This study aimed to explore the mental wellbeing profiles and their related factors among urban young adults in Vietnam.A cross-sectional study was conducted in Hanoi, which is the capital of Vietnam. There were 356 Vietnamese who completed the Mental Health Inventory-5 (MHI-5) questionnaire. The Latent Profile Analysis (LPA) was used to identify the subgroups of mental wellbeing through five items of the MHI-5 scale as the continuous variable. Multinomial logistic regression was used to determine factors related to subgroups.Three classes represented three levels of MHI-5 score, which included “Poor mental health,” “Fair mental health,” and “Good mental health,” were, respectively, 14.3, 46.6, and 39.0%. Compared to a low household economy, participants with an average household economy had 2.11 and 4.79 times higher odds of being in a good mental health class relative to fair and poor mental health classes. Respondents with more than two acute symptoms had 3.85 times higher odds of being in a good mental health class relative to a poor mental health class, as compared to those without acute symptoms. Regarding the measurement of the Perceived Social Support Scale (MSPSS), people having support from their family had 1.80 and 2.23 times higher odds of being in classes of fair and good mental health relative to the poor mental health class; and participants having friend support also had 1.87 times higher odds of being in a good mental health class compared with the fair mental health class, as the MSPSS score increased by 1 unit. People with Rosenberg’s self-esteem scale increased by 1 score, those who had 1.17, 1.26, and 1.47 times higher odds of being in a good compared to fair mental health class, fair compared to poor mental health class, and good compared to poor mental health class, respectively.Our findings were given to promote a new classification method for mental health screening among the general population. The current findings could be used as evidence to develop policies and plans that focus on encouraging early screening for mental health problems among the general young population in the future. The World Health Organization (WHO) defines mental health as “a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community” . Mental Nowadays, various screening tools have been developed to assist in detecting psychological and psychiatric problems. These tools were mainly based on the principles of symptom scoring and had good sensitivity to detect signs of poor mental health. Some of these could be completed in only a few minutes with 20 to 30 items, even shorter instruments, but showed good performance to detect mental health problems . The MenIn a large cohort of the surveyed population, it was likely that different profiles of mental levels existed, which means individuals were classified into the same mental health classes. A previous study regarding mental screening among American adolescents showed three latent classes included flourishing mentally healthy, moderately mentally status, and languishing status . Those wThe study was designed as a cross-sectional investigation of the young Vietnamese population from May 2020 to September 2020. A research facility was established at the Institute for Preventive Medicine and Public Health, Hanoi Medical University, which was implemented to collect voluntary participants.Participants were recruited following the inclusion criteria: (1) aged 18 to 25; (2) currently living in Hanoi, Vietnam; and (3) willing to sign informed consent and engage in the research. Exclusion criteria included: (1) participants who got serious illnesses; and (2) could not answer questions. The study used both methods of random and convenience sampling, with a completion rate of approximately 100%. During the data collection period, once participants agreed to participate in this study by signing informed consent, a face-to-face interview was conducted for 20–25 min by investigators who were well-trained to use questionnaires. Additionally, the interview took place in a closed room, to ensure privacy and limit outside influences.We used the registrar’s database of all currently enrolled students at Hanoi Medical University in 2020, with approximately 6,000 students and 1,000 graduate or professional students. A preliminary list was established based on the simple random sample selection, with 10% of students and 20% of graduate/professional students aged 18 to 25 living in Hanoi, Vietnam. Therefore, 600 students and 200 graduate or professional students were collected for the preliminary list. There were 80% of students and 90% of graduate/professional students who had phone numbers. A phone message about the study and a participating invitation would be randomly sent to people on the preliminary list. Approximately 20.8% of students and 55.5% of graduate/professional students responded that they could participate in our study. Those were invited to the research facility and conducted a face-to-face interview. Before starting the interview, participants would be given a written consent form to sign if they decided to participate. There were three research assistants who conducted the direct interviews. As a consequence, the study sample size was collected from a preliminary list of 200 participants, including 100 undergraduates and 100 graduate/professional students. To expand and diversify the study sample, after finishing the interview, we requested participants invite others, such as friends or relatives, to participate in the survey. As a result, the present study recruited a further 156 people from the initial group. A total of 356 participants were recruited for our study.To collect data, a semi-structured questionnaire consisting of seven main components was developed, including (1) socio-demographic characteristics; (2) alcohol consumption; (3) health conditions; (4) General Self-efficacy scale; (5) Multidimensional Scale of Perceived Social Support scale; (6) Rosenberg Self-Esteem scale; and (7) Mental Health Inventory scale. Before collecting data, this questionnaire was piloted on 10 people of different genders, ages, and occupations to secure the text and logical issue of each question and modify the question with unclear meaning.Respondents answered questions including gender , age , education level that participants completed (high school or lower/tertiary and upper), marital status (single/married), job (students/others), and household economy (low/average/high).We used the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scale to evaluate the alcohol consumption of participants. The AUDIT-C scale has been used in many studies in Vietnam. Moreover, the Vietnamese version of this tool was also validated elsewhere , 2014. TTo explore information about acute symptoms and chronic diseases that participants experienced, two questions were developed, including (1) “Have you ever been experienced any acute symptoms during the last 4 weeks?” (Yes/No), and (2) “Have you ever been diagnosed with any chronic diseases during the last three months?” (Yes/No). If participants indicated “yes” to the above question, they were then asked to self-report their symptoms or conditions. These acute symptoms could include headaches, backaches, allergies, constipation, coughs/sore throats, sneezes/runny noses, fever, helminth infections, diarrhea, gynecologic diseases, skin diseases, eye diseases, etc., that they experienced in the last 4 weeks and chronic diseases they experienced in the last 3 months. The chronic diseases consist of hypertension, cardiovascular disease, diabetes, cancer, asthma, epilepsy/psychiatry, stomach/digestive, chronic obstructive pulmonary disease, etc.A 10 items of the GSE are created to assess a general sense of perceived self-efficacy with the aim in mind to predict coping with daily hassles as well as adaptation after experiencing all kinds of stressful life events. For each item, a four-point Likert scale is used, ranging from 1  to 4 (exactly true). The total score of GES is calculated by summing all items. After calculating, the score ranged from 10 to 40, with a higher score indicating more self-efficacy . FurtherIt is a self-reported measure of subjectively assessed social support. The MSPSS consists of 12 items that are divided into three subdomains . Each item is measured by 7 Likert points from 1 (very strongly disagree) to 7 (very strongly agree) . The totA 10-item scale that measures global self-worth by measuring both positive and negative feelings about oneself. Items 2, 5, 6, 8, and 9 are used to measure negative feelings, while other items are utilized to assess positive feelings about A 10-item scale that measures global self-worth by measuring both positive and negative feelings about oneself. For negative items, a four-point Likert scale is used, including 1-strongly agree, 2-agree, 3-disagree, and 4-strongly disagree. Meanwhile, the options for positive items are reversed, ranging from 1-Strongly Disagree, 2-disagree, 3-agree, and 4-strongly agree. Finally, the total score of all items is calculated, with a higher score indicating higher self-esteem . The RosMHI-5 is considered a simple and valid instrument to detect depressive symptoms among the general population . This scLatent Profile Analysis is a type of categorical latent variable modeling that focuses on identifying latent subpopulations within a population based on a collection of factors . LPA hasp-value (p < 0.05) showed that a k-class model fitted better than the (k-1) – class model  < 0.05 was considered statistically significant.Both descriptive and analytical statistics were used to address the main aims of the study by STATA version 16. Continuous variables were presented as mean and standard deviation (SD), while categorical variables were presented as frequency with percentage. Descriptive, analytical statistics and multinomial logistic regression between all variables were calculated using STATA version 16 . We used Kruskal-Wallis tests for continuous variables and χThis study was ethically approved by the Institutional Ethical Review Board at Hanoi Medical University on March 13, 2020. Informed consent would be supplied to participants before starting the study. People would sign the written consent if they decided to participate. Participation was completely voluntary; they could feel free to decline to join for any reason. Even after signing the consent form, they could also stop participating in this project at any time or refuse to answer any individual questions. Collected data was saved in a secured system and served for study purposes only.A study sample consisting of 356 participants with a mean age of 22.03 (SD = ± 3.21) was assessed for mental health status by using the MHI-5.p < 0.05, which was the most appropriate model.In p < 0.05. Similarly, the mean score of the General Self-efficacy Scale and the Rosenberg Self-esteem Scale also show a higher value in the good mental health class than in the two remaining classes. These differences were also statistically significant (p < 0.05).p < 0.05) and a poor mental health class .In Furthermore, the odds ratio for participants with more than two acute symptoms was 0.26 , indicating that those had 3.85 times higher odds of being in a good mental health class relative to a poor mental health class, as compared to those without acute symptoms.Regarding the measurement of the perceived social support scale, people who received higher support from their family had a higher odds ratio of being in fair and good mental health classes about 1.80 times  and 2.23 times  than in poor mental health class.Similarly, participants who received the highest support from their friends were more likely in the good mental health class compared to the fair mental health class by 1.87 times .Related to Rosenberg’s self-esteem scale, participants have 1.17, 1.26, and 1.47 times higher odds of being in a good compared to fair mental health class , fair compared to poor mental health class , and good compared to poor mental health class , as Rosenberg’s self-esteem score increased by 1 unit.The current study was considered the first work in Vietnam using the LPA approach to explore unobserved subgroups of the mental health status of the young population. Our findings determined three latent subgroups based on the MHI-5 score from the study samples. The majority of respondents were classified as having fair mental health (46.63%), while those who were assessed as having poor mental health accounted for the smallest proportion . Notably, receiving family and friend support  was significantly related to having better mental health than the other groups. Moreover, it was the same case with the high individual’s self-esteem score as well as the household income aspect, which was at an average level compared to other groups. People with more than two acute symptoms, on the other hand, saw their mental health get worse in a big way.In detecting mental health issues, the MHI-5 was proved to be the comprehensive and commonly used General Health Questionnaire . This meLikewise, people with higher Rosenberg self-esteem scores are more likely to be in the better mental health groups, according to the current findings. In 2001, Richard et al. indicated regulation of emotional states was affected mainly by self-esteem . People One of the notable results was that participants who experienced more than two acute symptoms had a significant association with deteriorating mental health. Previous studies indicated the inverse association between acute diseases and mental illnesses such as stress, anxiety, depression, etc. These issues often occur when people are hospitalized with severe illnesses. The health status of those with more mental illness tended to deteriorate during and after hospitalization . The sysOur findings demonstrated several implications that could be helpful to improve mental health status based on the discussed evidence. First and foremost, our results reflected the MHI-5 score, which corresponded to the middle and poor mental health classes among the study population. Thus, raising optimal mental health as well as health-related quality of life was presented with the warning need to further study and expand mental healthcare aspects. Second, the risk factors lead to mental illness prevention needed to address (1) general community education related to mental problems and prevention; (2) improved approaches and care for the high-risk groups; and (3) emphasis on limiting access to high-risk factors causing mental illness from the analyzed study, such as acute diseases, economic problems, and lack of social support. Third, we further posited that approaching mental problems based on the LPA analysis would explore the following implications: (1) social-supports played an important role (particularly with family & significant others) in mental health, thus, it was necessary to increase an intimate connection between individuals, families, and communities; (2) people with higher Rosenberg self-esteem scores were found to have better mental health status, so future intervention strategies may refer to our findings for comprehensive effectiveness; and (3) policies development to promote and improve the mental health in the general community and strengthen the health care system.This study provided a valuable picture of the mental health of the general population and specifically young people in Vietnam. However, the findings of our study also entailed several limitations and sources of bias. First, no causal conclusions could be drawn because our research used a cross-sectional study. Second, a lack of participation on the part of those respondents who were identified as having mental problems was probably caused by selection bias. This would be challenging to prevent because participants attended voluntarily and there was no effort to access the mental patients. Third, the majority of participants were female (72.1%) and students (89.6%), so the study sample was non-representative of urban young adults in Vietnam. Moreover, we were not able to get a larger and more complete sample due to participants recruited during the outbreak of COVID-19. Hence, future research needs to extend the sample collection and ensure the representation of the study population. Hence, future research is needed to extend the sample collection. For future research, it would be helpful to consider the social-ecological effects of using the MHI-5 scale to evaluate the general Vietnamese population, especially the loneliness scores, which could be used to help formulate policies to improve mental health in the community.We found substantial evidence that the variables including self-esteem, perceived social support, and household economy on average are associated with higher profiles of mental health status. The impacts of acute symptoms on mental health outcomes were still insufficient, but our findings showed evidence that greater acute symptoms are related to more mental problems. For this study, evidence was given to raise awareness of mental health in the community and develop policies to promote social support and strengthen the general health care system.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Ethical Review Board in Hanoi Medical University, Vietnam. The patients/participants provided their written informed consent to participate in this study.TTPN, TV, HD, GV, CL, BH, RH, and CH: conceptualization. TTPN, TTN, VD, and AT: data curation. TTPN, TTN, and VD: formal analysis. TTPN, TV, HD, CL, BH, RH, and CH: methodology. TTPN, TV, HD, GV, and AT: supervision. TTN and VD: investigation. TTPN, TTN, VD, and GV: writing – original draft. TTPN, TTN, VD, TV, HD, GV, AT, CL, BH, RH, and CH: writing – review and editing. All authors contributed to the article and approved the submitted version.


Melosittacus undulatus). Here, we sought to examine whether yawning was contagious among juvenile common ravens (Corvus corax). By observing two small and undisturbed captive groups, we also assessed the contagious nature of other frequently observed and potentially contagious behaviors: stretching, scratching, and shaking. Overall, we found no evidence for behavioral contagion. Given the limitations to the observational methods, however, we suggest future experimental research be conducted to support these findings.Research suggests that contagious yawning evolved to synchronize activity and vigilance within groups. To date, yawning has shown to be contagious in a wide range of mammalian species, including humans, great apes, some monkey species, domesticated dogs and pigs, wolves, lions, and rats. However, yawn contagion has only been previously documented in one bird species: budgerigars (Corvus corax), across two groups. Using observational methods, we also examined the contagiousness of three other distinct behaviors: stretching, scratching, and shaking. A total of 44 20 min observations were made across both groups, including 28 in the morning and 16 in the afternoon. The time and occurrence of all the behaviors from each bird were coded, and the temporal pattern of each behavior across both groups was then analyzed to assess the degree of social contagion. Overall, we found no evidence for contagious yawning, stretching, scratching, or shaking. However, yawns were relatively infrequent per observation (0.052 ± 0.076 yawns/bird) and thus experimental methods should be used to support this finding.The overt and reflexive matching of behaviors among conspecifics has been observed in a growing number of social vertebrates, including avian species. In general, behavioral contagion—such as the spread of yawning—may serve important functions in group synchronization and vigilance behavior. Here, we performed an exploratory study to investigate yawn contagion among 10 captive juvenile ravens ( The overt and reflexive matching of behaviors among conspecifics, also referred to as behavioral contagion , is commPerhaps the exemplar of contagious behavior is yawning. In humans, seeing, hearing, or even thinking about others yawning triggers contagion ,18,19. AMelopsittacus undulatus). An initial observational study found that yawns were temporally clustered in a captive flock, and that the clumping of yawns could not be explained by circadian factors [To date, the only evidence for contagious yawning in a non-mammalian species is in budgerigars ( factors . A subse factors . To our Corvus corax). Ravens are a moderately social species, with non-breeders regularly forming groups during foraging and roosting [One avian species that has been of particular interest in behavioral research is common ravens , housed at Haidlhof research station , were used for this study. All individuals were juvenile, non-breeding, approximately 2 years of age, and had been living in this flock for 2 years. The birds were hand-raised socially, i.e., together with peers, and thus, just like in nature, their development was social, which should have facilitated behavioral contagion, if present. The study was conducted between March 2014 and June 2014. The birds were housed in an outdoor aviary , fed twiOn each testing day, the subjects were separated into 2 groups for better observation. We grouped the birds according to their social relationships to avoid stress during the observations, though this resulted in unequal numbers . The two groups remained consistent in all cases but one, where we were unable to separate one bird for testing. Once separated, the groups were kept split in two adjacent outdoor aviary compartments during all observation periods, and then reunited at the conclusion of testing each day. While there was some visual access between the two groups, this was mostly obscured. Approximately 1/3 of the barrier between the groups was opaque, and the remaining 2/3 consisted of two wire-mesh barriers with 2.5 m of separation see .We performed observations of the undisturbed groups to characterize any natural behavioral patterns of yawning, stretching, scratching, and shaking. The observations took place with two human observers seated in front of the aviary with a Canon HF-20 HD-Recorder . A total of twelve testing sessions were performed, which included two distinct 20 min observations of each group, though one testing session had to be excluded due to heavy rain, which caused the ravens to hide in the back area of the aviary. From the remaining 11 testing sessions, 7 took place in the morning and 4 in the afternoon. Each testing session lasted 90 min and consisted of four separate behavioral observations, with each observation lasting 20 min. The first two observations from each testing session were successive; the first was conducted on Group 1 and the second was conducted on Group 2. A 10 min break then followed before two additional successive observations were performed, again, with the first on Group 1 and the second on Group 2. Thus, all observations were independent. Morning observations took place from 9:00 to 11:30 h and afternoon observations took place between 15:00 and 18:30 h. During observations, all the birds were video recorded, and the behavioral data were coded instantly on a sheet, since the enclosure size and the positioning of the seating branches did not always allow the camera a complete view of each individual.Video data were transferred to a computer and analyzed using video software (VLC Mediaplayer). A.B.S. and M.A.Ü., who both received training to recognize each behavior beforehand, coded each session together for the time and occurrence of all behaviors. Since the behaviors of interest were clearly defined and very straightforward to observe, we did not have any drift in the identification of behavior. No inter-rater reliability statistics were conducted, since all behaviors were rated in the presence of both observers, with consensus. A description of each of the behaviors is provided in First, the overall frequency of each behavior was calculated per bird and then separately, across the morning and afternoon observations. To assess potential differences in these frequencies between the morning and afternoon testing sessions, as well as between males and females, we ran a Generalized Linear Mixed Model (GLMM) with a logit link function in R-studio , using tThe analyses of contagion followed similar methods to Miller et al.   and frequencies of occurrence were binned into 30 s intervals based on the previous work on budgerigars—work which indicated that there would be a higher chance of witnessing contagion when bins were extended to this timeframe . If yawnZ-scores are normally distributed, with negative values indicating a greater degree of temporal clustering or clumping , while positive values indicate a greater than expected level of dispersion. A total of 48 behavioral observations had to be removed due to a behavior being completely absent—spread across yawning (31), stretching (12), scratching (4), and shaking (1).Next, patterns of contagion were more closely examined by investigating whether behavioral runs occurred with a greater frequency than would be expected by chance. Each 20 min observation was broken into forty 30 s bins, and the frequency of each behavior was determined in a similar fashion to Miller et al.  and Massp-values were two-tailed, and alpha was set to 0.05 in all analyses.Lastly, a combined probability test was performed by hand, as described by Sokal and Rohlf  (pp. 778n = 23), followed by stretching (n = 157), scratching (n = 177), and shaking (n = 298) . The random effects from the GLMM are reported in A total of 655 targeted behaviors were observed across the 44 20 min observations. Yawning was by far the most infrequent behavior (n = 298) . Per 20 n = 298) , though X2(24) = 15.504, p = 0.905). Similar effects were observed for each of the other three behaviors. Only 2/24 (8.33%) observations for stretching showed significant clustering, and a combined probability test revealed that the degree of clustering across all observations was not significant (X2(48) = 28.698, p = 0.988). Just 1/31 (3.23%) observations for scratching showed significant clustering, with the combined probability test revealing no significant effect (X2(62) = 29.483, p = 0.999). Lastly, 3/41 (7.32%) observations for shaking showed significant clustering. Again, a combined probability test revealed that, across all observations, the degree of clustering for shaking was not significant (X2(82) = 61.911, p = 0.952).Overall, each of the four behaviors was relatively evenly distributed over time across the distinct morning and afternoon observations see . The comTo test whether the limited clustering we observed was specific to a single time interval (30 s), this analysis was also re-performed when parsing the data into twenty 60 s bins. However, these subsequent results were highly similar, again, showing no evidence for contagion see . DiffereThis study represents the second attempt to measure contagious yawning and stretching, and the first attempt to measure contagious scratching and shaking, in a species of bird. Despite prior studies reporting various forms of behavioral contagion among ravens ,46, the In addition to addressing behavioral contagion, the current findings also provide the first account of the naturalistic frequency of these behaviors in this species, albeit among small groups in captivity. The observational data collected here suggest that in each hour, ravens yawn 1.6 times, stretch 10.7 times, scratch 12.2 times, and shake 20.3 times, on average. However, there was large individual variability in the expression of these behaviors . YawningThe absence of yawn and stretch contagion in ravens is also in contrast to observational and experimental studies in budgerigars ,37. HoweTogether, these conflicting comparative findings cast doubt on the purported link between contagious yawning and emotional contagion  and suggGiven the inherent limitations of observation research, experimental methods should be performed in the future to support the null findings for contagion effects. In particular, the overall occurrence of yawning was quite low, limiting the ability to effectively analyze the social influence of this response. Generally, we cannot rule out that our sample size, though large by the standards of ravens in captivity, was too small to detect a significant effect. To a lesser extent, the same issue could have applied to all the other behaviors as well (though the frequencies for these were much higher). Future experimental research could also examine different time scales at which subsequent behaviors should be considered contagious. Due to the outdoor aviary, there were influential factors to be considered: throughout the observational study, the temperature was not constant, and this is known to influence yawning in birds ,78. ParaOverall, this study represents the second attempt to measure contagious yawning in birds. The temporal analyses presented here do not suggest the presence of contagious yawning, nor any of the other behaviors measured. Given the low frequency of yawning and the limitations of observation research, experimental setups are needed to confirm and clarify these findings, i.e., by using live birds or video recordings as a target stimulus. Nonetheless, this study revealed novel effects with respect to the naturalistic frequency and circadian variation of some everyday behaviors in juvenile common ravens.


Recurrent implantation failure (RIF) and recurrent pregnancy loss (RPL), collectively referred to as recurrent reproductive failure (RRF), are both challenging conditions with many unanswered questions relating to causes and management options. Both conditions are proposed to be related to an aberrant endometrial microenvironment, with different proposed aetiologies related to a restrictive or permissive endometrium for an invading embryo. The impressive regenerative capacity of the human endometrium has been well-established and has led to the isolation and characterisation of several subtypes of endometrial stem/progenitor cells (eSPCs). eSPCs are known to be involved in the pathogenesis of endometrium-related disorders (such as endometriosis) and have been proposed to be implicated in the pathogenesis of RRF. This review appraises the current knowledge of eSPCs, and their involvement in RRF, highlighting the considerable unknown aspects in this field, and providing avenues for future research to facilitate much-needed advances in the diagnosis and management of millions of women suffering with RRF. The endometrium is a highly dynamic, complex, and critical organ for successful human reproduction . A multiRecurrent reproductive failure (RRF) encompasses two separate but related conditions, recurrent implantation failure (RIF), and recurrent pregnancy loss (RPL) ,5,6,7. REndometrial glands are essential for the establishment of a pregnancy, with glandular topography and secretions integral to embryo attachment, and thus, are vital for the subsequent establishment of the decidua ,42,43,44Although evidence is now emerging on the possible link between non-eSPCs and RRF, little is known about the resident eSPCs and their association with these pathologies ,70. EvidThis review sought to examine and summarise the current knowledge base for eSPCs and their potential involvement in RRF, to identify important voids in the literature, and to highlight avenues for future research.Non-resident endometrial SPCs (including BMDMSCs) and non-endometrial MSCs  are other additional stem cell populations that have been previously explored in relation to endometrial regeneration , and lieAn extensive literature search was performed across multiple databases, including PubMed, Web of Science, EMBASE, and Scopus, and spanned publications from inception to February 2022. Studies were selected using keywords associated with eSPCs, RRF, RIF, and RPL. Additionally, all references cited within other relevant publications were screened. Publications related to all keywords were included, and this included both human and animal studies.The remarkable regenerative capacity of the endometrium is widely believed to arise from SPCs residing within the deeper basalis layer, which remains intact following menstruation and the menopause ,76,77,78Since the existence of endometrial adult stem cells (ASCs) was first postulated ,75, much+ platelet-derived growth factor receptor beta (PDGFRβ+) [+), as specific markers for their enrichment [+ cells and not the rest of the stromal fraction, and thus has been proposed as a marker for eMSCs located in the endometrial basal layer [+ cells  are found to increase during the proliferative phase, suggesting their involvement in regeneration of the functional stroma [+ cells confirming their perivascular phenotype [Work identifying endometrial stromal ASCs ) was first initiated by Gargett and colleagues, who examined cells displaying higher clonogenic colony-forming capacity in vitro . EndometPDGFRβ+) ,102 and richment . More real layer . SUSD2+ l stroma . They arl stroma . Their lhenotype ,96,104.+ epithelial eSPCs show higher telomerase activity and longer telomere lengths, a greater propensity to generate spheroids in 3D cell culture, and low expression of steroid hormone receptors [+ and N-cadherin+ endometrial epithelial cells in full thickness endometrium, Nguyen et al. have proposed that there is a spatial relationship between the two cell types, with SSEA-1+ cells located closer to the basalis–functionalis interface, whilst N-cadherin+ cells situated deeper in the basalis. With this observation, the authors proposed a possible differentiation hierarchy amongst the epithelial eSPCs [+ cells were found mainly within the basalis of the proliferative phase endometrium, supporting its possible SPC role; however, no functional data is available for these cells, thus the evidence for Musashi-1 as an eSPC marker is limited [Unlike endometrial stromal ASCs, epithelial eSPCs are yet to be conclusively defined, with specific universal markers remaining elusive . Work foeceptors ,61. Subseceptors  , with current knowledge limited to eMSCs. To date, eMSCs have been suggested to play a role in endometrial receptivity and regeneration, both of which are essential to successful pregnancy.HoxA11 and Noggin during the WOI [ITGβ1 [RAC1 [HOXA11 [ITGβ3 [NOGGIN [HOXA11 and ITGβ3 were seen in the eMSCs of women with RIF [HOXA11 encodes a transcription factor and is involved in proliferation, differentiation, and embryologic development of the endometrium [HOXA11 is thought to be important in establishing pregnancy [Rac1 expression is necessary for eMSC migration and is associated with increased cell motility at the site of implantation [HOXA11 antisense RNA in the endometrium of women with RIF, leading to downregulated decidualisation [Hoxa11 knockout mice are known to be associated with uterine factor infertility [HOXA11 and integrin β3 contribute to uterine receptivity and are therefore relevant to RIF. Hoxa11 is expressed in mouse uterine stromal cells during the receptive phase and during post-implantation decidualisation, suggesting a possible role in receptivity, implantation, and decidualisation [-/-Hoxa11 mice have hypoplastic uteri, fewer endometrial glands, and do not express Lif, which is essential for the progression of a normal pregnancy [HOXA11 and integrin β3 levels, remains undefined. The results from Esmaeilzadeh et al. (the only study concentrating on eMSCs and RIF) should be interpreted with caution as the number of women who participated in the study was very small (n = 5) and the control group utilised (n = 3) was extremely heterogenous, almost overlapping with the RIF group (history of less than three miscarriages and at least one live birth after ART cycle(s) (two of the controls had a child after their second ART cycle and the other after their third cycle) [+PDGFRβ+, SUSD2+, or NTPDase2), raising concerns regarding the appropriateness of the methodology and reliability of only eMSCs being isolated.Considering the well-established endometrial contribution to RIF, eSPC abnormalities are expected to be involved in generating a persistently abnormal functionalis layer. Unlike in RPL, the endometrium of women with RIF is proposed to be hostile and less receptive to embryo-attachment ,34,35. S the WOI . In 2020I [ITGβ1 , RAC1 [1β1 [RAC1 , HOXA11  [HOXA11 , ITGβ3 [1 [ITGβ3 ,114, and [NOGGIN ) were co [NOGGIN . eMSCs f [NOGGIN ,116. Notwith RIF . HOXA11 ometrium , thereforegnancy ,118. Racantation . Integriantation ,114,119.antation ,120, witantation . In agrelisation . Contradertility . As for ertility , but, inertility . It is aregnancy ,123. Howd cycle) . In addi+ and W5C5−, respectively) from luteinising hormone (LH) timed mid-luteal phase endometrial biopsies [+ perivascular cells between the women with RPL and control samples were noted. However, there was a significant decrease in the clonogenicity of W5C5+ and W5C5− cell populations from RPL samples when compared to fertile controls. No clonogenic W5C5− cells were recovered from 42% of the RPL sample versus 11% of the control samples. In the cohort studied, the presence of clonogenic W5C5+ or W5C5− cells were adversely associated with the number of previous miscarriages [Similarly to RIF, aberrant endometrium is expected to contribute to the pathology of RPL. RPL is proposed to be associated with a hyper-receptive endometrium, permissive to even a sub-optimal blastocyst , with pobiopsies . W5C5 wabiopsies . No diffarriages . This meThe discovery that a deficiency of eMSCs is connected to RPL has revealed new insights into pregnancy failure mechanisms. This has posed new questions concerning the pathways that control the maintenance of eMSCs from one pregnancy to another pregnancy.eSPCs have been found to play a crucial role in the regeneration and repair of the endometrium ,126,127.Persistently thin endometrium is a major challenge within the fertility setting ,130,131,Currently, treatment for AS is usually surgical, with hysteroscopic adhesiolysis ,147. In RPL has been associated with the loss of eMSCs . In 2020Although we strongly believe that eSPCs have a critical role to play in the pathology of RRF, evidence for direct eSPCs involvement in RRF is currently lacking. Available data is limited, sometimes contradictory, and of varying quality. Furthermore, the lack of clarity on the precise phenotypical and functional properties, origin, and location of eSPCs contributing to normal endometrial regeneration, hinders progress in the identification of eSPC aberration, specific to RRF, and thus, impedes the advancement of potential eSPC-based therapeutic avenues.The importance of understanding the critical role of the endometrium in the implantation and success of ongoing pregnancy is acutely apparent by the knowledge that only 50% of euploid embryos accomplish implantation . In addiCurrently, the majority of research exploring stem cells in unexplained infertility, RRF, or endometrial regenerative medicine is mainly restricted to non-endometrial stem cells . This prThe LE  and endometrial glands (which provide an abundance of secretions to enable successful implantation) have been proven to be essential for pregnancy establishment ,41. The There are many technical and ethical challenges to overcome in defining the intricacies of human embryo implantation, and there are still many aspects that are not fully understood. Much of our knowledge of embryo implantation has stemmed from animal studies and in vitro two-dimensional (2D) monolayer culture systems, neither of which accurately represent the in vivo endometrial or embryo physiology, or environment ,171. 3D RIF and RPL are devastating and challenging conditions, with many unanswered questions remaining. Evidence is now starting to emerge that eSPCs may be implicated in the aetiology of these conditions, giving rise to an abnormal endometrium, and therefore a suboptimal environment to support an ongoing pregnancy. Advances in endometrial stem cell biology and novel seminal discoveries, such as the 3D histoarchitecture of human endometrial glands ,51, have


The average scores of NLAI-P were 46.59 ± 9.27. With the adjustment of confounding factors, education level presented a significantly positive correlation with NLAI-P scores. In conclusion, NLAI-P were valid and reliable to inspect NL level of pregnant women in China. Poor NL was prevalent among Chinese pregnant women. Based on the education level, taking targeted propaganda and education measures would achieve the optimal effect. NLAI-P can be applied as the tool for monitoring and assessing NL of pregnant women, and facilitate the designation of targeted interventions policies.The study was designed to develop and validate the nutrition literacy assessment instrument for pregnant women in China (NLAI-P). The dimension, components and questions of NLAI-P were identified via literature review and expert consultation. A panel of experts evaluated the content validity. The construct validity was evaluated by using the exploratory factor analyses (EFA) and confirmatory factor analyses (CFA). Cronbach’s α coefficient and split-half reliability were applied for examining the reliability. The NLAI-P was divided into 3 dimensions including knowledge, behavior and skill dimension. Findings showed NLAI-P possessed the satisfactory content validity , acceptable construct validity (χ Globally, nutrition-related chronic diseases are on the rise year by year. The role of nutrition and diet in etiology of these diseases appears more and more important. Refining dietary quality, optimizing dietary structure and altering unhealthy dietary behaviors are of practical significance for the primary prevention of nutrition-related chronic diseases ,2,3,4. UGestational period is the initial stage of early life 1000 days. The nutritional status of pregnant women does not only affect their own health, but also has short- and long-term effects on offspring health. Maternal demands for nutrition during pregnancy are much higher than normal women’s in order to maintain their own demands and fetal growth and development, which means that pregnant women are more prone to suffering from nutrition-related health problems. In China, pregnant women are still confronted with a variety of nutrition-related problems including inadequate consumption of multiple nutrients, chronic low intake of calcium and vitamin D, anemia, vitamin A and vitamin D deficiency, gestational obesity, gestational hypertension and gestational diabetes mellitus ,10,11. IThe advanced NL is characterized of the profound cognition of nutrition knowledge, optimized dietary behaviors, and highly developed skills to address nutrition and health barriers . TherefoTherefore, our purpose is to develop the nutrition literacy assessment tool for Chinese pregnant women (NLAI-P), with the expectation of providing a unified tool for assessing and monitoring the staus of NL of pregnant women in China.The study was carried out into 2 phases:Phase1 was the establishment of NL core items for pregnant women in China.Phase2 was conducted for the development, validation and application of NLAI-P. The flow chart of the study was demonstrated in Phase1: Establishment of NL core items for pregnant women in China.The establishment of NL core items for Chinese pregnant women was divided into three steps. Firstly, the framework system of core items was determined. Based on the “Health Literacy of Chinese Citizens 66 Items-Basic Knowledge and Skills”, the framework system of NL core items for Chinese pregnant women was determined to contain 3 scales: basic knowledge and ideas, lifestyle and dietary behaviors, and basic skills. Secondly, a list of NL core items for Chinese pregnant women was built. Through literature review, expert consultation and group discussion, we identified item pool of NL for pregnant women by mainly referring to “Dietary Guidelines for Pregnant Women” issued by Chinese Nutrition Society along with recommendations and suggestions related to nutritional health of pregnant women issued by WHO. Thirdly, two rounds of Delphi expert consultation and group discussion were conducted to determine the final NL core items for Chinese pregnant women. The final version of NL core items for Chinese pregnant women consisted of 3 dimensions/scales , 10 components/sub-scales , and a total of 24 items.The core items were scientific, reliable and has been previously published . The NL Phase 2: Development, validation and application of NLAI-P.Based on above-mentioned NL core items for pregnant women, we developed NL questionnaire for Chinese pregnant women which consisted of 3 dimensions , 9 components under dimensions and a total of 38 questions in components.The NLAI-P consisted of two parts: the first part investigated demographical characteristics such as residence, age, career, education level, income and childbearing history. via a self-report questionnaire. The second part was NL questionnaire for Chinese pregnant women. The scoring standards of each question were detailed as follows:The questions consisted of multiple choice and Likert type questions. The full score of a question was 2 points. For some multiple-choice questions with only one right responses, 2 points were awarded for the correct answer and 0 points for the wrong answer. For multiple choice questions with at least 2 correct responses, 2 points were given if respondents choose all correct answers, 1 point for people no choosing all right answers, and 0 for those picking up the wrong answer. For questions with five-point Likert scale , If the question was positive, 2 points were rendered for “strongly agree”, 1 point for “agree” and 0 for “uncertain” or “disagree” or “strongly disagree”, vice versa. For questions with five-point Likert scale , if the question was positive, 2 points were awarded for “always”, 1 point for “often” and 0 for “sometimes” or “occasionally” or “rarely”, vice versa. The scores were categorized as excellent , good  or poor .699 pregnant women were recruited by the convenience sample from 10 September 2020 to 31 December 2020 in certain hospitals in Beijing. The on-site investigation and online survey were carried out. Inclusion criteria were as follows: having signed the informed consent, being able to read and write, being apparently healthy with no severe diseases or mental disorders. Exclusion criteria were: being illiterate or having difficulty with verbal communication, withdrawing from the ongoing investigation. That the sample size was 5–10 times the number of questions was considered sufficient to perform the reliability and validity tests. The NLAI-P contained 38 questions, so the expected sample size was between 190 and 380. Therefore, the sample size in our study was acceptable.The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Committee on Medical Ethics of the Peking University with the number of ethics approval of IRB00001052-17107.(1) Content validity:Questions were rated the relevance to the corresponding dimensions by using a five-point Likert scale  in the expert consultation. We mailed experts the self-made “expert consultation questionnaire” and required each expert to appraise the relevance of each question. In addition, the experts were also asked to make comments and recommendations for optimizing the questions.Content validity was assessed using the content validity index (CVI) and content validity ratio (CVR). CVI contained item-level CVI (I-CVI) for each question and scale-level CVI (S-CVI) for the scale. The I-CVI was calculated as the ratio of the number of experts that gave a relevance rating >3 to the total number of experts. The S-CVI was calculated as the average of I-CVI. I-CVI > 0.8 was considered the acceptability. The CVR was computed according to Lawshe scores which calculated CVR by subtracting half of the total number of experts from the number of experts rating the questions’ relevance more than 3, and the production dividing by the half of the total number of experts. According to the Lawshe scores table, CVR > 0.59 (for 11 experts) was considered acceptable ,20.Intra class correlation coefficient (ICC) was adopted to measure the consistency of experts’ ratings. ICC was computed by 2-way mixed effects ANOVA model by using IBM SPSS version 22.0  and then divided as poor (<0.5), moderate (0.50–0.75), good (0.76–0.9) or excellent (>0.9).Pearson correlation coefficient was computed to evaluate the correlation between the questions and the corresponding dimensions. The value of >0.4 was acceptable.(2) Construct Validity testp < 0.05 in Barrlett’s test of sphericity suggested the feasibility of EFA [The EFA was applied to test the construct validity of 3 dimensions. Kaiser Meyer Olkin measure of sampling adequacy (KMO) and Barrlett’s test of sphericity were performed to judge the suitability of EFA. KMO > 0.5 and y of EFA . The num2/df < 3.0, and root mean square error of approximation (RMSEA) < 0.08 [The CFA was used to test the fit degree of models derived from EFA. CFA is commonly implemented by structural equation modeling. The method of Weighted Least Squares was used for estimating the data. In CFA, the reasonable criteria of indices were as followings: goodness-of-fit indices (GFIs) > 0.9, adjusted goodness of fit index (AGFI) > 0.8, χ) < 0.08 .Internal reliability was commonly assessed through the Cronbach’α coefficient. It was derived from the formula:k was the number of items. i. The α > 0.7 manifested the good acceptability [The tability .The spilt-half reliability was another indicator used for evaluating the reliability . The queTo evaluate the NL level of pregnant women in China and analyze the potential influencing factors.Data processing and calculating was performed by using software SPSS25.0 . One-way analysis of variance (ANOVA) or T test was used to compare the differences in NL scores in different groups. Multiple linear regression model was established for determining the factors related to NL level of Chinese pregnant women. The CFA was carried out by using software AMOS25.0 .The framework of NLAI-P was finally defined with 3 dimensions: knowledge dimension, behavior dimension and skill dimension. Each dimension consisted of 5, 2 and 3 components, respectively shown in .699 pregnant women were recruited. The demographic characteristics were shown in The The result of Pearson correlation coefficients > 0.4 implied the acceptable content validity of NLAI-P shown in .p < 0.001, which implied the feasibility of EFA. In knowledge dimension, 4 factors were extracted and accounted for 32.12% of total variance. They represented food, nutrition and health, risk factors of pregnancy complication, knowledge of balanced diet and healthy lifestyles, and weight management. questions loaded between 0.22–0.77 in the dimension. In behavior dimension, 2 factors were obtained, accounting for 40.95% of the total variance, and they were named as healthy eating behaviors and healthy lifestyles. All of the questions had factor loadings >0.25. In skill dimension, 3 factors were identified, accounting for 60.70% of the total variance, and were named after food group and nutrition label analysis, judgement of nutrition information recognition, nutrition information access and nutrition-related decisions making, respectively. Factor loadings of each question kept up to the acceptable standard.In NLAI-P, the KMO in 3 dimensions were 0.76, 0.74 and 0.77, respectively, and Bartlett’s test of sphericity of CFA was used to evaluate the structure fit degree of NLAI-P, and the results were shown in Cronbach’s α coefficient of the overall evaluation tool was 0.82, and Spearman-Brown and Guttman split-half coefficients were 0.73, which could be interpreted as a good internal reliability of the NLAI. Cronbach’s α coefficient were 0.72, 0.60 and 0.68 in knowledge, behavior and skill dimension, respectively shown in .The average NLAI-P scores were 46.59 ± 9.27. Only 3.9% of pregnant women reached the excellent level, more than half (55.2%) of pregnant women had good nutritional literacy level, and 40.9% of pregnant women were in poor level shown in . As for The potential factors influencing the NL level of pregnant women included age, ethnicity, residence, occupation, education level and gestational age shown in . Some deThe Veen diagram showed that age, occupation and education level had impacts on all of 3 dimensions shown in .p < 0.01), knowledge dimension , behavior dimension  and skill dimension .Then, the multiple linear regression model was established by using the potential factors including age, residence, occupation and education level. The results showed that the education level presented significantly positive correlation with both the overall scores of NLAI-P and the scores of all dimensions shown in . As the The NLAI-P in the study consisted of 3 dimensions, 9 components and a total of 38 questions, and possessed the satisfactory validity and reliability. The NLAI-P appeared as a valid and reliable tool to assess NL level for Chinese pregnant women.The overall content validity of NLAI-P was 0.98, which suggested that the instrument was well designed to measure NL of Chinese pregnant women. The results of CFA also implied that the acceptable fit indices for the proposed models of NLAI-P. Our NLAI-P contained 3 dimensions: knowledge dimension, behavior dimension and skill dimension. Under knowledge dimension, there were 4 components: food and nutrition knowledge, nutrition and health knowledge, balanced diet and healthy lifestyles, and weight management as well as risk factors of pregnancy complications. The dimension was designed for evaluating whether pregnant women learnt balanced diet, whether to master the knowledge about the optimal food source of maternal essential nutrients  and about the adverse pregnancy outcomes induced by these nutrients’ deficiency, and whether to know the detrimental aspects of excessive/insufficient gestational weight gain as well as identifying the risk factors of pregnancy complications. Similarly, food, nutrition and health also appeared in the existing nutrition literacy assessment tools for school children ,18, the For behavior dimension with 2 components, one was healthy eating behaviors and the other was healthy lifestyles. The former aimed at inspecting whether respondents followed healthy eating behaviors such as how many kinds of food intake, the consumption of milk and dairy products, water drinking, et al. The component of healthy lifestyles was designed for evaluating whether pregnant women adopted healthy lifestyles such as taking proper exercise, paying attention on gestational weight gain and interpreting nutrition label. In accordance with ours, items concerning nutrition label also appeared in the existing nutrition literacy tools ,17,18,25For the skill dimension, it included 3 components representing food group and nutrition label analysis, the judgement of nutrition information and nutrition information access and nutrition-related decision making. For the component of food group and nutrition label analysis, classifying food correctly was the prerequisite and foundation for choosing a healthy meal, which was in line with previous assessment tools covering the skill of food classification . NutritiOur NLAI-P had a satisfactory Cronbach’s α of 0.82 indicating the acceptable internal consistency. NL assessment tools designed for Chinese adults, elderly and school-age children had acceptable Cronbach’s of 0.89, 0.68 and 0.69, respectively ,17,18. NThe results indicated that the average scores of NLAI-P was 46.59. Currently, there was no unified standards to evaluate whether to have sufficient NL because of different NL assessment tools for different target population. In this study, the standards were set by referring to health literacy evaluation standard officially issued in China . The scoIn the current study, age, occupation and education level came as the main factors affecting NL of pregnant women. Compared with those under 25 years old, the pregnant women in the older group had higher scores whether in overall NLAI-P or 3 dimensions, which might be related to young people’s lack of focus on nutrition-related knowledge, behavior and skills. Occupation was another influencing factor, and the scores of professional and technical personnel were the highest. It was considered that this population may have more access to NL related sources, and on the other hand, they tended to possess higher education level, which was supported by the positive correlation between education level and NLAI-P scores in our study. After adjusting the confounding factors, there still existed significantly positive association between education level and NLAI-P scores. In consistent with our findings, Portuguese adults with higher education were reported having higher levels of NL . LikewisThere are some advantages in our study. Firstly, it was the first instrument to evaluate the NL of Chinese pregnant women. We conducted the reliability and validity tests in a sufficiently large sample size and acquired desirable results. Secondly, we adopted the well-established theory as the basis of theoretical framework. At the same time, we extensively referred to the dietary guidelines issued by Chinese Nutrition Society and other reports, recommendations as well as guidelines published by WHO or other official organizations as the content basis, and were oriented by the main nutritional and health problems of Chinese pregnant women. Therefore, there were good grounds for us to state that NLAI-P was supported by the solid empirical and theoretical basis.Undoubtedly, there were some limitations we acknowledged. The application of NLAI-P was restricted by the certain social and cultural environment, and whether it can be popularized in the world remains uncertain. Furthermore, there is still some room left for conducting research on the association between NL with pregnancy outcomes.NLAI-P was valid and reliable for evaluating the NL level of Chinese pregnant women. The development of NLAI-P would provide an effective tool for assessing and monitoring the status of nutrition literacy among pregnant women and render a basis on the designation of targeted nutrition interventions.


It is commonly reported that maximizing surgical resection of contrast-enhancing regions in patients with glioblastoma improves overall survival. Efforts to achieve an improved rate of resection have included several tools: among those, the recent widespread of fluorophores. Sodium fluorescein is an unspecific, vascular dye which tends to accumulate in areas with an altered blood–brain barrier. In this retrospective analysis of patients prospectively enrolled in the FLUOCERTUM study, we aimed to assess the role of fluorescein-guided surgery on surgical radicality, survival, and morbidity. A retrospective review based on 93 consecutively and prospectively enrolled IDH wild-type glioblastoma patients (2016–2022) was performed; fluorescence characteristics, rate of resection, clinical outcome, and survival were analyzed. No side effect related to fluorescein occurred; all of the tumors presented a strong yellow-green enhancement and fluorescein was judged fundamental in distinguishing tumors from viable tissue in all cases. Gross total resection was achieved in 77 cases out of 93 patients (82.8%). After a mean follow-up time of 17.4 months (3–78 months), the median progression-free survival was 12 months, with a PFS-6 and PFS-12 of 94.2% and 50%, respectively, whereas median overall survival was estimated to be 16 months; survival at 6, 12, and 24 months was 91.8%, 72.3%, and 30.1%, respectively. Based on these results, we can assert that the fluorescein-guided technique is a safe and valuable method for patients harboring a newly diagnosed, untreated glioblastoma. Brain malignancies account for approximately 2% of the tumors afflicting humankind . Among mDespite decades of research on its pathobiology and clinical management, GBM still possesses an ominous prognosis, with a median survival of 15–18 months ,9. MaximTherefore, identifying different adjuncts to guide resection has become a tactical challenge in achieving maximal safe tumor resection. This need has fostered the exploration of a relatively new realm, that of fluorophores  such as On the other side of the tumor visualization battlefield, SF is encountered. This dye emits fluorescent radiation in the wavelength ranging from 540 to 690 nm and builds up in cerebral areas presenting damage to the blood–brain barrier (BBB) ,26. The In recent years, also thanks to our preliminary studies and the approval, in July 2015 (determination 905/2015), of the fluorescein molecule as a neuro-oncological tracer by the Italian Medicine Agency (AIFA), SF applications have increased exponentially ,25,33,34Therefore, considering that residual neoplastic tissue extending beyond c.e. borders contributes to disease recurrence, we hypothesize the potential role of SF in the implementation of a supramaximal GBM resection. In this study, we retrospectively analyzed data from the FLUOCERTUM prospective study conducted at our institute to investigate the utility of SF in improving the rate of GTR of GBM and to assess the outcomes of patients undergoing fluorescein-guided resection.In this study, we retrospectively reviewed the database of the prospective observational FLUOCERTUM study, started in March 2016 and approved by the institutional review board, to identify the cohort of GBM patients until June 2022. Written informed consent for the surgical procedure, including the use of sodium fluorescein, as well as to participate in this observational study was obtained from each patient. The protocol and the retrospective case series revision have been approved by the Ethical Committee of the Fondazione IRCCS Istituto Neurologico Carlo Besta.The inclusion criteria of the FLUOCERTUM study were as follows: patients of both genders, of any age, with suspected aggressive lesions of the CNS, as suggested by preoperative MRI with i.v. contrast agent administration. The exclusion criteria were: impossibility to give consent due to cognitive deficits or language disorders; a known allergy to contrast agents or history of previous anaphylactic shock; known severe previous adverse reactions to SF; acute myocardial infarction or stroke in the last 90 days; severe organ failure; and women in their first trimester of pregnancy or lactation .The retrospective case series revision aims to identify those patients scheduled for fluorescein-guided surgery with a histopathologically-confirmed GBM according to the 2021 WHO CNS5 tumor classification .www.osirix-viewer.com, accessed on 10 October 2022) by a dedicated neuroradiologist (M.M.). No aprioristic distinction was performed among tumors located in non-eloquent brain areas or adjacent to them ; as affirmed by the abovementioned information, only once complete fluorescent tissue removal was achieved was the case considered for further analyses.The preoperative assessment included physical and neurological examination (KPS), laboratory tests results, and contrast-enhanced MRI for neuronavigation. If judged necessary, fMRI and DTI were acquired for the best surgical planning. All of the patients were submitted to MRI, including 3D volumetric sequences with and without contrast (T1 weighted); tumor volume was calculated  by segmeTo evaluate the EOR, a volumetric MRI examination was performed for each patient within 72 h of surgery; in particular, to calculate the residual pathological residual volume (RV), the hyperintense alterations in volumetric basal T1 acquisitions were subtracted from the volume of hyperintense tissue in post-contrast volumetric T1 images to avoid the incidental inclusion of blood or blood products . The EORSurgery was to be followed by standard conformational radiotherapy and concurrent chemotherapy with temozolomide, followed by six cycles of maintenance chemotherapy with temozolomide according to the Stupp protocol ,42. No rThe postoperative clinical evaluation included a standard neurological examination as above, including KPS evaluation, as well as laboratory tests (kidney function) and exclusion of the occurrence of any side effect related to fluorescein injection. Periodic MRIs were performed according to regular clinical practice; the first clinical and radiologic evaluation following the postoperative one was performed before the beginning of radiotherapy and concomitant temozolomide; subsequently, follow-up was performed every two cycles of temozolomide during the Stupp protocol phase and, after tumor progression and change in chemotherapeutic approach, every 2 months. The demographics, clinical, neuroimaging, surgical, pathological, and adjuvant treatments data were obtained from the personal medical records, the institutional cancer registry, the institutional complication registry, the institutional pathology registry, follow-up visits, and telephonic interviews.The standardized surgical protocol of the fluorescein-guided technique, as already described in previous papers, is based on i.v. SF  injection at a standard dose of 5mg/kg, by a central or peripheral venous line, immediately upon completion of the induction of general anesthesia or anesthetic procedures in awake surgery .Surgery was performed with the aid of a surgical microscope equipped with an integrated fluorescent filter tailored to the excitation and emission wavelength of sodium fluorescein . During resection, the microscope could be switched alternatively from fluorescent to white light illumination; neuronavigation , intraoperative ultrasounds , or other tools could be used according to the surgeon’s preference ,45. The At the same time, to allow the safest surgery, in tumors located adjacent to eloquent areas, intraoperative neurophysiological monitoring (IONM) was used ; awake aThe surgical procedures were performed by four different neurosurgeons  with significant experience in the neuro-oncological field, after an adequate learning curve in using SF, since its first application at our institution in 2011 . The fluHistopathological analysis was performed in each case (B.P.); the tumors were classified according to the 2016 or 2021 WHO classification by the neuro-pathology group of our institute. IDH mutation was evaluated by immunohistochemistry; only glioblastoma patients as standardized according to CNS5 were included in this study, i.e., GBM IDH-wt.The methylation patterns in the CpG islands of the O-6-methylguanine-DNA methyltransferase (MGMT) promoter were determined by chemical modification of unmethylated cytosines to uracils, followed by methylation-specific PCR .The principal aim of the present study is to assess the contribution and the valuable role of fluorescein in the surgical resection (rate of GTR and RV) and visualization (fluorescein usefulness) of primary, untreated glioblastomas with a dedicated filter integrated in the surgical microscope.Secondary endpoints consist of evaluating short- and long-term clinical outcome, PFS at 6 and 12 months, and OS.Disease progression was defined as evidence of a new measurable enhancing lesion for patients with total removal or a ≥25% increase in the sum of the products of perpendicular diameters of enhancing lesions compared with the smallest tumor measurement at baseline for patients with incomplete removal, according to the RANO criteria . PFS-6 aThe sample was described by means of the usual descriptive statistics: the mean, median, and standard deviation for continuous variables and the proportions for categorical ones. PFS and OS were estimated by the Kaplan–Meier method; PRISM software for Macintosh was used for the statistical analysis.Ninety-three patients met the inclusion and exclusion criteria: patients’ ages ranged from 30 to 82 years, with a mean age of 61.2; 61 males (65.6%) and 32 females (34.4%) were enrolled in the study .3 (range: 0.74–334.69 cm3). All of the patients presented with a heterogeneous c.e. on the preoperative MRI, with different degrees of intensity, and, frequently, cystic-necrotic components, especially at the lesion core. Most patients underwent surgery until 2021; the cases have been reviewed to identify only glioblastoma IDH wild-type patients ; in 53 out of 93 cases (57%), the MGMT promoter was methylated whereas it was unmethylated in the remaining 40 patients (43%).The mean preoperative tumor volume was 60.27 cmThe majority of the tumors were located in not-eloquent regions (57 cases out of 93–61.3%); otherwise, 30 patients (32.2%) were scheduled for IONM-assisted surgery, whereas in six cases (6.5%), an awake anesthesia was planned.A summary of the demographic, surgical, and outcome characteristics of the patients is presented in No technical difficulties regarding the use of the microscope filter nor switching between white and yellow light were encountered during the surgical resections. No adverse drug reaction related to SF injection was reported in this cohort of patients; the only remarkable and visible effect was the transient yellowish staining of urine, which disappeared in about 24 h.All tumors included in this study showed a highly intense fluorescent yellow-green signal, clearly distinguishable from peritumoral brain parenchyma, depicted as pinkish tissue . Each caWe have never found SF uptake during surgical manipulation of healthy tissue in peritumoral parenchyma because of the limited amount of circulating fluorescein due to our strict protocol of low-dosage fluorescein use, thanks to the specific YELLOW 560 filter, injected at least 1 h before dural opening . However3 (0.17–22.76 cm3) or 4% of the initial tumor mass (0.6–9.7%). Six out of 16 cases (37.5%) of incomplete removal [GTR was achieved in 77 cases out of 93 patients (82.8%); the remaining 16 patients (17.2%) with a subtotal tumor resection had a mean RV of 4.05 cm removal ,53 had aIn few cases of large and necrotic tumors, the RV can be considered high in the absolute sense, although less than 10%; we have interpreted this eventuality to be due to the prolonged surgery, which causes a higher wash-out of fluorescein from the blood circulation and the hemorrhagic feature of these lesions, that can further reduce the capacity of SF discrimination attenuating the contrast between fluorescent and not-fluorescent tissue. Due to the small number of patients harboring a large tumor, we are not able to perform a statistical inference to demonstrate our empirical considerations.At baseline, 54/93 (58.1%) of patients had a KPS score of 90–100, indicating excellent clinical and neurological conditions, 33/93 (35.5%) of patients had a KPS score of 70–80, indicating moderate clinical and neurological conditions, and only 6 patients (6.4%) had a worse clinical and neurological state. Surgical morbidity led to a postoperative decline in KPS score in 29 patients at discharge, but only in 3 cases was clinical worsening marked with a decrease greater than 30 points in KPS score; 49 patients were discharged with an unchanged KPS score, whereas 15 patients presented with a clinical improvement using surgical treatment. At discharge, 51/93 (54.8%) of patients had a KPS score of 90–100, 29/93 (31.2%) of patients had a KPS score of 70–80, and 13/93 (14%) of patients had a KPS score ≤60 .Forty-three patients (46.2%) completed the total Stupp protocol ; eight aDuring the study period, 69 patients died due to tumor progression or other causes. The median OS was estimated as 16 months. Survival at 6, 12, and 24 months was 91.8%, 72.3%, and 30.1%, respectively b.It is well known that increasing the rate of HGG resection, achieving the GTR, improves survival since surgery is the mainstay of treatment with a propaedeutic role for adjuvant therapies according to the Stupp protocol ,9,24.For more than 10 years, SF has emerged as an intraoperative dye able to improve brain–tumor discrimination, due to its non-specific, vascular mechanism of action related to the accumulation in brain regions with BBB damage, as it happens with MRI c.e. in most aggressive, intra-axial tumors ,54,55,56This study confirmed that the fluorescein-guided resection of GBM is a feasible, safe, and valuable intraoperative tool which allows for a high rate of complete resection at early postoperative MRI . In all 3; EOR of >98% was achieved in 89.2% of patients. Thus, the fluorescein-guided technique seems to be able to assure a high-rate of total or near-total resection in GBM. Even more important from a prognostic point of view, it should be noted that 14 patients out of the 16 incomplete resected cases (87.5%) showed an RV that was inferior to 5 cm3, with 64.2% of them (9 of 14 patients) being <2 cm3 [Our results showed a complete resection in 82.8% of the cases with a mean RV in the remaining 16 cases of 4.05 cmg <2 cm3 ,53. Seveg <2 cm3 ,58 and iGlioblastoma still remains the most aggressive CNS tumor with a poor prognosis in the short term ,59; the Surgical resection of HGG under white light illumination is a ruinous technique; in the control group of the pivotal randomized clinical trial about 5-ALA published by the group of Stummer, the rate of patients with complete c.e. areas removal was only 36% . The awa5-ALA, the biochemical precursor of hemoglobin that provokes the synthesis and accumulation of fluorescent porphyrins in several malignant cancers among which HGG, can be visualized by means of the BLUE 400 filter with specific wavelength of 620–710 nm after the excitation wavelength of 400–410 nm. 5-ALA has been approved both by the EMA and by the FDA as a neurooncological tracer for malignant gliomas and this approval has paved the way to its broad use. In 2006, Stummer et al.  publishe3, which was calculated as every mismatch between the T1 post contrast administration sequence and T1 acquisition, without considering any minimal cut-off as non-specific enhancement [On the other side, fluorescein sodium salt , althougancement . Fluoresancement . Finallyancement . Thus, iAlthough the wider neuro-oncological field of application of SF if compared to 5-ALA, the most important application of fluorescein remains its use in improving HGG visualization and resection. In a study by Katsevman et al. , fluoresTo our knowledge, this study is one of the largest case series to date demonstrating the beneficial effect of applying SF as an adjunctive tool in GBM surgery. By employing fluorescein, we were able to achieve a great number of GTRs. It is important to consider that, even with fluorescein-guided techniques as well as with any fluorophore, a complete removal of pathological tissue is not always possible; indeed, yellow contrast can be appreciated if the tumor is properly exposed during the surgical approach ; thus, sThe main limitation of this study is represented by the lack of a direct comparison of surgery with and without SF aid, due to ethical reasons, or between different fluorophores (SF vs. 5-ALA), due to the authors’ surgical experience in the fluorescein field. Additionally, the patients were not centralized for oncological adjuvant therapies and this element could have influenced the survival analysis.Despite these weaknesses, our study could represent another cornerstone that may indicate that fluorescein use is useful in the identification of tumoral tissue and in achieving a high rate of GTR of GBM. Further studies could better elucidate the contribution of fluorescein-guided techniques in improving the survival of patients harboring a malignant glioma. We also have to stress that, in most countries, SF is still considered off-label for neuro-oncological procedures. Thus, a widespread utilization of fluorescence-guided surgery will depend on definitive approval by the competent authorities.This work corroborates sodium fluorescein as a promising, easy-to-apply, and affordable strategy for improving rates of total resection in patients affected by GBM with a possible impact on survival. Larger comparative studies, even including randomized clinical trials, will probably assess the advantage of this technique in terms of overall survival.


Objectives: This research measures the occurrence of malnutrition amongst under-five children in the Rahimyar Khan district of Southern Punjab in Pakistan. Employing different anthropometric measurement approaches such as (1) conventional indices , (2) CIAF, (3) BMI-for-age, and (4) MUAC, we compare their estimated results and examine the relationship between socioeconomic determinants and different anthropometric indicators. Methods: The study employs a proportional purposive random sampling method to collect data from 384 rural households in the community-based study using a self-administered survey and following the Lady Health Workers (LHWs) registered records. The nutritional status of 517 under-five children is measured with references to WHO (2009) child growth standards. Furthermore, the investigation used the model of binary logistic regression to measure the impact of socioeconomic factors on child malnutrition. Results: Compared with other approaches, the CIAF identifies more malnourished children (63%). The results of binary logistic regression illustrate that all the explanatory variables indicate a more significant empirical association with CIAF than conventional indices, BMI-for-age, and MUAC. Conclusion: CIAF is a more reliable tool for assessing child nutrition because it not only demonstrates more accurate estimates of malnutrition but also recognizes children with multiple anthropometric failures. Globally, 19% (110 million) of children below the age of five are severely underweight, while 30% 170 million) are stunted ,3. Pakis0 millionSvedberg  proposedSeveral studies have comparatively analyzed and discussed the different anthropometric measurement approaches. Most analyze whether the conventional indices or CIAF is a better approach to screening more malnourished children. However, limited studies have discussed comparing more than two anthropometric measurement tools for malnutrition screening. To the knowledge of the present investigation, no such investigation from Pakistan has evaluated the malnourishment screening tools or comparison of malnutrition prevalence through different approaches. Most of the literature in Pakistan is on socioeconomic determinants of malnutrition or the incidence of malnutrition. Therefore, the current study not only measures the occurrence of malnourishment in under-five children but also draws a comparison among them for screening malnutrition among children in one of the marginalized and high malnutrition prevalence districts of Punjab. Furthermore, this research investigates the association between socioeconomic determinants and different anthropometric indicators, which is missing in the literature.The district of Rahimyar Khan is located in the South Punjab province in Pakistan. It covers an area of 11,880 km with two main ecological zones-desert and agricultural ground land. It is divided into four administrative sub-districts. According to the 2017 census of Pakistan, the district’s population is 4,814,006, of which ~78% reside in rural areas; 50% are deprived of proper sanitation facilities . Also, iThe current investigation was a community-based and cross-sectional exploration, and 384 rural households were part of the primary data collection by a self-applied survey using a balanced purposive random sampling method. Keeping a 5% confidence interval and 95% confidence level, the data were allocated proportionally surrounded by four sub-districts: (1) Khan Pur, (2) Rahimyar Khan, (3) Liaquatpur, and (4) Sadiqabad. The statistical strategy focused on the probability of size ratios in each of the 4 sub-district. A stratified random sampling of Union Councils (UC) in each sub-district was included in the first phase. The rural families for the study were selected arbitrarily with the help of the record from a female health worker. The sample size (n = 384 families) was derived with the help of the Raosoft calculator by reviewing the 5% confidence interval and 95% confidence level. The calculations of the sample size (n) are described underneath:In the above equation:Z = A value that is 1.96 for 95% confidence levelp = It refers to percentage picking a choice and expressed as decimal (0.5 used for sample size needed)c = It means confidence interval and expressed as decimal 2 × (0.5) × (1 − 0.5)/(0.05)2 = 384.16 = 384n = (1.96)In Formula for each UC sample calculation = Population of UC 1,2,3/total Population of 3 UCs × sample size of tehsilNI = number of sampled respondents in each UCi = number of the UCs in the study area, i.e., 1, 2, 3,…,12N = total size of the sampleChildren in a household under five were considered for the survey. If more than one household existed in a single building, or families combined into a single household during the survey, then the investigation took them as independent if they prepared meals separately. The anthropometric assessments were carried out by female health workers, given training by the principal author before allocating the task of anthropometric assessment. The study utilized height assessments tape, weight machine, and MUAC tape to gather data for the measurement of age, weight, and height of the samples.Research data were collected for three months between November 2017 to January 2018. After getting study approval from the office of the district health officer, mothers of children and their close relatives were brought up-to-date in local languages with the help of female health workers who told them about the type of the investigation one week prior to seek their verbal agreement, as well as readying them to contribute in the investigation. Mothers belonging to 384 different families agreed to contribute willingly to the research, and all 384 mothers provided their verbal agreement in the meeting before the interview. In black and white, consent was not taken as 74% of mothers were uneducated and also showed reluctance because of their cultural boundaries.The study was approved in the 6th meeting of the Graduate Research Management Council (GRMC) of the Pakistan Institute of Development Economics [No. HE-01/2017 (PIDE)]. GRMC serves as an institutional review board. In addition, the Department of Health Economics at PIDE and the District Health Office in Rahimyar Khan also checked and approved the tools and protocols of this study. Furthermore, all the study details were explained to health officials, LHWs, and mothers before taking their consent.Stunting: z-score of height-for-age i.e., (HAZ) < −2 SD was termed as stunting; wasting: z-score of weight-for-height i.e., (WHZ) < −2 SD was termed as wasting; underweight: z-score of weight-for-age i.e., (WAZ) < −2 SD was termed as underweight. The CIAF sees the general occurrence of malnourishment within children. Based on this classification, children are distributed into 7 groups: group-A for “No Failure”, group B for Stunted, group C for Wasted, group D for Underweight, group E for Stunted + Underweight, group F for Wasted + Underweight, group G for Stunted + wasted, and group-H for Stunting + Wasting + Underweight. The total for malnourishment occurrence is measured by combining all groups excluding A. CIAF was dichotomized, “1” for the undernourished child and “0” for a non-undernourished child. CIAF was established on three indexes, such as stunting, underweight, and wasting, specified by World Health Organization (WHO) children development standards rules using anthropometric assessments . The curThe detail about CIAF classification of children with anthropometric failure is given below in The investigation predictor variables were the age of children in months, gender of the child, childbirth order, maternal educational status, maternal employment status, and household socioeconomic status . To measure the socioeconomic status, this study constructed a simple index of socioeconomic status based on six indicators: (1) mud type house or have cemented type household, (2) family is some landholding or not, (3) facility of electricity is available in the household or not, (4) within the house water drinking facility is present or absent, (5) any family member in the house is educated or not, (6) House keeps Television, newspaper, and radio or not. The response for these six indicators was in binary form (0 or 1). The total scores for the socioeconomic status index were 0 to 6 after adding these six indicators. These six indicators represent the household’s basic life amenities. Those having none or 1 or 2 items are included in the SES-1 category, representing the poor socioeconomic status of the household. The middle socioeconomic status (SES-2 category) of households was indicated when households had 3 to 4 items. Those households having 5 to 6 items were considered to be in the SES-3 category, representing their financial socioeconomic status. Studies in India and Pakistan used the household deprivation status index, which depicts the socioeconomic status (SES). We followed those studies to construct the SES index ,15,16.Before constructing the anthropometric indicators, data cleaning was done, and outliers were drawn out. Z-scores that did not fit the WHO flags were reduced from the data set while estimating the CIAF. Of 517 under-five children, 316 were included in the study, and 201 were skipped because of over range (less than −5 and greater than +5). Excel 2013 was used for data entry, while the STATA-15, Excel 2013, and WHO Anthro software were used to conduct the analysis. Descriptive statistics were performed to compute and then compare the rates of malnutrition through different anthropometric approaches. Furthermore, to measure the impact of socioeconomic dynamics on child malnourishment, the binary logistic regression model was used.The logistic regression method assesses the chances of malnourishment in basically two methods: 1 = if a child is undernourished, or 0 = if a child is not undernourished. The hypothesis set in the present investigation is that the malnourishment status of children is affected by many socioeconomic indicators. Malnutrition in this study was assessed through different anthropometric approaches. So, Child BMI-for-age, CIAF, and conventional indices  as dependent variables. Similarly, MUAC < 12.5 cm coded 1, which means the child is malnourished, and MUAC ≥ 12.5 cm coded as 0, showing the child is not malnourished. These outcomes or dependent variables were set in binary form (0 or 1). The model logistic regression measures the chance of the dependent variable, which is malnourishment of the child conditioned on socioeconomic signs. The binary logistic regression description form is given below:i is denoting the child’s signs of malnourishment “i” as the outcome variable ; X shows the explanatory variables; the coefficients of interest are represented by β’s, which elucidate the amount of correlation with outcome variables. And Y, a dependent or binary outcome variable, and (Yi = 0) indicates no undernourishment in a child, and (Yi = 1) represents that the child is undernourishment/stunted/underweight/wasted/low BMI/low MUAC, X =  as predictor variables, and xi is seen as the predictor variable value for “i” observation.In this equation, YPresent exploration focused on the nutritive status of 517 under-5 children. Of the total, 55.32% were male and 44.68% were female. After the anthropometric assessment, it is first important to look at the data distribution. In the distribution, <−1 to >−2 z-scores show normal category, <−2 to >−3 shows moderate malnutrition, and <−3 to >−5 or −6 shows serve malnutrition. WHO does not consider the z-scores >−6. To understand the nature of malnutrition, it can be useful to look at the mean z-scores of children’s ages in months. The prevalence of malnutrition using different approaches, i.e., BMI approach, MUAC, and conventional anthropometric indices  in children, is given in The results in The results in Logistic Regression EstimatesIn the current study, it was supposed that child growth is affected by different socioeconomic factors. For this purpose, the study measured the association between child health indicators and with age and sex of the child.The logistic regression estimates for CIAF and other anthropometric indicators are represented in Conventional indices , CIAF, BMI-for-age, and MUAC estimated malnutrition in children of preschool age in rural Southern Punjab, Pakistan. The results were as follows: CIAF approach identified 63%, MUAC, 33.46%, BMI-for-age, 62.24%. Conventional indices showed Stunting: 58.86%, Wasting: 8.11%, and Underweight: 41.89%. CIAF assessed more malnourished children than other approaches, including conventional indices. Our results and studies conducted in the Middle East and Africa seem consistent. Research in Nigeria’s rural community compared malnutrition through conventional indices and CIAF. Conventional indices were as follows: wasting at 14.1%, stunting at 33.1%, and underweight at 23.2%. At the same time, CIAF identified more malnourished children with multiple failures  . A studyWhen we compare our findings with the regional literature, we find that in India and Bangladesh, CIAF identified malnourished children greater than conventional indices or BMI and MUAC. In India, a study in rural Varanasi indicated that CIAF reported 62.5% of children malnourished compared to conventional indices  . Also, aNext, a study in Kolkata revealed that the anthropometry approach identified 29% stunting, 30.5% underweight, and 28.8% wasting in under-five children, which was higher than the undernutrition reported through MUAC (20.3%) and BMI-for-age (28.8%) . Also, aThe finding of the logistic regression models in The logistic results depicted that higher birth intervals decrease the chances of child malnourishment. On the other hand, it may not have a linear association with the rise in order of birth. It may be because the majority of the parents were satisfying the primary necessities of food for their children as food items such as vegetables, fruits, and milk are available at discounted rates and are accessible in rural regions. Research in Nepal revealed that the intermission of birth of fewer than 2 years was significantly correlated with severe acute malnourishment . SimilarIt is considered that there may be a link between the women’s employment status and the care of a child. If the mother is involved in a proper type of job or work, then the child’s growth and care, particularly feeding of the child, might be influenced due to the less time provided to the child because of work or job . BesidesThe results depicted through logistic regression revealed that as the socioeconomic status increases, the chances of malnourishment prevalence in under-five children decrease. Research in India emphasized that household socioeconomic deprivation significantly influenced the nutrition status of children as a deficiency in basic facilities augmented the malnourishment occurrence in children . Due to Around 38.9% of children’s z-scores in the study area were over the flag of WHO ranges (less than −5 and greater than +5), which depicts that one or two pieces of information, i.e., height, age, or weight, may be misinformed in data handling, or could be written/taken incorrectly. The chances of error in height and weight measurement were less. At the same time, it was noticed that most of the mothers in the study area were unsure of their children’s exact age, that perhaps they reported the wrong age. Because of this, 38.9% of children’s z-scores crossed the WHO ranges and skipped measuring the conventional indices and CIAF. Thus, in assessing malnutrition, care must be taken in anthropometric measurement that information on height, age, and weight of the child should be accurate. Especially age should be checked through children’s birth cards. Conventional indices covered malnutrition in only three groups of children  while CIAF covered all groups of malnourished children : underweLimitation of the StudyThis study has some limitations as it covers only one district of the Punjab province in Pakistan with a limited sample owing to financial and logistic limitations. These results have been based on the data collected from the poorest district of Pakistan. Generalizing these results could be difficult.Malnutrition prevalence through MUAC, BMI-for-age, and conventional indices is lower than the CIAF approach. The results of binary logistic regression illustrated that all the explanatory variables have a significant association with CIAF compared to other anthropometric approaches, i.e., MUAC, BMI-for-age, and conventional indexes like stunting, wasting, and underweight. The study concludes that CIAF is a better tool for child nutritional assessment, which exhibits more accurate estimates of malnutrition. Also, it identifies more children having numerous anthropometric failures and provides malnourishment patterning among preschool children living in low-resource settings.