressed’ (18% of participants). Second, we conducted ROC analysis to evaluate the diagnostic power of the DYNAMIK scales. The presence or absence of depression served as a classification variable. Results of ROC analysis are presented in Table AUC for workload was 0.61 (95% CI [0.51 0.72]). For boundary permeability, the optimal cut-off was 10.5 with a sensitivity of 0.92 (95% CI [0.81 1.00]), a specificity of 0.50 (95% CI [0.43 0.57]), and a Youden index of 1.42 (95% CI [1.30 1.53]). The AUC for boundary permeability was 0.74 (95% CI [0.67 0.81]). For participation, the optimal cut-off was 9.5 with a sensitivity of 0.63 (95% CI [0.47 0.79]), a specificity of 0.71 (95% CI [0.64 0.78]), and a Youden index of 1.34 (95% CI [1.17 1.50]). The AUC for participation was 0.72 (95% CI [0.64 0.81]). For leader support, the optimal cut-off was 11.5 with a sensitivity of 0.92 (95% CI [0.81 1.00]), a specificity of 0.41 (95% CI [0.35 0.49]), and a Youden index of 1.34 (95% CI [1.22 1.44]). The AUC for leader support was 0.72 (95% CI [0.63 0.81]). For usability, the optimal cut off was 7.5 with a sensitivity of 0.37 (95% CI [0.24 0.53]), a specificity of 0.69 (95% CI [0.63 0.76]), and a Youden index of 1.06 (95% CI [0.90 1.23]). The AUC for usability was 0.46 (95% CI [0.36 0.57]).Cut-off values differ between the five scales. For workload, the optimal cut-off was 17.5 with a sensitivity of 0.32 (95% CI [0.16 0.47]), a specificity of 0.89 (95% CI [0.83.93]), and a Youden index of 1.20 (95% CI [1.05 1.36]). The The aim of Study 2 was to evaluate the empirically generated cut-off values of Study 1 within an independent sample. It was tested whether there were differences in the reported level of depression and effort-reward imbalance with participants working under conditions that were classified as ‘critical’ in comparison to participants who fall under the category of ‘uncritical’ working conditions.In Study In total, 295 employees from the seven companies took part in the psychosocial risk assessment and gave information on demographics, psychosocial working conditions, depressive symptoms, and effort-reward imbalance. Mean age of the 295 participants was 47.62 years (SD = 8.73) and 71% were male. Of the participants, 73% worked in the information and communication sector and 27% in manufacturing. Concerning the highest educational degree, 34% of the participants completed vocational training, 15% technical college, 19% achieved a polytechnic degree, 23% a university degree, and 3% a doctorate.The DYNAMIK questionnaire  were used to measure depression  = − 1.49, ns. Regarding the ERI, the critical group significantly differed from the uncritical group  with an effect size of Cohen’s d = 0.95.We conducted t(291) = 4.74, p < 0.01]. Cohen’s d was 0.59. With regard to ERI values, the critical group significantly differed from the uncritical group .For boundary permeability, both groups differed with regard to PHQ-2 scores . The ERI score of the critical group was also significantly higher than mean value for the uncritical group  with Cohen’s d = 0.75.For participation, mean PHQ-2 score for the critical group was higher than for the uncritical group . For the ERI score, the critical group’s mean was significantly higher than the uncritical group’s mean .For leader support, the critical group scored higher in the PHQ than the uncritical group  in PHQ-2 scores but not in ERI-scores . In sum, cut-off values determined in Study 1 enabled a valid classification of participants in Study 2. Overall, groups differed regarding their level of depression as well as effort-reward imbalance.With regard to usability, both groups significantly differed [To summarize, the main goal of the study was to compute criterion-related cut-off values for five central stressors within the psychosocial risk assessment via ROC analysis. We applied this method and focused on depression as a relevant outcome criterion in occupational health. In the second step, cut-off values were evaluated using an independent sample. Results showed that cut-off values tend to be a promising approach to classify working conditions in the two broad categories of ‘critical’ and ‘uncritical’. Participants exposed to critical working conditions in the domains of boundary permeability, participation, leader support, and usability reported more depressive symptoms as well as a greater effort-reward imbalance.Study 1 shows the development of different cut-off values for each of the five scales of the DYNAMIK questionnaire. For each scale, the Youden index varied in its level. Some scales displayed a high level of both aspects of diagnostic validity (sensitivity and specificity) while other scales only displayed high levels for one of these aspects. A potential explanation for these results might be that each scale has a different relative weight in explaining variance within the criterion depression (Diebig et al. In Study 2, cut-off values were evaluated. Here, most groups classified by cut-off values also differed with regard to the evaluation criteria depression and imbalance between effort and reward. Yet, for workload, groups did not differ regarding depressive symptoms. Also, for usability, groups did not differ with regard to their perceived level of effort-reward imbalance. Similarly to the results of Study 1, it might be that both variables only have small predictive validity concerning the evaluation criteria. Therefore, calculated cut-off values for these variables do not provide enough information to classify working conditions.Generally, procedures that facilitate the labeling of critical and uncritical working conditions focus on two different approaches: theoretical approaches and benchmarks. The ERI model, as an example of a theoretical approach, postulates that an imbalance between effort and reward is most relevant for individuals’ health (Siegrist et al. This study wants to encourage researchers to empirically determine cut-off values for screening instruments within the psychosocial risk assessment. This procedure can help detect which working conditions need to be improved to create a healthier working environment.The procedure outlined in this study aims at presenting a method that helps to generate information for the process of psychosocial risk assessment. It serves as a guideline to determine interventions with higher priorities in relation to detected risks. Therefore, cut-off values for a screening instrument were developed based on the Youden index aimed at identifying optimal cut-offs as a function of sensitivity as well as specificity. Cut-off values varied depending on the underlying dimension of the screening instrument and thus represent the different impact they have on the outcome of depression. Practitioners may use this information to decide which working conditions need improvement to prevent depression of their employees. This information helps to design healthier working conditions and to focus on those aspects of work that pose a high risk for potential unfavorable health outcomes. With this, we encourage researchers to apply the ROC-analysis to generate empirically driven cut-offs for screening instruments that are applied within the psychosocial risk assessment.Apart from the study’s several strengths like the development and evaluation of the cut-off values within two independent samples, some limitations have to be mentioned as well. First, due to limitations of the overall length of questionnaires applied, only short forms of validated measures could be implemented in this study. Particularly in Study 1, the PHQ-9 was used whereas in Study 2 only the shorter version, the PHQ-2, could be implemented. Yet, recent research has demonstrated that the short versions of these two questionnaires are strongly related to the corresponding full versions and also significantly correlate with each other (Manea et al. Second, observed prevalence rates of depressive symptoms in our study are higher than prevalence rates reported within a representative German sample (Kocalevent et al. Third, it was only possible to generate data in a cross-sectional manner. According to this, only one source could be used as an informant for predictor and criterion variables (Podsakoff et al. Fourth, the sample size for the development and validation of the cut-off values was rather small. Future studies should adopt the outlined procedure and compute cut-off values based on representative samples for different types of jobs. Following this, the sample used to generate cut-off values was not clinical in nature i.e., classifications of participants as ‘depressed’ and ‘non-depressed’ were not based on a clinical diagnosis (Lehr et al. In this study, the ROC analysis was presented as a method to empirically generate criterion-related cut-off values for a screening instrument within the psychosocial risk assessment. Cut-off values were identified to classify working conditions as either critical or uncritical. We would like to encourage researchers to empirically determine cut-off values for screening instruments within the psychosocial risk assessment. This procedure can help detect which working conditions need to be improved to create a healthier working environment.


In the original article, there was a mistake in In the original article, there was an error. We made the mistake of writing “GPA” as “DS-GPA”. A correction has been made to the Abstract. The corrected section appears below.Among 19,225 patients with ESCC, 66 (0.34%) were diagnosed with brain metastases. Five patients were treated with surgery, 40 patients were treated with radiotherapy, 10 with systemic therapy alone, and 15 with supportive care alone. The median follow-up time was 7.3 months (95% CI 7.4-11.4). At last follow-up, 59 patients are deceased and 7 patients are alive. Median overall survival (OS) from time of brain metastases diagnosis was 7.6 months (95% CI 5.3-9.9) for all cases. For patients who received locoregional treatment, median OS was 10.9 months (95% CI 7.4-14.3), and survival rates at 6 and 12 months were 75.6% and 37.2%, respectively. For patients without locoregional treatment, median OS was 3.0 months (95% CI 2.5-3.5), and survival rates at 6 and 12 months were 32% and 24%, respectively. OS was significantly improved for patients who received locoregional treatment compared to those treated with systematic treatment alone or supportive care . The median OS of patients with graded prognostic assessment (GPA) score 0-2 was 6.4 months, compared to median OS of 12.3 months for patients with GPA >2 .Conclusion. The corrected section appears below.A correction has been made to the Brain metastases are rare in patients with ESCC. GPA score maybe a useful prognostic tool for ESCC patients with brain metastases. Receipt of locoregional treatment including brain surgery and radiotherapy was associated with improved survival.A correction has been made to the keywords. The corrected section appears below.brain metastases, esophageal squamous cell carcinoma, surgery, brain radiotherapy, GPA score.Materials and Methods, Patient Population. The corrected section appears below.A correction has been made to th edition of American Joint Committee on Cancer (AJCC) TNM staging classification for carcinoma of the esophagus and esophagogastric junction (8). Brain metastases were diagnosed by contrast-enhanced CT or MRI scans. Graded prognostic assessment  was used to estimate the prognosis (9). Brain radiation therapy was administered as stereotactic radiosurgery (SRS) by Gamma Knife, or whole or partial brain radiation by a 6-MV linear accelerator with three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT) techniques. All patients were followed through November 30, 2020 by outpatient clinical visit and/or telephone.For this retrospective cohort study, consecutive patients with EC treated at the Fourth Hospital of Hebei Medical University between January 1, 2009 and May 31, 2020 were identified in an institutional tumor registry through a protocol approved by the institutional review board with waiver of informed consent. In this study, we analyzed the subset of patients with ESCC. All included patients had no history of other malignant tumors, and diagnosis was pathologically confirmed as ESCC. The primary tumor in esophagus was restaged according to the 8Results, Survival, Paragraph 5. The corrected paragraph appears below.A correction has been made to There were 45 patients with GPA score 0-2 and 21 patients with GPA score >2. The median OS of patients with GPA score 0-2 was 6.4 months, compared to median OS of 12.3 months for patients with GPA >2. OS was significantly improved for patients with high GPA score compared to those with low score .Discussion, Paragraph 5. The corrected paragraph appears below.A correction has been made to Due to its quantitative nature, the GPA score is an objective prognostic index used to estimate expected OS (9). Li et al. (7) demonstrated that patients with a GPA score of 0-2.0 achieved median OS of 4.6 months compared to 31.5 months for patients with GPA scores 2.5-3.0 (P<0.01). In the current study, median OS of patients with GPA score of 0-2.0 versus >2.0 was 6.4 months versus 12.3 months, respectively . GPA score may be a useful prognostic tool for ESCC patients with brain metastases. Given their improved prognosis, locoregional treatment should be considered for patients with a GPA score over 2.0.Discussion, Paragraph 9. The corrected paragraph appears below.A correction has been made to In conclusion, the development of symptomatic brain metastases is rare for patients with ESCC. Locoregional treatment is associated with improved OS in our study. Thus, brain surgery and radiation therapy should be considered for patients with brain metastases from ESCC with good performance status. In addition, GPA score may be a useful prognostic tool for ESCC patients with brain metastases. Given their improved prognosis, locoregional treatment should be more considered for patients with a GPA score over 2.0. Given limitations of our study, further study is needed to confirm these findings and compare the efficacy and safety of different locoregional treatment options and explore more effective systematic treatment.The authors apologize for these errors and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.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.


Chronic fatigue syndrome (CFS) is a long-term disabling illness accompanied by medically unexplained fatigue. This study aimed to explore the epidemiological characteristics of CFS in South Korea.Using the nationwide medical records provided by the Korean Health Insurance Review & Assessment Service (HIRA), we analyzed the entire dataset for CFS patients diagnosed by physicians in South Korea from January 2010 to December 2020.The annual mean incidence of CFS was estimated to be 44.71 ± 6.10 cases per 100,000 individuals , and the prevalence rate was 57.70 ± 12.20 cases per 100,000 individuals . These two rates increased by 1.53- and 1.94-fold from 2010 to 2020, respectively, and showed an increasing trend with aging and an approximately 1.5-fold female predominance.This study is the first to report the nationwide epidemiological features of CFS, which reflects the clinical reality of CFS diagnosis and care in South Korea. This study will be a valuable reference for studies of CFS in the future. Uncontrolled chronic fatigue substantially impairs health-related quality of life (QoL), especially in cases of medically unexplained fatigue compared to explained chronic fatigue . Chronicvs. 0.2% by Holmes' definitions and 1.1% via interviews vs. 0.1% via physician diagnosis were reported . Using the Healthcare Big Data Hub of HIRA, we extracted the entire dataset for health services to patients who had been diagnosed or treated for postviral fatigue syndrome  during the past 11 years .We analyzed the epidemiological features of CFS among the entire South Korean population using HIRA-derived datasets to address the following questions: absolute frequency of CFS based on the year, sex and age and in relation to whole South Korean population, treatment periods associated with CFS after 1st diagnosis on 2011, and any specific disease profile present before the initial diagnosis with CFS. Regarding the estimation of incidence rates, we considered an event a ‘new’ diagnosis of CFS in each year, if there was no preceding diagnosis of CFS in the patient’s medical record. For the prevalence of CFS, we extracted all cases of CFS diagnosis in each year.The annual incidence rate and prevalence of CFS, including 95% confidence intervals, were calculated by the number of recorded diagnosis cases divided by the number in the entire general population for each corresponding year. Subsequently, the overall rate with a 95% confidence interval (95% CI) per 100,000 patients was calculated. The data for the whole population were obtained from the Korean Statistical Information Service . Statistvs. females 13,598 ± 2179) over 11 years. This physician diagnosis-derived annual incidence of CFS increased 1.57-fold between 2010  and 2020  and was slightly higher in females (1.66-fold) than in males (1.44-fold)  . Over the past 11 years, this prevalence increased approximately twofold, and this increase was the same in males (1.78-fold) and females (2.05-fold) . In a similar format as our study using the General Practice Research Database (GPRD) that includes data from participating general practices across the UK, the annual incidence was 27.0 CFS/ME/PVFS cases per 100,000 persons for the period 2001–2013 , and the prevalence rate was estimated to be 57.70 ± 12.20 cases per 100,000 individuals . These frequencies increased with aging and showed an approximately 1.5-fold female predominance


T. congolense, T. vivax, and T. b. brucei. Northern Uganda has been politically unstable with no form of vector control in place. The return of displaced inhabitants led to the restocking of cattle from AAT endemic areas. It was thus important to estimate the burden of trypanosomiasis in the region. This study was designed to compare the prevalence of animal African trypanosomes in cattle in Lira District using microscopy and polymerase chain reaction amplification (PCR) methods. In this cross-sectional study, a total of 254 cattle from the three villages of Acanakwo A, Barropok, and Acungkena in Lira District, Uganda, were selected by simple random sampling technique and screened for trypanosomiasis using microscopy and PCR methods. The prevalence of trypanosomiasis according to microscopic results was 5/254 (2.0%) as compared to 11/254 (4.3%) trypanosomiasis prevalence according to PCR analysis. The prevalence of trypanosomiasis infection in the animal studied is 11/254 (4.3%). Trypanosoma congolense was the most dominant trypanosome species with a proportion of 9/11 (81.8%), followed by T. vivax 1/11 (9.1%) and mixed infection of T. congolense/T. vivax1/11 (9.1%). Barropok village had the highest prevalence of trypanosomiasis with 6/11 (54.5%). There is a statistically significant relationship  between abnormal PCV and trypanosome infection. Polymerase reaction amplification was the most reliable diagnostic method due to its high sensitivity and specificity as compared to the conventional microscopic method. Polymerase reaction amplification appears to have adequate accuracy to substitute the use of a microscope where facilities allow. This study, therefore, underscores the urgent need for local surveillance schemes more especially at the grassroots in Uganda to provide data for reference guideline development needed for the control of trypanosomiasis in Uganda.Trypanosomes are the causative agents of animal African trypanosomiasis (AAT) and human African trypanosomiasis (HAT), the former affecting domestic animals prevalent in Sub-Saharan Africa. The main species causing AAT in cattle are  Trypanosoma species which are transmitted cyclically by the tsetse fly belonging to the Glossina spp. Animal African trypanosomiasis (AAT) affects a wide range of hosts, namely, goats, sheep, donkeys, and cattle. The disease is characterized by the presence of parasites in the blood and alternating fever [Animal African trypanosomiasis (AAT) is one of the most significant vector-borne diseases of domestic animals in the tsetse belt of Africa including East Africa . AAT is ng fever . Anaemiang fever . Animal ng fever . Therefong fever . Also, Ang fever , and becng fever .Trypanosoma congolense, Trypanosoma vivax, Trypanosoma evansi, Trypanosoma simiae, and Trypanosoma brucei brucei [Trypanosoma species infection in cattle is primarily spread through bites of infected tsetse flies found in over 37 African countries in Sub-Saharan Africa including Uganda [Stomoxys have also been implicated in the spread of AAT although they lack epidemiological significance [T. congolense, T. vivax, or T. b. brucei is characterized by fluctuating parasitaemia with periods of paroxysms and intermission. This leads to anaemia; the roughness of the hair coat, abortion, reduced milk yield, intermittent pyrexia, depression, and gradual loss of condition lead to extreme emaciation and death of the animal [In livestock, AAT is caused by i brucei . Trypanog Uganda . Other bificance . Severalificance . Illnesse animal .Trypanosoma parasites in blood either through a wet film system for detecting mobile trypanosomes or as thick and thin dried smears. Recently, with the explosion of new techniques, because of the rapid developments in molecular biology, new approaches and technologies can be used for diagnosis [Trypanosoma species [Diagnosis is an important factor in the controlling of infection. Several diagnostic techniques for trypanosomiasis exist; however, only a few tests have been objectively analyzed and standardized. Trypanosomiasis has traditionally been diagnosed using microscopy to directly observe the iagnosis . The use species .There are several methods for detecting trypanosomiasis in animals, including parasitological, immunological, and molecular methods , 16. Thi″N 32°54′00.0″E  in Northern Uganda [This study took place in Lira District, Uganda , which in Uganda . Lira Din = z2p (1 − p)/d2, where z is the Z score for 95%confidence interval = 1.96, p is the prevalence, and d is the acceptable error (5%). We used the prevalence of bovine African trypanosomes15.3% in Tororo District, southeastern Uganda [This study used a survey formula previously reported by Kish : n = z2pn = z2p  − p/d2, This was a cross-sectional study aimed at establishing the prevalence of Animal African trypanosomes in Lira District using two selected diagnostic methods. A simple random sampling technique was used to identify the study sites. Two hundred and fifty-four (254) animals were selected and assigned unique numbers for identification according to the village and farm that they came from. This study was carried out from March 2020 to April 2020.From each selected animal, the blood was collected from the jugular vein into vacutainer tubes containing EDTA and stored at 4°C in a cooler box and transported to the district laboratory for microscopy analysis and sample processing for molecular analysis. For molecular analysis, the blood from the vacutainer tubes was applied onto Whatman FTA cards and left to dry and then stored in sealed plastic bags at room temperature. To have higher chances of detecting parasites, blood sample collection was done in the morning .μl of whole blood was used to make thin and thick blood films. The blood films were allowed to air dry and then fixed in concentrated methyl alcohol for about 1-2 minutes followed by staining with 10% Giemsa for 25-35 minutes. The blood films were then washed with distilled water to remove the excess stain, and the slides were left to air dry before viewing under an oil immersion lens [For microscopy, 50 ion lens .μl of sterile water was added, and the tube incubated at 37°C for 30 min in a heating block. The tubes were then centrifuged at high speed (14000 RPM) for 1 minute, and the resulting supernatant was collected and discarded.DNA was extracted with slight modification as previously described by . A 6 mm μl aliquot of sterile water was added to the Whatman FTA card discs in the original tube and incubated at 100°C for 30 min in the heating block. After incubation, the sample was centrifuged at 14000 RPM for 1 minute. The supernatant was removed and stored at -20°C ready for PCR analysis.A second 100 μl reaction volume containing 1 gm of Taq , 1 μl of each primer (1 μM), 2 μl DNA sample, and double distilled water to a final volume of 25 μl. Trypanosoma brucei brucei reference DNA was used as a positive control, and nuclease-free PCR water was used as a negative template control. The cycling conditions that were used are as follows: first denaturation at 98°C for 1 min, denaturation at 98°C for 5 seconds, annealing at 64°C for 30 seconds, extension at 72°C for 30 seconds (25 cycles), and the final extension for 72°C for 10 mins [μg/ml ethidium bromide solution, and viewed using a UV illuminator and documented. The sequences of the primers used in the amplification and expected base pairs size of each Trypanosoma species are shown in PCR was performed with slight modification as previously reported by Njiru et al.  using a  10 mins . The PCRData were entered in Microsoft Office Excel 2007 and then exported to IBM SPSS version 20. Descriptive statistic was used to determine the prevalence and distribution of trypanosome species in the villages.The study was carried out according to the guidelines stated in the Kampala International University Research Ethics Committee Manual of 2017. Only animals whose owners consented were recruited into the study. All animals were handled under the considerations of the National Institute of Health guidelines for the care of animals with the help of a veterinary assistant.A total of 254 cattle from Acungkena, Barropok, and Acanakwo A subcounties were screened. Of these, 107 cattle were positive for trypanosomes by hematocrit centrifugation technique (HCT) . There wThe prevalence of trypanosomiasis according to microscopic results was 5/254 (2.0%) as compared to 11/254 4.3%) trypanosomiasis prevalence according to PCR analysis  and 3/9 (33.3%), respectively (T. vivax and mixed infection (T. congolense/T. vivax) showed 1/1 (100.0%) trypanosomiasis status in the normal and abnormal PCV ranges, respectively. Noninfected animals demonstrated 21/243 (8.6%) and 222/243 (91.4%) in the abnormal and normal PCV ranges, respectively , followed by T. vivax 1/11 (9.1%) and mixed infection of T. congolense/T. vivax1/11 (9.1%) . Barropok village had the highest proportion of trypanosomiasis with 6/11 (54.5%), followed by Acanakwo A village2/11 (18.2%) and Acungkena village 3/11 (27.3%) . Trypano1 (9.1%) .p < 0.05) between abnormal PCV and trypanosomiasis infection. This result also indicates that the animal with a PCV volume ≤ 29 is at risk of trypanosomiasis infection  as compared to 11/254 (4.3%) trypanosomiasis prevalence according to PCR analysis. The microscopic results of this study are comparable to reports elsewhere , 22, andTrypanosoma congolense was the most common Trypanosoma species with 9/11 (81.8%), followed by T. vivax 1/11 (9.1%) and mixed infection of T. congolense/T. vivax1/11 (9.1%). The high proportion of T. congolense 9/11 (81.8%) demonstrated in this study as compared to T. vivax 1/11 (9.1%) is in agreement with previous reports [Trypanosoma congolense is known to be the leading aetiology of trypanosomiasis of the salivarian livestock group that is highly prevalent in Sub-Saharan Africa and results into a huge negative impact on the economy on the affected countries where it is endemic [ endemic . This paT. congolense/T. vivax. The significantly low prevalence of 1/11 (9.1%) of mixed infection prevalence demonstrated is conformity with other previous reports [This study also showed a significantly low prevalence of 1/11 (9.1%) of mixed infection caused by  reports . The pre reports , 26, tho reports . The var reports .T. congolense species with the highest proportion of 9/11 (81.8%) among AAT disease complex in the Lira District, the current investigation revealed 1/11 (9.1%) and 1/11 (9.1%) proportions of T. vivax and T. congolense/T. vivax, respectively. This research further demonstrates that T. brucei brucei, T. vivax, and T. congolense are still present in livestock reservoirs in the broader Lango subregion, of the Lira District [Trypanosoma vivax, on the other hand, can be spread by a wide range of haematophagous insects. A high proportion of T. vivax has been reported in southwestern Uganda. Trypanosoma vivax is more difficult to manage than the other species since it has previously been known to be mechanically transmitted by haematophagous insects, making it difficult to control even in regions with intensive vector control strategies [T. vivax by hematophagous insects in southeastern Uganda has been documented on the doorstep of Lira District [T. vivax by haematophagous insects in Lira District.In addition to District . The AATrategies . A reporSeveral causes, including the gradual deterioration in state veterinary services, particularly due to adverse legislation, as well as insecurity in some parts of Uganda, may be contributing to the persistence of trypanosome infection in cattle . AcariciPolymerase chain reaction amplification demonstrated that Barropok village had the highest prevalence of trypanosomiasis with 6/11 (54.5%), followed by Acanakwo A village 2/11 (18.2%) and Acungkena village 3/11 (27.3%). Microscopy as well demonstrated the highest trypanosomiasis status in Barropok. This is of high concern; therefore, measures should be put in place to control the tsetse flies that transmit this infection as well as treat the infected animals.p < 0.05) demonstrating a statistically significant relationship between trypanosomiasis infection statuses with abnormal PCV range. The finding of this study is in agreement with other previous reports [Noninfected animals demonstrated 21/243 (8.6%) and 222/243 (91.4%) in the abnormal and normal PCV ranges, respectively. Most of the healthy animals had normal PCV ranges. This finding is comparable with studies done elsewhere . When PC reports , 31.Trypanosoma congolense was the most common trypanosome species with 9/11 (81.8%). Polymerase reaction amplification was the most reliable diagnostic method due to its high sensitivity and specificity as compared to the conventional microscopic method. Barropok village had the highest proportion of trypanosomiasis with 6/11 (54.5%). Polymerase reaction amplification appears to have adequate accuracy to substitute the use of a microscope where facilities allow. This study, therefore, underscores the urgent need for local surveillance schemes more especially at the grassroots in Uganda to provide data for reference guideline development needed for control of trypanosomiasis in Uganda.Polymerase reaction amplification demonstrated that the prevalence of trypanosomiasis in Acanakwo A, Barropok, and Acungkena villages in Lira District, Uganda, was 11/254 (4.3%).


Handful studies report the prevalence of cardiovascular disease (CVD) risk factors among medical students from India and none from the eastern part of the country.To estimate the prevalence of risk factors of CVD and their correlation with CVD risk ratio among the MBBS students from eastern India.433 students were studied. International Physical Activity Questionnaire-long form was used for assessment of physical activity and Perceived Stress Scale (PSS) to elicit psychological stress levels. Waist-to-height ratio (WHtR) was calculated. Total cholesterol to high-density lipoprotein ratio was calculated as the CVD risk ratio.R = 0.33, p < 0.001). 82.7% of the variance in CVD risk ratio could be explained by WHtR, Body mass index, Triglycerides and Low-density lipoprotein  = 296.085), of which LDL (β = 0.755) contributed the most.39.3% were women and 68.6% of the subjects were in junior classes. 22.4% subjects had high PSS while 30% performed low physical activity. Tobacco and alcohol intake was prevalent in 29.3% and 21.0% respectively. High CVD risk ratio was found in 14.3%. Most risk factors were more prevalent among juniors except diabetes. Among the non-overweight and non-obese subjects there was a significant positive correlation between WHtR and CVD risk score (High prevalence of different modifiable CVD risk factors revealed among the subjects in this study is concerning. WHtR appears promising as an independent early predictor of CVD risk in Indian population. A dedicated CVD risk assessment tool for the young population is necessary.The online version contains supplementary material available at 10.1186/s43044-021-00219-9. Cardiovascular diseases (CVDs) lead the causes of morbidity and mortality worldwide and more than 75% of Cardiovascular diseases related deaths occurs in low- and middle-income countries , 2. It iAtherogenic diet, sedentary lifestyle and ‘South Asian lipid profile’ are the most important behavioural risk factors for insulin resistance which leads to metabolic syndrome, diabetes mellitus, obesity and eventually Cardiovascular diseases .Long term Cardiovascular diseases risk in young adults can be strongly predicted by their risk factor profiles . The magUndergraduate medical students form a very important subset of young adults in any society since they are the forming elements of the future healthcare infrastructure. The stress associated with intense training in medical school and lack of physical exercise puts the students at higher risk of Cardiovascular diseases . VariousThe objective of the current study was to estimate the prevalence of risk factors of Cardiovascular diseases and their association with Cardiovascular diseases risk ratio among the undergraduate medical students of a tertiary care facility of eastern India.The study employed the descriptive, cross-sectional approach. Undergraduate medical students pursuing Bachelor of Medicine, Bachelor of Surgery (MBBS) course, who did not have known cardiovascular diseases, were recruited from 1 May 2019 to 31 July 2020. The students in 1st and 2nd year of their MBBS curriculum have been referred to as the junior students and those in 3rd and final years as senior students in the following text. Purposive sample size was calculated to be ≥ 385 to have confidence level of 95% so that the real values were within ± 5% of measured or surveyed value . All proAn anonymous, confidential, self-administered structured questionnaire was used which included their age, gender, year of education, family history of Cardiovascular diseases, tobacco intake and alcohol use. Tobacco intake or alcohol use was defined as history of regular or occasional tobacco or alcohol use respectively . Urban a2), normal body mass index (18.0–22.9 kg/m2), overweight (23.0–24.9 kg/m2), obese (> 25 kg/m2) /2.2) . The ranDiabetes was defined as fasting plasma glucose (FPG) ≥ 126 mg/dL where fasting was defined as no caloric intake for at least 8 h. In the absence of unequivocal hyperglycemia, diagnosis was done based on two abnormal test results from the same sample or two separate test samples .Statistical package for Social Science (SPSS) version 25  was used to analyse the data. Mean and standard deviation (SD) for continuous variables and percentages for categorical variables were calculated as part of descriptive analysis. Continuous variables were compared by Student’s t test while categorical variables were compared by Chi-square test. A p value of less than 0.05 was considered statistically significant. Associations were assessed using Chi-Square tests of association. Correlation between the cardiovascular risk factors was assessed by Pearson’s correlations. Multiple linear regressions were used to assess the extent of independent contribution of variables to the development of Cardiovascular diseases risk.433 undergraduate medical students were included of whom 263 were men and 170 were women. 68.6% of the subjects were in junior classes. 62.1% students belonged to urban population. Mean Triglyceride, Total cholesterol, low-density lipoprotein, waist circumference, diastolic blood pressure and cardiovascular risk ratio were significantly higher in men; mean high density lipoprotein was significantly lower in men. Baseline characteristics have been outlined in Table p 0.03). Approximately 30% of both men and women had low physical activity while none in the study reported of high physical activity. Tobacco and alcohol intake was significantly higher in men (39.2% and 31.6% respectively) than women (p < 0.001). High low-density lipoprotein (35.4%), triglyceride (39.2%) and total cholesterol (25.1%) were significantly more frequent in men while low high-density lipoprotein was significantly more frequent in women (30%) (p < 0.005). Diabetes was more prevalent among men (p = 0.01). High cardiovascular disease risk ratio was found to be significantly more common in men (19%) (p < 0.001). The gender wise prevalence is outlined in Fig. Significantly higher proportion of men (25.9%) had high perceived Stress Scale (PSS) than women 17.1%) (7.1% (p 0p < 0.05). Diabetes was more prevalent among seniors (p = 0.001). Similarly, increased waist-height ratio (WHtR) (52.9%), high low-density lipoprotein (33%), high triglyceride (38%), high total cholesterol (22.6%) were significantly more common among junior students (p < 0.05). The seniority wise prevalence is outlined in Fig. High Perceived Stress Scale 27.3%), low physical activity (36.4%), F/H of diabetes mellitus (DM) (33.7%), tobacco intake (35.4%), alcohol intake (24.9%), overweight (20.9%), obesity (57.2%) was significantly more common among juniors , high triglyceride and high low-density lipoprotein had significant association with high cardiovascular disease risk ratio as outlined in Fig. R = 0.19 (p < 0.001) across overall population. Among overweight and obese subjects there was no significant correlation (p = 0.6) while among the non-overweight and non-obese subjects there was a weak but significant positive correlation  as depicted in Fig. Waist-height ratio and cardiovascular risk score was weakly correlated with Pearsons’s The INTERHEART and INTERSTROKE study defined the impact of the 9 potentially modifiable risk factors  on cardiovascular disease and thus the approach to prevention of the same , 29. OurHigh perceived Stress Scale was noted in 22.4% of the subjects in this study. The study by Khan AAA et al. found stress to be present in 25.5% medical students and sadness or depression in 3.0%. Stress was detected in 22.5% of the Indian urban affluent adults aged 30–45 years in the study by Aeri et al. . The med29.6% of the students in this study had low physical activity. Physical activity was nil or occasional among 42.6% subjects in the study by Rustagi et al. . Paul B Family history of cardiovascular disease was present in 21% of the subjects. Family history of dyslipidemia and diabetes was also prevalent in 21.5% and 30.0% students respectively, these nearly similar proportions reflecting the fact that dyslipdemia, diabetes and cardiovascular disease are closely related and goes hand in hand. Family history of cardiovascular disease varied widely across the different studies done across the Indian subcontinent from 64.2% in the study by Paul B et al. to 8.1% in the study by Thomas A et al., 14.2% in the study by Nanjesh SK et al. and 12.0% in that by Kurian et al. , 31. 56.29.3% of the students were tobacco users which was significantly higher than the values reported in other Indian studies but similar to the data from 2 studies among Egyptian and Saudi Arabian students where smoking was practiced by 29.7%.and Croatian medical students where 30.4% were smokers , 30, 37.Alcohol intake was prevalent in 21.0% of the subjects which was nearly similar to the studies by Rustagi N et al. (28.8%) and Nanjesh SK et al. (27.0%) , 30. PauIntake of tobacco and alcohol were significantly more prevalent among men similar to other Indian data . But conMost of the students were overweight or obese in this study (70%) with the proportion being more in junior students (78.1%) which must be due to the sedentary habits, altered food habits in hostel, alcohol consumption and the covid pandemic induced alteration in lifestyle. Overweight and obesity were prevalent in medical students in other studies across the world as well (25–38%) but such high proportions are only reported by the studies by Mahmoud AE et al. and Ofori EK et al. where obesity was prevalent in 61.6% of the Saudi Arabian students and overweight or obesity were prevalent in 53.4% of students from Ghana respectively , 35, 37.Increased waist circumference was noted in 26.1% of the subjects, more prevalent in juniors (29.6%) which was higher than 23.0% reported from central Kerala and 15.2% from coastal city of Karnataka, reason probably being same as discussed above , 31.Unlike the other studies among medical students from India or abroad, this study analysed the Waist-to-height ratio and found it to correlate significantly with cardiovascular disease risk ratio, the strength of correlation increasing slightly when applied among non-overweight and non-obese subjects. As pointed out by Ashwell et al., high Waist-to-height ratio in subjects with “healthy” body mass index can be an indicator of ‘early health risk . Hence tWhile overweight and obesity were slightly more prevalent among men, increased waist circumference was significantly more prevalent among women in this study.High systolic blood pressure and diastolic blood pressure were noted in 18.5% and 13.9% subjects respectively. While high systolic blood pressure had nonsignificant gender-wise or seniority wise difference in prevalence, high diastolic blood pressure was significantly more common among men and juniors (66.3% of the juniors were men). This difference can be attributed to more smoking and alcohol consumption in men. The prevalence was similar to those found in studies by Paul B et al. and Kurian S et al. whereas, Nanjesh SK et al. and Thomas A et al. found negligible proportion subjects with high blood pressure , 31. IbrHigh low-density lipoprotein was observed in 29.3% subjects, high triglyceride in 33.9%, High total cholesterol in 19.2% which were also more prevalent in men and among junior students may be because bulk of junior students included in the study were men as discussed earlier. Low high-density lipoprotein was prevalent in 17.8% with female predominance. Hypercholesterolemia was present in 17.2% of the students in King Abdulaziz University, Jeddah, Saudi Arabia while dyslipidemia was reported to be present in 6.1% in another study on Egyptian and Saudi Arabian medical students , 37. TriPrevalence of high cardiovascular disease risk ratio did not differ between the two studies probably because of the higher prevalence of low high-density lipoprotein in the study from central Kerala . PrevaleIn the current study prevalence of high systolic blood pressure and diastolic blood pressure were noted in 18.5% and 13.9% subjects respectively with 5.5% subjects being known hypertensives. 13.4% subjects had high FPG, 4.4% were known type 2 diabetics and 1 was type 1 diabetic. 29.3% were tobacco users. High low-density lipoprotein, triglyceride, total cholesterol and low high density lipoprotein were noted in 29.3%, 33.9%, 19.2% and 17.8% respectively and 12.9% had known dyslipidemia. Large prevalence studies from Indian adults found hypertension to be prevalent in 10.6–39.0%, diabetes to be prevalent in 1.5%- 21.0%, high cholesterol to be present in 23.0–54.1%, smoking in 18.1–42.0% .In this study, correlation was noted between body mass index, waist to height ratio, triglyceride, low density lipoprotein and cardiovascular disease risk ratio. Similarly, Ofori EK et al. found strong correlations between low density lipoprotein and CVD risk ratio and moderate correlation between total cholesterol and cardiovascular disease risk ratio .Modification of QRISK2 including smokeless tobacco has been proven to be an important tool for cardiovascular disease risk stratification among Indians but the age group in QRISK 2 and QRISK 3 is 25–84 years , 40. TheAnother major limitation of the study was the comparison between two generation of students. Evaluation of the same population from junior to senior levels would have given clearer conclusion about the success of medical education and development of awareness. Multi-centre based prospective study including larger sample size comprising of undergraduates, interns, postgraduates would give a clearer idea regarding the cardiovascular disease risk factors among medical students in Indian subcontinent. One has to keep in mind that medical undergraduates may not represent the general youth. Covid-19 pandemic scenario may have affected the physical activity and mental stress of the students. Food habits, Lipoprotein (a), High sensitivity C-reactive protein, homocysteine, hemoglobin A1C, uric acid was not included in analysis.High prevalence of different modifiable cardiovascular disease risk factors revealed among the subjects in this study is concerning and needs implementation of screening programs, awareness initiatives and surveillance activities. Medical core curriculum should be modified in the direction of awareness and prevention. Regulatory and legislative actions for in-campus tobacco and alcohol use are required. Further research is warranted for the assessment of waist to height ratio (WHtR) as an independent early predictor of cardiovascular disease risk in Indian population and development of a cardiovascular disease risk assessment tool for the young population, given the steep rise of cardiovascular disease in young population across the globe.Additional file 1: Table S1. Gender-wise comparison of cardiovascular risk factors prevalence among students. Table S2. Comparison of cardiovascular risk factors prevalence among junior students and senior students. Table S3. Association of the baseline parameters with CVD risk ratio


Moreover, the collagen area in the fibrin with laminin-nidogen group was smaller than in the fibrin only group (p ˂ 0.05). The areas of myofiber formation in the fibrin only group (31.77 ± 10.81%) and fibrin with laminin-nidogen group (43.13 ± 10.39%) were larger than in the empty wounds . Fibrin-based constructs with laminin-nidogen reduce fibrosis and improve muscle regeneration in the wounded soft palate. This is a promising strategy to enhance cleft soft palate repair and other severe muscle injuries.This study aimed to analyze the effects of fibrin constructs enhanced with laminin-nidogen, implanted in the wounded rat soft palate. Fibrin constructs with and without laminin-nidogen were implanted in 1 mm excisional wounds in the soft palate of 9-week-old rats and compared with the wounded soft palate without implantation. Collagen deposition and myofiber formation were analyzed at days 3, 7, 28 and 56 after wounding by histochemistry. In addition, immune staining was performed for a-smooth muscle actin (a-SMA), myosin heavy chain (MyHC) and paired homeobox protein 7 (Pax7). At day 56, collagen areas were smaller in both implant groups (31.25 ± 7.73% fibrin only and 21.11 ± 6.06% fibrin with laminin-nidogen)) compared to the empty wounds (38.25 ± 8.89%,  Cleft lip and/or palate (CLP) is the most common congenital orofacial malformation with a worldwide incidence of 1:700 to 1:1000 live births each year . Around SCs are located between the sarcolemma and the basement membrane of the muscle fiber, and are surrounded by extracellular matrix (ECM) components including collagen type IV, glycoproteins and glycosaminoglycans ,10,11. LFibrin is a viscoelastic biomaterial with a variable stiffness that mostly depends on the concentrations of fibrinogen and thrombin . PlateleIn skeletal muscle, fibrin has been used to deliver cells, ECM components, and drugs into extensive muscle injuries ,24. ThesIn in situ tissue engineering, an acellular construct is implanted containing cues to attract local cells and guide their differentiation into the desired cell type . This in2/O2 protocol. The soft palates were dissected for histological analysis.A total of 104 male wistar rats, 9 weeks old and weighing 250–320 g, were randomized and used for the experiments . The animals were housed two per cage. All rats received food and water ad libitum and a dark/light cycle of 12 h each. After surgical wounding, the animals received powdered chow in water during three days in addition to the standard food. The animals were divided into four groups. Group 1 (W) received an experimental 1 mm excisional wound in the soft palate without implant (n = 32). Group 2 (WF) received an excisional wound and implantation of fibrin alone (n = 32). Group 3 (WFL) received an excisional wound and implantation of a construct of fibrin with laminin-nidogen (n = 32). Group 4 (C) was an age control at 56 days (n = 8) without an excisional wound. The rats were marked by ear punching. Eight rats of each experimental group were euthanized at days 3, 7, 28 and 56 by the standard CO2) under sterile conditions. Fibrinogen was reconstituted in 0.9% NaCl at 37 °C and filtered through a 0.2 μm filter. Thrombin was reconstituted in BSA 0.1% and mixed with CaCl2 4 mM (1:1). Aprotinin  was diluted in PBS and mixed with the fibrinogen solution (1:1). The fibrin construct had final concentrations of 5mg/mL fibrinogen, 100 μg/mL aprotinin, 2.5 U/mL thrombin and 1 mM CaCl2 in PBS buffer. Fibrin constructs were prepared by mixing fibrinogen , thrombin , aprotinin  and calcium chloride  was added to an adjusted fibrin mixture to a final concentration of 100 µg/mL. The laminin-nidogen complex contains the laminins LN111 and LN211 also present in the basal lamina of the skeletal muscle tissue . The conPresurgical and perioperative analgesia was provided as described . In shorThe excisional wound was made as previously described . In brieThe soft palate in rats is about 1mm thick including two outside mucosal layers with skeletal muscle and salivary glands in between . A totalReversion of the anesthesia was obtained by atipamezole  1.25 mg/kg injected subcutaneously (0.1 mL/100 g). The animals were placed in a pre-warmed cage and monitored for respiratory arrest and postoperative bleeding. During the next three days after surgery, weight loss, dehydration and activity were followed up for each animal. Post-operative analgesia with carprofen  was provided in the drinking water. The soft palate of the rat was dissected as described previously . In shor2O2 3% in methanol for 20 min to destroy endogenous peroxidase. After rehydration, the sections were post-fixed in formalin 4% in PBS for 10 min. For MyHC antigen retrieval, the sections were immersed in TRIS/EDTA buffer pH 9.5, heated at 100 °C for 10 min and cooled down at room temperature. For α-SMA antigen retrieval, sections were immersed in TRIS/EDTA buffer pH 5.8, heated at 100 °C for 10 min and cooled to room temperature. For Pax7 antigen retrieval, citrate buffer pH 5.8 heated at 70 °C was used followed by trypsin treatment (0.075% in PBS at 37 °C for 5 min). The blocking was undertaken using normal donkey serum 10% in PBS plus glycine 0.075% (PBSG) for 30 min. Then, sections were incubated overnight at 4 °C in the primary antibodies , mouse anti-fast MyHC , mouse anti-Pax7 ). At the next day, the sections were rinsed with PBSG and incubated with a biotinylated secondary antibody donkey-anti-mouse IgG (H + L) . Finally, the sections were incubated in biotinylated horseradish peroxidase-avidin complex for 45 min  and the detection was with 3,3-diaminobenzidine substrate for a maximum of 10 min. Azocarmine G and aniline blue (AZAN) staining was used to differentiate connective tissue (blue) and muscle (red). Immunohistochemistry was used to detect myosin heavy chain (MyHC), alpha-smooth muscle actin (α-SMA) and paired box protein7 (Pax7) as described . In summ2. All stained sections were automatically scanned using a Pannoramic1000 scanner  with an AdimecQ camera  at standard settings. Digital images were visualized using CaseViewer-2.3  and exported as TIFF files. For each image, the regions of interest (ROI) were determined as described . In shorwww.graphpad.com) (accessed on 24 August 2021). For all parameters, p values less than 0.05 were considered significant.The stained areas in the different groups were compared by a two-way ANOVA and a Bonferroni post-hoc test. At day 56 the experimental groups were also compared with the age control group by a one-way ANOVA and a Bonferroni post-hoc test. The statistical analysis and the graphs were made in GraphPad Prism version 5 . There were no prolonged bleedings and no signs of infection. In the two days after surgery the rats lost less than 15% of their body weight pre-surgery, which had recovered by day five. The body weight in the experimental rats at day 56 was not different from the age control.The normal soft palate of the rat contains a pseudostratified respiratory epithelium at the nasal side and an epithelium that is keratinized and stratified at the oral side A,C. In bp ˂ 0.05) and the wounds with fibrin plus laminin-nidogen . All these areas at day 56 were higher than the age control, p ˂ 0.05. The muscle area was measured at the same timepoints (p ˂ 0.05). All the muscle areas were lower than the age control, p ˂ 0.05.The role of fibrin constructs on collagen deposition was measured as a marker of fibrosis. The collagen area was quantified in the samples stained with AZAN at days 3, 7, 28 and 56, and expressed as percentage of the total area B. The comepoints C. The mu2 (p < 0.05). By days 7 and 28, the muscle areas in the wounds treated with fibrin-only (WF) and WFL increased over time, and both were higher than in the control wounds W (p ˂ 0.05). At day 56, the muscle area in the WF group (31.77 ± 10.81%) was lower than in the WFL group (43.13 ± 10.39%) but higher than in the control wounds W (28.10 ± 11.68%) (p ˂ 0.05). The muscle areas in all experimental groups were smaller than in the age control . We also performed a MyHC immune staining to visualize specifically the layer of muscle fibers (brown) A. A clea2 B. The arp ˂ 0.05). At days 28 and 56 the stained areas had decreased to about 5% in all experimental wounds (p ˂ 0.05) without significant differences between the groups. The α-SMA (brown) staining detects myofibroblasts as well as vascular smooth muscle cells in blood vessels and myoepithelial cells of salivary glands but these latter two were excluded from analysis A. A highp ˂ 0.05). At day 7, the number of Pax7-positive SCs in the WF group (99.0 ± 36.87) and WFL group (96.90 ± 25.13) was higher than in the control wounds (W) (73.33 ± 21.04) (p ˂ 0.05). At days 28 and 56, the number of positive cells in the experimental groups was not different from each other and from the age control (C) (The paired homeobox protein 7 (Pax7) is a marker of SCs and is shown in brown A. In thetrol (C) B. This study aimed to evaluate the effects of fibrin constructs with or without laminin-nidogen on fibrosis and myofiber regeneration in the wounded soft palate. As a measure for fibrosis, we analyzed collagen deposition as well as the presence of myofibroblasts. To evaluate muscle regeneration, we analyzed muscle quantity and the numbers of Pax7-positive satellite cells. Generally, our findings show that the implantation of fibrin enhanced with laminin-nidogen improves the regeneration of the soft palate by limiting fibrosis and stimulating myofiber formation. Fibrin has been applied to wounds in different forms such as micro and nanoparticles, nanofibers, microtubes, sealants and hydrogels . The eleOur findings show that, in the control wounds, the muscle layer was mainly replaced by collagenous tissue indicating fibrosis. This confirms our earlier findings in this rat model . SeveralIn our study, fibrin alone as well as fibrin with laminin-nidogen show reduced collagen deposition in the wounds. This effect is remarkable as fibrin is a main component of the normal blood clot that forms after injury . In an uSimilarly, in a nidogen-1 deficient mouse model, alteration of the laminin distribution, impairment of the basement membrane structure, and an increase of α-smooth muscle actin levels was found . Nidogenmdx mice that also have a mutation in myostatin show increased myofiber formation similar to wildtype mice [The reduction of fibrosis by laminin-nidogen alone might already allow more efficient myofiber formation. However, also direct specific effects of laminin-nidogen on myofiber formation may also contribute. In vitro binding assays showed that the binding of laminin to myostatin inhibits its activity, which increases myofiber formation . Myostatype mice . In immuype mice . Moreoveype mice . All thiAdditionally, nidogen may stimulate myofiber formation as observed in studies using C2C12 myoblasts ,55. In vThe function of the soft palate decreases after surgical palatal injury as shown by electromyography (EMG) in rodents and humans ,60. ThisAn additional finding from the current study was that the salivary glands in the wounds treated with the fibrin constructs regenerated faster than in the control wounds. In the control wounds, the acini seemed to be smaller or absent and the ducts enlarged. In contrast, the fibrin constructs-treated wounds showed a complete layer of salivary glands. The regeneration of salivary glands mainly depends on multipotent epithelial progenitor cells that differentiate into α-SMA-positive myoepithelial cells, and the cells that form the acini and the ducts . Acini aThe implantation of fibrin constructs with laminin-nidogen reduced fibrosis and stimulated muscle and salivary gland regeneration in our in vivo model for palatal fibrosis and regeneration. The use of enhanced acellular fibrin constructs might be more efficient and cost-effective than constructs with isolated cells. This seems to be a promising strategy to improve soft palate regeneration after cleft palate surgery. Similar strategies might be employed to improve the regeneration of other severely injured skeletal muscles.